Clgv Assisted Living

Summary: MDH found the licensee failed to ensure the employee record contained the required content to include an

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the employee record contained the required content to include an annual performance evaluation for one of two employees (clinical nurse supervisor (CNS) -A). [...]”

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

Summary: MDH found the licensee failed to ensure employee tuberculosis (TB) symptom and history screenings were completed and documented for one of two employees (unlicensed personnel (ULP)-B).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure employee tuberculosis (TB) symptom and history screenings were completed and documented for one of two employees (unlicensed personnel (ULP)-B). [...]”

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 have a written emergency preparedness plan (EPP) with all the required content.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to have a written emergency preparedness plan (EPP) with all the required content. This had the potential to affect all residents receiving services under the assisted living license, staff, and 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 [...]”

Summary: MDH found the licensee failed to ensure the physical environment of the facility was maintained in compliance with the requirements of Minnesota Statute 144G.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the physical environment of the facility was maintained in compliance with the requirements of Minnesota Statute 144G. [...]”

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

Summary: MDH found the licensee failed to ensure a background study was affiliated to the licensee's health facility identification number (HFID) as required for one of two employees (unlicensed personnel (ULP)-E).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure a background study was affiliated to the licensee's health facility identification number (HFID) as required for one of two employees (unlicensed personnel (ULP)-E). [...]”

Rule cited: “(a) Employees, contractors, and regularly scheduled volunteers of the facility are subject to the background study required by section 144.057 and may be disqualified under chapter 245C. [...]”

Summary: MDH found the licensee failed to ensure employees received orientation to include all required content for two of two employees (clinical nurse supervisor (CNS) -A, unlicensed personnel (ULP)-B).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure employees received orientation to include all required content for two of two employees (clinical nurse supervisor (CNS) -A, unlicensed personnel (ULP)-B). [...]”

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 [...]”

Summary: MDH found the licensee failed to ensure employees received at least eight hours of annual training for each 12 months of employment for two of two employees (clinical nurse supervisor (CNS) -A, unlicensed personnel (ULP)-B).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure employees received at least eight hours of annual training for each 12 months of employment for two of two employees (clinical nurse supervisor (CNS) -A, unlicensed personnel (ULP)-B). [...]”

Rule cited: “(a) All staff that perform direct services must complete at least eight hours of annual training for each 12 months of employment. [...]”

Summary: MDH found the licensee failed to ensure direct care staff received the required two hours of initial training on mental illness and de-escalation topics for two of two employees (clinical nurse supervisor (CNS-A), unlicensed personnel (ULP)-B).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure direct care staff received the required two hours of initial training on mental illness and de-escalation topics for two of two employees (clinical nurse supervisor (CNS-A), unlicensed personnel (ULP)-B). This had the potential to affect all residents and staff. [...]”

Rule cited: “(a) All assisted living facilities must meet the following dementia care, mental illness, and de-escalation training requirements: (1) supervisors of direct-care staff must have at least eight hours of initial training on dementia topics specified under [...]”

Summary: MDH found the licensee failed to ensure a registered nurse (RN) conducted ongoing resident monitoring and reassessment 14 calendar days from the initial assessment, and not to exceed 90 calendar days from the previous assessment for two of three residents (R2, R3).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure a registered nurse (RN) conducted ongoing resident monitoring and reassessment 14 calendar days from the initial assessment, and not to exceed 90 calendar days from the previous assessment for two of three residents (R2, R3). [...]”

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

Summary: MDH found the licensee failed to ensure that all services required by the current service plan were documented as provided to each resident according to the service plan for three of three residents (R1, R2, R3).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure that all services required by the current service plan were documented as provided to each resident according to the service plan for three of three residents (R1, R2, R3). [...]”

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 the required content for three of three residents (R1, R2, R3).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the service plan included all the required content for three of three residents (R1, R2, 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 a widespread scope (when problems are pervasive or represent a systemic [...]”

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 develop and maintain a current

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop and maintain a current individualized medication management record to include all required content for two of three residents (R2, R3) and failed to included medication management services in a resident's service plan for one of three residents (R3). [...]”

Rule cited: “(a) For each resident receiving medication management services, a registered nurse, advanced practice registered nurse, or qualified staff delegated the task by a registered nurse must prepare and include in the service plan a written statement of the [...]”

Summary: MDH found the licensee failed to ensure medications were administered as prescribed for two of four residents (R6, R7).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medications were administered as prescribed for two of four residents (R6, R7). 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 a pattern scope (when more than a limited number of residents are affected, [...]”

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 failed to ensure medications were securely stored for one of four residents (R2) who had medication management services. [...]”

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 provide documentation in the resident's record regarding the disposition of medication to include quantity and names of staff and other individuals involved in the disposition of medications for one of one discharged resident (R5).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide documentation in the resident's record regarding the disposition of medication to include quantity and names of staff and other individuals involved in the disposition of medications for one of one discharged resident (R5). [...]”

Rule cited: “(a) Any current medications being managed by the assisted living facility must be provided to the resident when the resident's service plan ends or medication management services are no longer part of the service plan. [...]”

Summary: MDH found the licensee failed to develop, implement, and include on the service plan an individualized treatment management plan (ITMP) to include all required content for two of three residents (R2, R3) who had a treatment.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop, implement, and include on the service plan an individualized treatment management plan (ITMP) to include all required content for two of three residents (R2, R3) who had a treatment. [...]”

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 treatments were documented as administered, or documented as to why they were not administered, for two of three residents (R2, R3) who had a treatment.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure treatments were documented as administered, or documented as to why they were not administered, for two of three residents (R2, R3) who had a treatment. [...]”

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

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 a suitable and up-to-date plan, and subject to acceptable health care and medical, or nursing standards for three of three residents with hospital bed rails (R1, R2, R4). [...]”

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.”

Summary: MDH found the licensee failed to ensure residents received assisted living services from staff who

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure residents received assisted living services from staff who were trained and competent when an unlicensed personnel (ULP) set up medications for later administration for two of four residents (R6, R7). [...]”

Rule cited: “(b) Residents have the right to receive health care and other assisted living services with continuity from people who are properly trained and competent to perform their duties and in sufficient numbers to adequately provide the services agreed to in the [...]”