Colleens Caring Hands

Summary: MDH found the licensee failed to execute a written contract with the required content for three of three residents (R1, R2, R5).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to execute a written contract with the required content for three of three residents (R1, R2, R5). 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 [...]”

Rule cited: “(a) The contract must include in a conspicuous place and manner on the contract the legal name and the health facility identification of the facility. [...]”

Summary: MDH found the licensee failed to ensure the assisted living contract included all required content for three of three residents (R1, R2, R5).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the assisted living contract included all required content for three of three residents (R1, R2, R5). This had the potential to affect all ten residents who received assisted living services. [...]”

Rule cited: “(5) a description of the facility's policies related to medical assistance waivers under chapter 256S and section 256B.49 and the housing support program under chapter 256I, including: (i) whether the facility is enrolled with the commissioner of human [...]”

Summary: MDH found the licensee failed to ensure three of three residents'

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure three of three residents' (R1, R2, R5) assisted living contract included a notice with the required verbiage for the residents to identify a designated representative. This had the potential to affect all ten residents who received services at the facility. [...]”

Rule cited: “(a) Before or at the time of execution of an assisted living contract, an assisted living facility must offer the resident the opportunity to identify a designated representative in writing in the contract and must provide the following verbatim notice on a [...]”

Summary: MDH found the licensee failed to ensure a background study was affiliated with the assisted living license for one of two employees (unlicensed personnel (ULP)-I).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure a background study was affiliated with the assisted living license for one of two employees (unlicensed personnel (ULP)-I). [...]”

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 conduct a comprehensive reassessment for one of one resident (R3) with a change of condition.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to conduct a comprehensive reassessment for one of one resident (R3) with a change of condition. 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) and was issued at an isolated scope (when one or a limited number of residents are affected or one or a limited number of staff are involved, or the situation has [...]”

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 medications were maintained bearing the original prescription label with legible information including the expiration date for time sensitive medications for

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medications were maintained bearing the original prescription label with legible information including the expiration date for time sensitive medications for two of three residents (R7, R9). [...]”

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 provide a hazard vulnerability assessment or safety risk assessment of the physical environment on and around the property.

MDH’s finding, as written: “Based on record review and interview, the licensee failed to provide a hazard vulnerability assessment or safety risk assessment of the physical environment on and around the property. This deficient practice had the ability to affect all staff, residents, and visitors. [...]”

Rule cited: “An assisted living facility with dementia care that has a secured dementia care unit must meet the requirements of section 144G.45 and the following additional requirements: (1) a hazard vulnerability assessment or safety risk must be performed on and around [...]”

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

MDH’s finding, as written: “Based on observation and interview, the licensee failed to post the required information related to the grievance procedure. This had the potential to affect all current 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 email contact information for the individuals who are responsible for handling resident grievances. [...]”

Summary: MDH found the licensee failed to ensure an individual abuse prevention plan (IAPP) was implemented for one of one resident (R3).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure an individual abuse prevention plan (IAPP) was implemented for one of one resident (R3). [...]”

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 post required content to include the 911 emergency number in common areas.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to post required content to include the 911 emergency number in common areas. This had the potential to affect all ten 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 complete a two-step TST (tuberculin skin test) or other evidence of

MDH’s finding, as written: “Based on interview and record review, the licensee failed to complete a two-step TST (tuberculin skin test) or other evidence of tuberculosis (TB) screening such as a blood test for one of two employees (licensed practical nurse (LPN)-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 develop a written emergency

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop a written emergency preparedness plan (EPP) with all the required content. This had the potential to affect all residents, staff, and visitors of the facility. [...]”

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 resident record included a discharge summary for one of one resident (R10) discharged from the facility.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the resident record included a discharge summary for one of one resident (R10) discharged from the facility. [...]”

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 provide interconnected smoke alarms in the individual dwelling units throughout the facility.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to provide interconnected smoke alarms in the individual dwelling units throughout the facility. This deficient condition had the ability to affect all staff and residents. [...]”

Rule cited: “(a) Each assisted living facility must comply with the State Fire Code in Minnesota Rules, chapter 7511, and: (1) for dwellings or sleeping units, as defined in the State Fire Code: (i) provide smoke alarms in each room used for sleeping purposes; (ii) [...]”

Summary: MDH found the licensee failed to provide portable fire extinguishers within 75' of travel distance as required for the facility.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to provide portable fire extinguishers within 75' of travel distance as required for the facility. This deficient condition had the ability to affect all staff and residents. [...]”

Rule cited: “(2) install and maintain portable fire extinguishers in accordance with the State Fire Code; (3) install portable fire extinguishers having a minimum 2-A:10-B:C rating within Group R-3 occupancies, as defined by the State Fire Code, located so that the travel [...]”

Summary: MDH found the licensee failed to maintain the facility's physical environment in a continuous state of good repair and operation regarding the health, safety, and well-being of the residents.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to maintain the facility's physical environment in a continuous state of good repair and operation regarding the health, safety, and well-being of the residents. This had the potential to directly affect all residents, staff, and visitors. [...]”

Rule cited: “(4) keep the physical environment, including walls, floors, ceiling, all furnishings, grounds, systems, and equipment in a continuous state of good repair and operation with regard to the health, safety, comfort, and well-being of the residents in accordance [...]”

Summary: MDH found the licensee failed to maintain the facility's fire safety and evacuation plan with required elements.

MDH’s finding, as written: “Based on record review and interview, the licensee failed to maintain the facility's fire safety and evacuation plan with required elements. This had the potential to directly affect all residents, staff, 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 contract with the required content for three of three residents (R1, R2, R7).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to execute a written contract with the required content for three of three residents (R1, R2, R7). 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 [...]”

Rule cited: “(a) The contract must include in a conspicuous place and manner on the contract the legal name and the health facility identification of the facility. [...]”

Summary: MDH found the licensee failed to ensure the assisted living contract included all required content for three of three residents (R1, R2, R7).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the assisted living contract included all required content for three of three residents (R1, R2, R7). This had the potential to affect all ten residents who received assisted living services. [...]”

Rule cited: “(c) The contract must include: (1) a disclosure of the category of assisted living facility license held by the facility and, if the facility is not an assisted living facility with dementia care, a disclosure that it does not hold an assisted living facility [...]”

Summary: MDH found the licensee failed to ensure the assisted living contract included all required content for three of three residents (R1, R2, R7).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the assisted living contract included all required content for three of three residents (R1, R2, R7). This had the potential to affect all ten residents who received assisted living services. [...]”

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 the assisted living contract included all required content for three of three residents (R1, R2, R7).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the assisted living contract included all required content for three of three residents (R1, R2, R7). This had the potential to affect all ten residents who received assisted living services. [...]”

Rule cited: “(5) a description of the facility's policies related to medical assistance waivers under chapter 256S and section 256B.49 and the housing support program under chapter 256I, including: (i) whether the facility is enrolled with the commissioner of human [...]”

Summary: MDH found the licensee failed to offer the resident the opportunity to identify a designated representative in writing for three of three residents (R1, R2, R7).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to offer the resident the opportunity to identify a designated representative in writing for three of three residents (R1, R2, R7). This had the potential to affect all ten residents. [...]”

Rule cited: “(a) Before or at the time of execution of an assisted living contract, an assisted living facility must offer the resident the opportunity to identify a designated representative in writing in the contract and must provide the following verbatim notice on a [...]”

Summary: MDH found the licensee failed to ensure background studies were conducted prior to staff providing services, for one of nine employees (unlicensed personnel (ULP)-F).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure background studies were conducted prior to staff providing services, for one of nine employees (unlicensed personnel (ULP)-F). [...]”

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 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 one of one unlicensed personnel (ULP-F).

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 one of one unlicensed personnel (ULP-F). [...]”

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 service plans were updated for one of one resident (R1).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure service plans were updated for one of one resident (R1). 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 one or a limited [...]”

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 security and accountability of controlled substances were maintained for two of two residents (R2, R5).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the security and accountability of controlled substances were maintained for two of two residents (R2, R5). [...]”

Rule cited: “(a) This section applies only to assisted living facilities that provide medication management services. [...]”

Summary: MDH found the licensee failed to ensure the registered nurse (RN) conducted a face-to-face medication management reassessment to include all required content for one of one

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) conducted a face-to-face medication management reassessment to include all required content for one of one resident (R1) who received medication management services. [...]”

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 annually review the individualized medication management plan for one of one resident (R1).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to annually review the individualized medication management plan for one of one resident (R1). 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 [...]”

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 ordered for one of one resident (R1) who received medication management services.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medications were administered as ordered for one of one resident (R1) who received medication management services. [...]”

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. [...]”

Summary: MDH found the licensee failed to renew prescriptions at least every 12 months for one of one resident (R1).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to renew prescriptions at least every 12 months for one of one resident (R1). 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 one or a [...]”

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 three of three residents (R2, R4, R5) medications were stored according to manufacturer's recommended temperatures and failed to ensure the medication refrigerator maintained an acceptable temperature.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure three of three residents (R2, R4, R5) medications were stored according to manufacturer's recommended temperatures and failed to ensure the medication refrigerator maintained an acceptable temperature. [...]”

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 medications were maintained bearing the original prescription label with legible information including the expiration date for time sensitive medications for two of two residents (R3, R9) and failed to monitor for expired medications for one of five residents (R3).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medications were maintained bearing the original prescription label with legible information including the expiration date for time sensitive medications for two of two residents (R3, R9) and failed to monitor for expired medications for one of five residents (R3). [...]”

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 and implement a treatment or therapy management plan to include all required content for one of one resident (R1) who had treatments managed by the facility.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to develop and implement a treatment or therapy management plan to include all required content for one of one resident (R1) who had treatments managed by the facility. [...]”

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 treatment or therapy services were documented for one of one resident (R1).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure treatment or therapy services were documented for one of one resident (R1). 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 one [...]”

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 renew treatment orders at least every 12 months for one of one resident (R1).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to renew treatment orders at least every 12 months for one of one resident (R1). 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 one or a [...]”

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 provide a hazard vulnerability assessment or safety risk assessment of the physical environment on and around the property.

MDH’s finding, as written: “Based on record review and interview, the licensee failed to provide a hazard vulnerability assessment or safety risk assessment of the physical environment on and around the property. This deficient practice had the ability to affect all staff, residents, and visitors. [...]”

Rule cited: “An assisted living facility with dementia care that has a secured dementia care unit must meet the requirements of section 144G.45 and the following additional requirements: (1) a hazard vulnerability assessment or safety risk must be performed on and around [...]”

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 two of two residents (R1, R2) with a hospital bedrail.

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 two of two residents (R1, R2) with a hospital bedrail. In addition, the licensee failed to safely store strong chemicals which had the potential to affect all 10 residents, staff, and visitors; and failed to safety store oxygen for one of one resident (R1). [...]”

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 two of two residents' (R7, R8) privacy was respected with regards to electronic monitoring.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure two of two residents' (R7, R8) privacy was respected with regards to electronic monitoring. [...]”

Rule cited: “(a) Residents have the right to consideration of their privacy, individuality, and cultural identity as related to their social, religious, and psychological well-being. [...]”

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to obtain consent for electronic monitoring for two of two residents (R7, R8) who had an electronic monitor device in place. [...]”

Rule cited: “(b) Facilities must make the notification and consent form available to the residents and inform residents of their option to conduct electronic monitoring of their rooms or private living unit.”