Colony Court

MDH’s finding, as written: “No further action required.”

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

Summary: MDH found the licensee failed to develop and execute a written assisted living contract prior to providing assisted living services for six of eight residents (R4, R5, R6, R2, R3, R9) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop and execute a written assisted living contract prior to providing assisted living services for six of eight residents (R4, R5, R6, R2, R3, R9) with records reviewed. [...]”

Rule cited: “(a) An assisted living facility may not offer or provide housing or assisted living services to any individual unless it has executed a written contract with the resident. [...]”

Summary: MDH found the licensee failed to ensure two of six employees providing services (unlicensed personnel (ULP)-H and ULP-O) completed an orientation to assisted living facility licensing requirements and regulations before providing services to residents with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure two of six employees providing services (unlicensed personnel (ULP)-H and ULP-O) completed an orientation to assisted living facility licensing requirements and regulations before providing services to residents with records reviewed. [...]”

Rule cited: “All staff providing and supervising direct services must complete an orientation to assisted living facility licensing requirements and regulations before providing assisted living services to residents. [...]”

Summary: MDH found the licensee failed to ensure staff completed the required amount of dementia care training in the required time frame for one of six employees (unlicensed personnel (ULP)-M), with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure staff completed the required amount of dementia care training in the required time frame for one of six employees (unlicensed personnel (ULP)-M), 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 the registered nurse (RN) completed a reassessment not to exceed 90 days for one of five residents (R6) as required with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the registered nurse (RN) completed a reassessment not to exceed 90 days for one of five residents (R6) as required 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 document treatment administration and follow through for one of four residents (R11) reviewed who received treatments.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to document treatment administration and follow through for one of four residents (R11) reviewed who received treatments. [...]”

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

MDH’s finding, as written: “No further action required.”

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 establish and maintain a tuberculosis (TB) prevention program, based on

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, including completion of a two-step TST (tuberculin skin test) or other evidence of TB screening such as a blood test, for three of four employees, (unlicensed personnel (ULP)-B, ULP-H, and [...]”

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 [...]”

MDH’s finding, as written: “Based on observation, interview, and record review the facility failed to develop an all-hazards risk assessment emergency preparedness program and plan to include Appendix Z required elements. In addition the facility failed to post emergency exit diagrams. This had the potential to affect all residents, 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 provide smoke alarms in all sleeping rooms and failed to provide smoke alarms that are interconnected so that actuation of one alarm causes all alarms in the dwelling unit to actuate as required by MN Statute 144G.45 subd. 2(a)(1).

MDH’s finding, as written: “Based on observation and interview, the licensee failed to provide smoke alarms in all sleeping rooms and failed to provide smoke alarms that are interconnected so that actuation of one alarm causes all alarms in the dwelling unit to actuate as required by MN Statute 144G.45 subd. 2(a)(1). [...]”

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 fire safety and evacuation training at least twice per year after hire to employees and failed to require evacuation drills twice per year per shift with at least one evacuation drill every other month, as required by MN Statute 144G.45 Subd. 2 (c) and (f).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide fire safety and evacuation training at least twice per year after hire to employees and failed to require evacuation drills twice per year per shift with at least one evacuation drill every other month, as required by MN Statute 144G.45 Subd. 2 (c) and (f). This deficient practice had 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 develop and execute a written assisted living contract prior to providing assisted living services for five of five residents (R4, R5, R6, R2, R3) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to develop and execute a written assisted living contract prior to providing assisted living services for five of five residents (R4, R5, R6, R2, R3) with records reviewed. [...]”

Rule cited: “(a) An assisted living facility may not offer or provide housing or assisted living services to any individual unless it has executed a written contract with the resident. [...]”

Summary: MDH found the licensee failed to ensure a background study had been completed prior to providing services for one of four employees (unlicensed personnel (ULP)-B) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure a background study had been completed prior to providing services for one of four employees (unlicensed personnel (ULP)-B) with records reviewed. This resulted in an immediate correction order on November 18, 2021, at approximately 1:30 p.m. [...]”

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 training and competency evaluations of unlicensed personnel (ULP) providing assisted living services were conducted by a registered nurse (RN) for one of two unlicensed personnel (ULP-B) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure training and competency evaluations of unlicensed personnel (ULP) providing assisted living services were conducted by a registered nurse (RN) for one of two unlicensed personnel (ULP-B) with records reviewed. [...]”

Rule cited: “Instructors and competency evaluators must meet the following requirements: (1) training and competency evaluations of unlicensed personnel who only provide assisted living services specified in section 144G.08, subdivision 9, clauses (1) to (5), must be [...]”

Summary: MDH found the licensee failed to ensure training and competency evaluations contained all the required training, prior to providing direct care for one of two unlicensed personnel (ULP-H) with records reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure training and competency evaluations contained all the required training, prior to providing direct care for one of two unlicensed personnel (ULP-H) with records reviewed. [...]”

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) [...]”

MDH’s finding, as written: “Based on observation, interview, and record review the licensee failed to ensure training and competency evaluations contained all the required training for one of two unlicensed personnel (ULP-H) with records reviewed. [...]”

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 four of four employees providing services (licensed assisted living director (LALD)-A, unlicensed personnel (ULP)-B, ULP-H, and registered nurse (RN)-D) completed an orientation to assisted living facility

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure four of four employees providing services (licensed assisted living director (LALD)-A, unlicensed personnel (ULP)-B, ULP-H, and registered nurse (RN)-D) completed an orientation to assisted living facility licensing requirements and regulations before providing services to residents with records reviewed. [...]”

Rule cited: “All staff providing and supervising direct services must complete an orientation to assisted living facility licensing requirements and regulations before providing assisted living services to residents. [...]”

Summary: MDH found the licensee failed to ensure staff completed the required amount of dementia care training in the required time frame for four of four employees (unlicensed personnel (ULP)-B, licensed assisted living director (LALD)-A, registered nurse (RN)-D, and ULP-H), with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure staff completed the required amount of dementia care training in the required time frame for four of four employees (unlicensed personnel (ULP)-B, licensed assisted living director (LALD)-A, registered nurse (RN)-D, and ULP-H), 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 the registered nurse (RN) completed a change in condition assessment for one of one resident (R6).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) completed a change in condition assessment for one of one resident (R6). In addition, the RN failed to conduct a reassessment not to exceed 90 days for one of one resident (R4) as required 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 one of five residents (R6) service plans were 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 five residents (R6) service plans were 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 time sensitive medications were labeled with the date open for three of three residents (R7, R3, R8) and failed to ensure medications were maintained bearing the original prescription label with legible information for two of two residents (R7, R9) with medication storage reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure time sensitive medications were labeled with the date open for three of three residents (R7, R3, R8) and failed to ensure medications were maintained bearing the original prescription label with legible information for two of two residents (R7, R9) with medication storage reviewed. [...]”

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 upon disposition, document in the resident's record the disposition of the medication including the medication's prescription number as applicable for one of one discharged resident (R1) with record review.

MDH’s finding, as written: “Based on interview and record review, the licensee failed upon disposition, document in the resident's record the disposition of the medication including the medication's prescription number as applicable for one of one discharged resident (R1) with record review. [...]”

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 and implement a treatment or therapy management plan to include all required content for four of four

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 four of four residents (R5, R4, R2, R3) with treatment records 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 [...]”

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 record for four of four residents (R5, R4, R2, R3) with treatments and records reviewed.

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 record for four of four residents (R5, R4, R2, R3) with treatments and records reviewed. [...]”

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 document treatment administration for two of four residents (R5 and R4) reviewed who received treatments.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to document treatment administration for two of four residents (R5 and R4) reviewed who received treatments. [...]”

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

Summary: MDH found the licensee failed ensure up-to-date written or electronically recorded orders were maintained for one of four residents (R3) receiving treatments.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed ensure up-to-date written or electronically recorded orders were maintained for one of four residents (R3) receiving treatments. [...]”

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 hazard vulnerability assessment or safety risk of the physical environment specific to the facility, as required by MN Statute 144G.81 Subd.1 (a).

MDH’s finding, as written: “Based on record review and interview, the licensee failed to provide hazard vulnerability assessment or safety risk of the physical environment specific to the facility, as required by MN Statute 144G.81 Subd.1 (a). This had the potential to affect all residents, staff 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 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 [...]”