Cherrywood Richmond

Summary: MDH found the licensee failed to designate a staff person to be responsible for providing assistance and responding to written requests that result from meetings and failed to develop a process to consider family council recommendations and grievances.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to designate a staff person to be responsible for providing assistance and responding to written requests that result from meetings and failed to develop a process to consider family council recommendations and grievances. This had the potential to affect all 17 residents receiving assisted living services, and their families. [...]”

Rule cited: “The facility must provide a family council with space and privacy for meetings, where doing so is reasonably achievable. [...]”

Summary: MDH found the licensee failed to display the original current license at the main entrance as required.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to display the original current license at the main entrance as required. This practice resulted in a level one violation (a violation that has no potential to cause more than a minimal impact on the resident and does not affect health or safety), and was issued at a widespread scope (when problems are pervasive or represent a systemic failure that has affected or has potential to affect a large portion or all of the [...]”

Rule cited: “The original current license must be displayed at the main entrance of each assisted living facility. The facility must provide a copy of the license to any person who requests it.”

Summary: MDH found the licensee failed to ensure an individual abuse prevention plan (IAPP) was developed to include the required content for two of two residents (R2, R3) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure an individual abuse prevention plan (IAPP) was developed to include the required content for two of two residents (R2, R3) with records reviewed. [...]”

Rule cited: “(b) The facility must develop and implement an individual abuse prevention plan for each vulnerable adult. [...]”

Summary: MDH found the licensee failed to ensure employee records contained the required content for three of four employees (licensed practical nurse (LPN)-F, registered nurse (RN)-D, and unlicensed personnel (ULP)-E) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure employee records contained the required content for three of four employees (licensed practical nurse (LPN)-F, registered nurse (RN)-D, and unlicensed personnel (ULP)-E) with records reviewed. [...]”

Rule cited: “(a) The facility must maintain current records of each paid employee, each regularly scheduled volunteer providing services, and each individual contractor providing services. [...]”

Summary: MDH found the licensee failed to establish and maintain a tuberculosis (TB) prevention program based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC) and the Minnesota Department of Health (MDH), which included completion of a two-step tuberculin skin test (TST) or other evidence of TB screening such as a blood test, for one of four employees (licensed assisted living director (LALD)-B) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to establish and maintain a tuberculosis (TB) prevention program based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC) and the Minnesota Department of Health (MDH), which included completion of a two-step tuberculin skin test (TST) or other evidence of TB screening such as a blood test, for one of four employees (licensed assisted living director (LALD)-B) with records reviewed. [...]”

Rule cited: “(a) The facility must establish and maintain a comprehensive tuberculosis infection control program according to the most current tuberculosis infection control guidelines issued by the United States Centers for Disease Control and Prevention (CDC), Division [...]”

Summary: MDH found the licensee failed to ensure resident records included a discharge summary with the required content for one of one discharged resident (R4) with record reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure resident records included a discharge summary with the required content for one of one discharged resident (R4) with record reviewed. [...]”

Rule cited: “Contents of a resident record include the following for each resident: (1) identifying information, including the resident's name, date of birth, address, and telephone number; (2) the name, address, and telephone number of the resident's emergency contact, [...]”

Summary: MDH found the licensee failed to develop a fire safety and evacuation plan with required elements, failed to provide required employee and resident training on fire safety and evacuation, and failed to

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop a fire safety and evacuation plan with required elements, failed to provide required employee and resident training on fire safety and evacuation, and failed to conduct required evacuation drills. This had the potential to affect all staff, residents, and visitors. [...]”

Rule cited: “(b) Each assisted living facility shall develop and maintain fire safety and evacuation plans. [...]”

Summary: MDH found the licensee failed to execute a written assisted living contract with the required content for two of two residents (R2, R3) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to execute a written assisted living contract with the required content for two of two residents (R2, R3) with records reviewed. This had the potential to affect all 17 residents. [...]”

Rule cited: “(d) The contract must include a description of the facility's complaint resolution process available to residents, including the name and contact information of the person representing the facility who is designated to handle and resolve complaints. [...]”

Summary: MDH found the licensee failed to ensure one of four employees (licensed practical nurse (LPN)-F) received the required amount of dementia care training in the required time frame with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure one of four employees (licensed practical nurse (LPN)-F) received the required amount of dementia care training in the required time frame with records reviewed. [...]”

Rule cited: “(3) for assisted living facilities with dementia care, direct-care employees must have completed at least eight hours of initial training on topics specified under paragraph (b) within 80 working hours of the employment start date. [...]”

Summary: MDH found the licensee failed to ensure a registered nurse (RN) conducted an initial assessment using the uniform assessment tool for one of one resident (R2) as required, with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure a registered nurse (RN) conducted an initial assessment using the uniform assessment tool for one of one resident (R2) as required, with records reviewed. [...]”

Rule cited: “(a) Residents who are not receiving any services shall not be required to undergo an initial nursing assessment. [...]”

Summary: MDH found the licensee failed to ensure the registered nurse (RN) completed a comprehensive reassessment no more than 14 days after the initiation of services and/or a reassessment not to exceed 90 days as required for three of three residents (R2, R3, R10) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure the registered nurse (RN) completed a comprehensive reassessment no more than 14 days after the initiation of services and/or a reassessment not to exceed 90 days as required for three of three residents (R2, R3, R10) with records reviewed. [...]”

Rule cited: “(c) Resident reassessment and monitoring must be conducted no more than 14 calendar days after initiation of services. [...]”

Summary: MDH found the licensee failed to ensure the service plan included the required content for two of two residents (R2, R3) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the service plan included the required content for two of two residents (R2, R3) with records reviewed. [...]”

Rule cited: “(f) The service plan must include: (1) a description of the services to be provided, the fees for services, and the frequency of each service, according to the resident's current assessment and resident preferences; (2) the identification of staff or [...]”

Summary: MDH found the licensee failed to ensure the registered nurse (RN) conducted an individualized medication assessment with the required content for two of two residents (R2, R3) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the registered nurse (RN) conducted an individualized medication assessment with the required content for two of two residents (R2, R3) with records reviewed. [...]”

Rule cited: “(a) For each resident who requests medication management services, the facility shall, prior to providing medication management services, have a registered nurse, licensed health professional, or authorized prescriber under section 151.37 conduct an [...]”

Summary: MDH found the licensee failed to ensure the registered nurse (RN) developed comprehensive written procedures for the unlicensed personnel (ULP) providing medications for residents having unplanned time away when the licensed nurse was not available, with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the registered nurse (RN) developed comprehensive written procedures for the unlicensed personnel (ULP) providing medications for residents having unplanned time away when the licensed nurse was not available, with records reviewed. [...]”

Rule cited: “(2) for unplanned time away, when the pharmacy is not able to provide the medications, a licensed nurse or unlicensed personnel shall provide medications in amounts and dosages needed for the length of the anticipated absence, not to exceed seven calendar [...]”

Summary: MDH found the facility failed to renew prescriptions at least every 12 months for one of two residents (R3) with record reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the facility failed to renew prescriptions at least every 12 months for one of two residents (R3) with record reviewed. [...]”

Rule cited: “Prescriptions must be renewed at least every 12 months or more frequently as indicated by the assessment in subdivision 2. Prescriptions for controlled substances must comply with chapter 152.”

Summary: MDH found the licensee failed to ensure refrigerated medications were maintained at manufacturer recommended temperatures by failing to monitor and/or document medication refrigerator temperatures for two of two medication refrigerators (140 side, 150 side).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure refrigerated medications were maintained at manufacturer recommended temperatures by failing to monitor and/or document medication refrigerator temperatures for two of two medication refrigerators (140 side, 150 side). [...]”

Rule cited: “An assisted living facility must store all prescription medications in securely locked and substantially constructed compartments according to the manufacturer's directions and permit only authorized personnel to have access.”

Summary: MDH found the licensee failed to ensure services plans were revised to reflect the current treatment or therapy service provided for one of two residents (R3) reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure services plans were revised to reflect the current treatment or therapy service provided for one of two residents (R3) reviewed. [...]”

Rule cited: “For each resident receiving management of ordered or prescribed treatments or therapy services, the assisted living facility must prepare and include in the service plan a written statement of the treatment or therapy services that will be provided to the [...]”

MDH’s finding, as written: “Based on interview and record review, licensee failed to ensure policies and procedures required in the licensing of assisted living facilities with dementia care were provided to each resident and/or the residents legal/designated representative at the time of move-in. This had the potential to affect all residents with dementia care. [...]”

Rule cited: “(a) In addition to the policies and procedures required in the licensing of all facilities, the assisted living facility with dementia care licensee must develop and implement policies and procedures that address the: (1) philosophy of how services are [...]”

Summary: MDH found the licensee failed to conduct an evaluation for activities that addressed all provisions and failed to develop an individualized activity plan based on the evaluation, for three of three residents (R1, R2, R3) who resided in the assisted living with dementia care facility, with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to conduct an evaluation for activities that addressed all provisions and failed to develop an individualized activity plan based on the evaluation, for three of three residents (R1, R2, R3) who resided in the assisted living with dementia care facility, with records reviewed. [...]”

Rule cited: “(b) Each resident must be evaluated for activities according to the licensing rules of the facility. [...]”

Summary: MDH found the licensee failed to ensure the care and services were provided according to acceptable health care and medical, or nursing standards for eight of eight residents (R5, R10, R9, R8, R2, R6, R7, R3) with siderails.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure the care and services were provided according to acceptable health care and medical, or nursing standards for eight of eight residents (R5, R10, R9, R8, R2, R6, R7, R3) with siderails. [...]”

Rule cited: “(a) Residents have the right to care and assisted living services that are appropriate based on the resident's needs and according to an up-to-date service plan subject to accepted health care standards.”