Cornerstone Care

Summary: MDH found the licensee failed to ensure the employee record

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the employee record contained the required content for one of three employees (unlicensed personnel (ULP)-D). [...]”

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 two of four employees (unlicensed personnel (ULP-C, ULP-D).

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 two of four employees (unlicensed personnel (ULP-C, ULP-D). [...]”

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 licensee failed to have a written emergency preparedness (EP) plan with all of the required content defined in Appendix Z and failed to post an emergency preparedness plan prominently. In addition, the licensee lacked a missing resident plan with the required content and failed to evaluate/revise its plan at least quarterly. [...]”

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 an inspected and approved septic system.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to provide an inspected and approved septic system. 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 the potential to affect a large portion or all the residents). [...]”

Rule cited: “The following are required for all assisted living facilities: (1) public utilities must be available, and working or inspected and approved water and septic systems must be in place; (2) the location must be publicly accessible to fire department services [...]”

Summary: MDH found the licensee failed to comply with the provisions of the Minnesota State Fire Code and failed to provide smoke alarms that are interconnected throughout the facility so that actuation of one alarm will cause all alarms in the dwelling to actuate.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to comply with the provisions of the Minnesota State Fire Code and failed to provide smoke alarms that are interconnected throughout the facility so that actuation of one alarm will cause all alarms in the dwelling to actuate. 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 current tags and documentation of annual inspections of all the fire extinguishers and was unable to provide an adequately rated portable fire extinguishers as required for the facility.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to provide current tags and documentation of annual inspections of all the fire extinguishers and was unable to provide an adequately rated portable fire extinguishers 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 develop a fire safety and evacuation plan with required elements.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to develop a fire safety and evacuation plan with required elements. Also, failed to provide required employee training and drills on fire safety and evacuation as well as training to the residents who are capable. 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 provide proper door locking arrangements that did not constitute a distinct hazard to life.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to provide proper door locking arrangements that did not constitute a distinct hazard to life. This had the potential to directly affect all residents and staff. [...]”

Rule cited: “(g) Existing construction or elements, including assisted living facilities that were registered as housing with services establishments under chapter 144D prior to August 1, 2021, shall be permitted to continue in use provided such use does not constitute a [...]”

Summary: MDH found the licensee failed to execute a written assisted living contract with the required content for three of three residents (R1, R2, R4).

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 three of three residents (R1, R2, R4). This had the potential to affect all residents residing in the facility. [...]”

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 execute a written contract with the required content for three of three residents (R1, R2, R4).

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, R4). This had the potential to affect all residents residing in the facility. [...]”

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 a registered nurse (RN) conducted supervision of unlicensed staff performing delegated services as required,

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure a registered nurse (RN) conducted supervision of unlicensed staff performing delegated services as required, for two of three employees (unlicensed personnel (ULP)-B, 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 provide in written or electronic form to residents, families, or other persons who request it, a description of the dementia care training program, the categories of employees trained, the frequency of training, and the basic topics covered.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide in written or electronic form to residents, families, or other persons who request it, a description of the dementia care training program, the categories of employees trained, the frequency of training, and the basic topics covered. This had the potential to affect all residents. [...]”

Rule cited: “(5) new employees may satisfy the initial training requirements by producing written proof of previously completed required training within the past 18 months. [...]”

Summary: MDH found the licensee failed to ensure the registered nurse (RN) completed resident reassessment and monitoring no more than 14 calendar days after initiation of services for one of one resident (R2), and within 90 calendar days from the last date of the assessment using the uniform assessment tool as required, for three of three residents (R1, R2, R4).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the registered nurse (RN) completed resident reassessment and monitoring no more than 14 calendar days after initiation of services for one of one resident (R2), and within 90 calendar days from the last date of the assessment using the uniform assessment tool as required, for three of three residents (R1, R2, R4). [...]”

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 a signature or other authentication by the resident and the facility to document agreement on the services to be provided, for four of four residents (R1, R2, R4, R5).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the service plan included a signature or other authentication by the resident and the facility to document agreement on the services to be provided, for four of four residents (R1, R2, R4, R5). [...]”

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 the required content for four of four residents (R1, R2, R4, R5).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the service plan included the required content for four of four residents (R1, R2, R4, R5). 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 ensure the registered nurse (RN) conducted an individualized medication assessment with the required content for one of one resident (R2).

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 one of one resident (R2). [...]”

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) conducted a face-to-face medication management reassessment to include all required content for two of two residents (R1, R4) who received medication management services.

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 two of two residents (R1, R4) 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 develop an individualized medication management plan prior to providing medication management services, and with the required content, for three of three residents (R1, R2, R4).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to develop an individualized medication management plan prior to providing medication management services, and with the required content, for three of three residents (R1, R2, R4). [...]”

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 according to manufacturer's guidelines and failed to verify accuracy of prescriber orders when transcribing orders for

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medications were administered according to manufacturer's guidelines and failed to verify accuracy of prescriber orders when transcribing orders for one of two residents (R4). [...]”

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 ensure written or electronically recorded prescriptions were obtained for one of four residents (R2).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure written or electronically recorded prescriptions were obtained for one of four residents (R2). 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 [...]”

Rule cited: “There must be a current written or electronically recorded prescription as defined in section 151.01, subdivision 16a, for all prescribed medications that the assisted living facility is managing for the resident.”

Summary: MDH found the licensee failed to ensure refrigerated medications were maintained at manufacturer recommended temperatures by failing to monitor medication refrigerator temperatures for one of one medication refrigerator.

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 medication refrigerator temperatures for one of one medication refrigerator. [...]”

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 develop and implement procedures for loss and spillage of all controlled substances defined in Minnesota Rules part 6800.4220.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop and implement procedures for loss and spillage of all controlled substances defined in Minnesota Rules part 6800.4220. [...]”

Rule cited: “(a) Assisted living facilities providing medication management must develop and implement procedures for loss or spillage of all controlled substances defined in Minnesota Rules, part 6800.4220. [...]”

Summary: MDH found the licensee failed to provide care and services according to the acceptable health care medical or nursing standards for medication set up by unlicensed personnel (ULP) for other ULP's to adminiiter at a later time.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to provide care and services according to the acceptable health care medical or nursing standards for medication set up by unlicensed personnel (ULP) for other ULP's to adminiiter at a later time. [...]”

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.”