Claddagh Senior Living

Summary: MDH found the licensee failed to post information related to the grievance procedure.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to post information related to the grievance procedure. This had the potential to affect all residents, staff, and visitors. [...]”

Rule cited: “All facilities must post in a conspicuous place information about the facilities' grievance procedure, and the name, telephone number, and e-mail contact information for the individuals who are responsible for handling resident grievances. [...]”

Summary: MDH found the facility failed to ensure development of an individual abuse prevention plan with the required content for one of three residents (R1).

MDH’s finding, as written: “Based on interview and record review, the facility failed to ensure development of an individual abuse prevention plan with the required content for one of three residents (R1). [...]”

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 support protection and safety by not posting information and phone numbers for reporting to the Minnesota Adult Abuse Reporting Center (MAARC) and failed to post the 911 emergency number in common areas and near telephones provided by the assisted living facility.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to support protection and safety by not posting information and phone numbers for reporting to the Minnesota Adult Abuse Reporting Center (MAARC) and failed to post the 911 emergency number in common areas and near telephones provided by the assisted living facility. This had the potential to affect all 37 residents, staff, and visitors. [...]”

Rule cited: “The facility shall support protection and safety through access to the state's systems for reporting suspected criminal activity and suspected vulnerable adult maltreatment by: (1) posting the 911 emergency number in common areas and near telephones provided [...]”

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) which included documentation of a completed health history and symptom screening for one of two employees (unlicensed personnel (ULP-F).

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) which included documentation of a completed health history and symptom screening for one of two employees (unlicensed personnel (ULP-F). [...]”

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 emergency exit diagrams were posted on each floor.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure emergency exit diagrams were posted on each floor. This had the potential to affect all 37 residents, staff and any visitors. [...]”

Rule cited: “(a) The facility must meet the following requirements: (1) have a written emergency disaster plan that contains a plan for evacuation, addresses elements of sheltering in place, identifies temporary relocation sites, and details staff assignments in the event [...]”

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee's registered nurse (RN) failed to ensure documentation of weekly wound condition and measurements for one of one residents (R1); failed to document the services provided for one of three residents (R3) and failed to ensure the resident record included a discharge summary with the required content and provided information to the receiving facility as required for two of two discharged residents (R4, R5). [...]”

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 facility failed have detailed fire safety and evacuation plans and associated confirming documentation.

MDH’s finding, as written: “Based on observation, and staff interview, the facility failed have detailed fire safety and evacuation plans and associated confirming documentation. This deficient condition has the ability to affect all staff and residents. [...]”

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

Summary: MDH found the licensee failed to ensure the assisted living contract did not include language waiving the facility's liability for health, safety, or personal

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the assisted living contract did not include language waiving the facility's liability for health, safety, or personal property of a resident. This had the potential to affect all 37 residents. [...]”

Rule cited: “The contract must not include a waiver of facility liability for the health and safety or personal property of a resident. [...]”

Summary: MDH found the licensee failed to provide a written notice with

MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide a written notice with required content for an emergency relocation for four of four residents (R1, R2, R3, R4) and failed to notify the Office of Ombudsman for Long-Term Care of the emergency relocation for three of four residents (R1, R2, R4). [...]”

Rule cited: “(a) A facility may remove a resident from the facility in an emergency if necessary due to a resident's urgent medical needs or an imminent risk the resident poses to the health or safety of another facility resident or facility staff member. [...]”

Summary: MDH found the licensee failed to ensure training and competency evaluations for the required topics for two of two unlicensed personnel (ULP-F, ULP-D).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure training and competency evaluations for the required topics for two of two unlicensed personnel (ULP-F, ULP-D). [...]”

Rule cited: “(a) Training and competency evaluations for all unlicensed personnel must include the following: (1) documentation requirements for all services provided; (2) reports of changes in the resident's condition to the supervisor designated by the facility; (3) [...]”

Summary: MDH found the licensee failed to ensure competency training and evaluations were completed as required prior to providing direct care for two of two unlicensed personnel (ULP-D, ULP-F).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure competency training and evaluations were completed as required prior to providing direct care for two of two unlicensed personnel (ULP-D, ULP-F). [...]”

Rule cited: “(b) In addition to paragraph (a), training and competency evaluation for unlicensed personnel providing assisted living services must include: (1) observing, reporting, and documenting resident status; (2) basic knowledge of body functioning and changes in [...]”

Summary: MDH found the licensee failed to ensure the registered nurse (RN) conducted training and competency evaluations for two of two unlicensed personnel (ULP-F, ULP-D) who performed delegated tasks.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) conducted training and competency evaluations for two of two unlicensed personnel (ULP-F, ULP-D) who performed delegated tasks. [...]”

Rule cited: “(b) When the registered nurse or licensed health professional delegates tasks to unlicensed personnel, that person must ensure that prior to the delegation the unlicensed personnel is trained in the proper methods to perform the tasks or procedures for each [...]”

Summary: MDH found the licensee failed to ensure direct supervision of staff performing delegated tasks was provided within 30 calendar days after the date on which the individual begins working for the licensee for two of two unlicensed personnel (ULP-F, ULP-D).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure direct supervision of staff performing delegated tasks was provided within 30 calendar days after the date on which the individual begins working for the licensee for two of two unlicensed personnel (ULP-F, ULP-D). [...]”

Rule cited: “(a) Staff who perform delegated nursing or therapy tasks must be supervised by an appropriate licensed health professional or a registered nurse according to the assisted living facility's policy where the services are being provided to verify that the work [...]”

Summary: MDH found the licensee failed to ensure staff providing services completed an orientation to assisted living facility licensing requirements and regulations before providing services for two of two unlicensed personnel (ULP-F and ULP-D).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure staff providing services completed an orientation to assisted living facility licensing requirements and regulations before providing services for two of two unlicensed personnel (ULP-F and ULP-D). [...]”

Rule cited: “(a) The orientation must contain the following topics: (1) an overview of this chapter; (2) an introduction and review of the facility's policies and procedures related to the provision of assisted living services by the individual staff person; (3) handling [...]”

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure direct care staff completed all of the the required topics for dementia training and the required amount of dementia care training in the required time frame for one of two employees (unlicensed personnel (ULP)-D). [...]”

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 the registered nurse (RN) had completed and/or documented a comprehensive assessment for change in condition (wounds, emergency room (ER) visits, readmission following hospitalization, fall) for three of three residents (R1, R2, R3) and failed to ensure the RN documented comprehensive monitoring and review reassessment for 90 days as required for for three of three residents (R1, R2, R3).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) had completed and/or documented a comprehensive assessment for change in condition (wounds, emergency room (ER) visits, readmission following hospitalization, fall) for three of three residents (R1, R2, R3) and failed to ensure the RN documented comprehensive monitoring and review reassessment for 90 days as required for for three of three residents (R1, R2, R3). [...]”

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 one of three resident's (R3) service plan was revised to reflect the current services provided.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure one of three resident's (R3) service plan was revised to reflect the current services provided. [...]”

Rule cited: “(a) No later than 14 calendar days after the date that services are first provided, an assisted living facility shall finalize a current written service plan. [...]”

Summary: MDH found the licensee failed to ensure the service plan included all required content for three of three residents (R1, R2, R3).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure the service plan included all required content for three of three residents (R1, R2, R3). [...]”

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 reassessment of medication management services at a minimum annually included all required content for three of three residents (R1, R2, R3).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure reassessment of medication management services at a minimum annually included all required content for three of three residents (R1, R2, R3). [...]”

Rule cited: “The assisted living facility must monitor and reassess the resident's medication management services as needed under subdivision 2 when the resident presents with symptoms or other issues that may be medication-related and, at a minimum, annually.”

Summary: MDH found the licensee failed to ensure an individualized medication management plan to include all required content for three of three residents (R1, R2, R3).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure an individualized medication management plan to include all required content for three of three residents (R1, R2, R3). [...]”

Rule cited: “(a) For each resident receiving medication management services, the assisted living facility must prepare and include in the service plan a written statement of the medication management services that will be provided to the resident. [...]”

Summary: MDH found the licensee failed to ensure medications were administered as per prescriber orders; failed to transcribe a medication order as written and failed to document dosage of a medication for one of three residents (R3).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medications were administered as per prescriber orders; failed to transcribe a medication order as written and failed to document dosage of a medication for one of three residents (R3). [...]”

Rule cited: “Each medication administered by the assisted living facility staff must be documented in the resident's record. The documentation must include the signature and title of the person who administered the medication. [...]”

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee's registered nurse (RN) failed to develop written procedures for medication management services during unplanned times away from home and failed to ensure training and competency evaluations for preparing medications for resident unplanned times away were completed as required for two of two unlicensed personnel (ULP-F, ULP-D). [...]”

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 licensee failed to ensure the medication refrigerator maintained an acceptable temperature to ensure the medications were stored according to manufacturer's recommendations in one of three refrigerators (2nd floor).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the medication refrigerator maintained an acceptable temperature to ensure the medications were stored according to manufacturer's recommendations in one of three refrigerators (2nd floor). Additionally, the licensee failed to ensure medications were securely stored for one of three (R3) residents. [...]”

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 label time sensitive medications with an opened date for two of two residents (R1, R6) and failed to ensure labels on medication containers (house supply medicine) were legible.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to label time sensitive medications with an opened date for two of two residents (R1, R6) and failed to ensure labels on medication containers (house supply medicine) were legible. [...]”

Rule cited: “A prescription drug, prior to being set up for immediate or later administration, must be kept in the original container in which it was dispensed by the pharmacy bearing the original prescription label with legible information including the expiration or [...]”

Summary: MDH found the licensee failed to develop an individualized treatment management plan to include all required content for two of three residents (R1, R3).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to develop an individualized treatment management plan to include all required content for two of three residents (R1, R3). [...]”

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 [...]”

Summary: MDH found the licensee failed to ensure the registered nurse (RN) specified, in writing, specific instructions for each resident and documented those instructions in the resident's records for one of three residents (R3); had instructed the unlicensed personnel (ULP) in the proper methods with respect to each resident and two of two unlicensed personnel (ULP-F, ULP-D) had demonstrated the ability to competently follow the procedures.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) specified, in writing, specific instructions for each resident and documented those instructions in the resident's records for one of three residents (R3); had instructed the unlicensed personnel (ULP) in the proper methods with respect to each resident and two of two unlicensed personnel (ULP-F, ULP-D) had demonstrated the ability to competently follow the procedures. [...]”

Rule cited: “Ordered or prescribed treatments or therapies must be administered by a nurse, physician, or other licensed health professional authorized to perform the treatment or therapy, or may be delegated or assigned to unlicensed personnel by the licensed health [...]”

Summary: MDH found the licensee failed to ensure documentation of treatments administered as required for two of three residents (R2, R3).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure documentation of treatments administered as required for two of three residents (R2, R3). [...]”

Rule cited: “Each treatment or therapy administered by an assisted living facility must be in the resident record. [...]”

Summary: MDH found the licensee failed to ensure a prescriber's order for treatment or therapy for one of three residents (R3).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure a prescriber's order for treatment or therapy for one of three residents (R3). This practice resulted in a level two violation (a violation that did not harm a resident's health or safety but had the potential to have harmed a resident's health or safety, but was not likely to cause serious injury, impairment, or death), and was issued at an isolated scope (when one or a limited number of residents are affected or [...]”

Rule cited: “There must be an up-to-date written or electronically recorded order from an authorized prescriber for all treatments and therapies. [...]”

Summary: MDH found the licensee failed to ensure policies and procedures for assisted living with dementia care (ALFDC) were provided to residents and the residents' legal and designated representatives at the time of move in for three of three residents (R1, R2, R3).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure policies and procedures for assisted living with dementia care (ALFDC) were provided to residents and the residents' legal and designated representatives at the time of move in for three of three residents (R1, R2, R3). [...]”

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 designate a qualified person to oversee staff training in the care of individuals with dementia.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to designate a qualified person to oversee staff training in the care of individuals with dementia. This had the potential to affect all residents, staff, and visitors. [...]”

Rule cited: “Persons providing or overseeing staff training must have experience and knowledge in the care of individuals with dementia, including: (1) two years of work experience related to Alzheimer's disease or other dementias, or in health care, gerontology, or [...]”

Summary: MDH found the licensee failed to ensure evaluation for activities and an individualized activity plan

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure evaluation for activities and an individualized activity plan was developed for one of three residents (R3). [...]”

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 behavioral symptoms were identified and were addressed on the care plan for one of three residents (R3).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure behavioral symptoms were identified and were addressed on the care plan for one of three residents (R3). [...]”

Rule cited: “(e) Behavioral symptoms that negatively impact the resident and others in the assisted living facility with dementia care must be evaluated and included on the service or care plan. [...]”