Cottage Grove Wp II

Survey completed April 19, 2023: 7 correction orders

• Tag 480: 144G.41 Subd 1 (13) (i) (B) Minimum requirements Level 2, widespread scope, scope/level letter F · correction period: Twenty-one (21) days
  Details

  Summary: MDH found the licensee failed to ensure food was prepared and served according to the Minnesota Food Code.

  MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure food was prepared and served according to the Minnesota Food Code. 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 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 [...]”

  Rule cited: “(13) offer to provide or make available at least the following services to residents: (B) food must be prepared and served according to the Minnesota Food Code, Minnesota Rules, chapter 4626; and”

• Tag 800: 144G.45 Subd. 2 (a) (4) Fire protection and physical environment Level 2, widespread scope, scope/level letter F · correction period: Twenty-one (21) days
  Details

  Summary: MDH found the licensee failed to maintain the physical environment of the facility in a continuous state of good repair and operation.

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

  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 [...]”

• Tag 1060: 144G.52 Subd. 9 Emergency relocation Level 2, isolated scope, scope/level letter C · correction period: Twenty-one (21) days
  Details

  Summary: MDH found the licensee failed to provide a written notice with the required content for an emergency relocation to the resident, legal representative, or designated representative for one of one resident (R4) with an emergency relocation.

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide a written notice with the required content for an emergency relocation to the resident, legal representative, or designated representative for one of one resident (R4) with an emergency relocation. [...]”

  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. [...]”

• Tag 1890: 144G.71 Subd. 20 Prescription drugs Level 2, widespread scope, scope/level letter F · correction period: Seven (7) days
  Details

  Summary: MDH found the licensee failed to ensure an opened date was placed on time sensitive medications stored in a secured medication cart which the licensee managed medications for residents.

  MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure an opened date was placed on time sensitive medications stored in a secured medication cart which the licensee managed medications for residents. [...]”

  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 [...]”

• Tag 1960: 144G.72 Subd. 5 Documentation of administration of treatments Level 2, isolated scope, scope/level letter D · correction period: Seven (7) days
  Details

  Summary: MDH found the licensee failed to accurately transcribe provider's orders for one of two residents (R3) who had treatment orders.

  MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to accurately transcribe provider's orders for one of two residents (R3) who had treatment orders. [...]”

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

• Tag 2040: 144G.81 Subdivision 1 Fire protection and physical environment Level 2, widespread scope, scope/level letter F · correction period: Twenty-one (21) days
  Details

  Summary: MDH found the licensee failed to develop a site-specific safety risk assessment plan to identify hazard vulnerabilities and mitigations on and around the property to protect memory care residents from harm.

  MDH’s finding, as written: “Based on the document review and interview, the licensee failed to develop a site-specific safety risk assessment plan to identify hazard vulnerabilities and mitigations on and around the property to protect memory care residents from harm. This has the potential to directly affect staff, visitors, and all memory care residents receiving assisted living services. [...]”

  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 [...]”

• Tag 2350: 144G.91 Subd. 7 Courteous treatment Level 1, widespread scope, scope/level letter C · correction period: Twenty-one (21) days
  Details

  Summary: MDH found the licensee failed to treat residents with courtesy and respect when serving breakfast to residents.

  MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to treat residents with courtesy and respect when serving breakfast to residents. This had the potential to affect all residents. [...]”

  Rule cited: “Residents have the right to be treated with courtesy and respect, and to have the resident's property treated with respect”

From MDH’s letter: no immediate fines.

Allegation, as written: “The facility neglected the resident when the facility did not administer medication(s) to the resident as ordered and overdosed the resident.”

“The Minnesota Department of Health determined neglect was not substantiated.”

Summary: MDH looked into an allegation and found: neglect not substantiated.

MDH’s conclusion, as written: “The Minnesota Department of Health determined neglect was not substantiated. Although it is true the resident required hospitalization and treatment for narcotic (Fentanyl) overdose, the facility followed medical providers orders. When the resident became nonresponsive with shallow breathing, the facility identified this and sought emergency care appropriately. During the course of the investigation, an allegation of abuse arose but it was inconclusive because there was insufficient evidence to demonstrate abuse occurred.”

Action taken by facility: “The facility reviewed its policy and procedures regarding administration of Fentanyl via patches.”

Action taken by MDH: “No further action taken at this time.”

Survey completed May 22, 2024: no correction orders issued.

Allegation, as written: “The facility neglected the resident when staff failed to assess and monitor the resident with a change in condition and failed to provide care as directed by the resident's service plan. The resident was hospitalized multiple times within a two-month period for pneumonia, urinary tract infection (UTI), and infected wounds. In addition, staff chemically restrained the resident when medication was administered to "keep her quiet".”

“The Minnesota Department of Health determined neglect was inconclusive.”

Summary: MDH looked into an allegation and found: neglect inconclusive.

MDH’s conclusion, as written: “The Minnesota Department of Health determined neglect was inconclusive. Although the resident developed pneumonia and wounds that required hospitalization, it is unable to be determined if the action or inaction of facility staff was the direct cause of the resident's condition or progression of her wounds. Wound care was provided as ordered and the facility made several attempts to arrange for an outside agency to provide additional wound care and treatment. In addition, although the resident's pain management plan wasn't followed the An equal opportunity employer. resident was administered ordered as-needed pain medication. There was not enough evidence to support that staff chemically restrained the resident.”

Action taken by facility: “The facility communicated with the primary care team, outside wound care agency, and family throughout the time the wounds were being treated.”

Action taken by MDH: “The facility was found to be in noncompliance.”

Survey completed July 14, 2023: no correction orders issued.

Allegation, as written: “The facility neglected the resident when staff failed to reposition and provide incontinent care in accordance with the resident's service plan. The resident developed bed sores and was hospitalized for wound care. In addition, the facility neglected the resident when staff failed to discontinue a medication in accordance with physician orders.”

“The Minnesota Department of Health determined neglect was inconclusive.”

Summary: MDH looked into an allegation and found: neglect inconclusive.

MDH’s conclusion, as written: “The Minnesota Department of Health determined neglect was inconclusive. Although the resident developed wounds that required skilled nursing care, it is unable to be determined if the action or inaction of facility staff was the direct cause of the resident's wounds. Wound care was provided as ordered, and the facility made attempts for additional evaluations and treatments to be provided for the resident's wounds. In addition, although a medication error occurred, there was no evidence that the resident experienced negative or adverse effects as a result of the error. An equal opportunity employer.”

Action taken by facility: “The facility requested consult for skilled wound care and communicated with the resident's primary care team, outside agency staff, and family regarding the wound care treatments.”

Action taken by MDH: “The facility was found to be in noncompliance.”

Survey completed June 28, 2023: 2 correction orders

• Tag 1620: 144G.70 Subd. 2 (c-e) Initial reviews, assessments, and monitoring Level 2, isolated scope, scope/level letter D · correction period: Twenty-one (21) days
  Details

  MDH’s finding, as written: “Based on interview and record review the licensee failed to ensure resident 14-day reassessments and on-going monitoring was completed as required for one of one resident (R1). [...]”

  Rule cited: “(c) Resident reassessment and monitoring must be conducted no more than 14 calendar days after initiation of services. [...]”

• Tag 1760: 144G.71 Subd. 8 Documentation of administration of medication Level 2, isolated scope, scope/level letter D · correction period: Seven (7) days
  Details

  MDH’s finding, as written: “Based on interview and document review facility staff failed to discontinue medication as prescribed for one of one resident (R1) reviewed for medication errors. R1 continued to receive scheduled doses of trazodone (an antidepressant) for an additional five days after a physician's order for a change in the frequency of administration was received. [...]”

  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. [...]”

Allegation, as written: “The facility neglected the resident when staff failed to monitor and report poor oral intake and a change in condition, resulting in the resident's admission to the hospital's intensive care unit (ICU) for dehydration and required further treatment.”

“The Minnesota Department of Health determined neglect was inconclusive.”

Summary: MDH looked into an allegation and found: neglect inconclusive.

MDH’s conclusion, as written: “The Minnesota Department of Health determined neglect was inconclusive. Although the resident was hospitalized and required advanced medical treatment, the direct cause of the decline in the resident's condition could not be determined. The status of the resident's condition throughout her stay at the facility was not consistently documented and it could not be established if a lack of monitoring or a delay in reporting a change in condition, led to the resident's decline in status. An equal opportunity employer.”

Action taken by facility: “The facility alerted the resident's family when a change in condition was observed. Emergency medical services were contacted, who assumed care and transported the resident to the hospital for further treatment.”

Action taken by MDH: “The facility was found to be in noncompliance.”

Survey completed May 19, 2023: no correction orders issued.

Allegation, as written: “Three facility staff/alleged perpetrators (AP#1, AP#2, AP#3) restrained and physically abused the resident, in retaliation to the resident being uncooperative, when facility staff administered oral medication while other facility staff held the resident down.”

“The Minnesota Department of Health determined neglect was inconclusive.”

Summary: MDH looked into an allegation and found: neglect inconclusive.

MDH’s conclusion, as written: “The Minnesota Department of Health determined neglect was inconclusive. Due to conflicting accounts of the incident, it is unable to be determined if maltreatment occurred.”

Action taken by facility: “The unlicensed facility staff reported the incident to the nurse for further review. The facility conducted an internal review of events, including an interview with the resident. The resident was transferred to another facility for care.”

Action taken by MDH: “The facility was found to be in noncompliance.”

Survey completed May 31, 2023: 4 correction orders

• Tag 2310: 144G.91 Subd. 4 (a) Appropriate care and services Level 2, isolated scope, scope/level letter D · correction period: Seven (7) days
  Details

  MDH’s finding, as written: “Based on interview and record review the licensee failed to provide the care and services according to the acceptable health care medical or nursing standards of 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.”

• Tag 2330: 144G.91 Subd. 5 Refusal of care or services Level 2, isolated scope, scope/level letter D · correction period: Seven (7) days
  Details

  MDH’s finding, as written: “Based on interview and record review the licensee failed to provide care and services according to the acceptable health care medical or nursing standards when medication or treatment was forced on a competent resident who was refusing the intervention for one of one resident (R1). [...]”

  Rule cited: “Residents have the right to refuse care or assisted living services and to be informed by the facility of the medical, health-related, or psychological consequences of refusing care or services.”

• Tag 2350: 144G.91 Subd. 7 Courteous treatment Level 2, isolated scope, scope/level letter D · correction period: Seven (7) days
  Details

  MDH’s finding, as written: “Based on interview and record review the licensee failed to treat a resident with courtesy and respect when facility staff were witnessed restraining and forcing administration of medication to one of one resident (R1). [...]”

  Rule cited: “Residents have the right to be treated with courtesy and respect, and to have the resident's property treated with respect”

• Tag 2410: 144G.91 Subd. 13 Personal and treatment privacy Level 2, isolated scope, scope/level letter D · correction period: Seven (7) days
  Details

  MDH’s finding, as written: “Based on interview and record review the licensee failed to ensure privacy while providing care according to the acceptable health care medical or nursing standards when medication was forced on a competent resident who was refusing the intervention in the common area of a memory care unit with other residents and family member present for one of one resident (R1). [...]”

  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. [...]”

Allegation, as written: “The facility neglected resident #1 and resident #2 when they failed to provide adequate supervision. Resident #1 was punched and struck in the eye and jaw by resident #2. Resident #1 sustained injuries to his face, including injury to his left eye, and a scratch on the left side of his face. An equal opportunity employer.”

“The Minnesota Department of Health determined neglect was inconclusive.”

Summary: MDH looked into an allegation and found: neglect inconclusive.

MDH’s conclusion, as written: “The Minnesota Department of Health determined neglect was inconclusive. Resident #1's record indicated he and resident #2 had physical altercations on multiple occasions and with other residents too. Although resident #1 sustained facial injuries, the injuries did not require care of a physician and he returned to his baseline health condition. Resident #2 was moved to another floor after the incident. A family member stated resident #1's physical altercations decreased after resident #2 moved to a different floor.”

Action taken by facility: “The facility moved resident #2 to a different floor to decrease physical altercations.”

Action taken by MDH: “The facility was found to be in noncompliance.”

Survey completed October 25, 2022: 9 correction orders

• Tag 320: 144G.30 Subdivision 1 Regulatory powers Level 2, isolated scope, scope/level letter D
  Details

  Summary: MDH found the licensee did not provide requested necessary resident and staff records in a timely manner to determine compliance to licensure laws and rules.

  MDH’s finding, as written: “Based on observation, interview, and record review, the licensee did not provide requested necessary resident and staff records in a timely manner to determine compliance to licensure laws and rules. [...]”

  Rule cited: “(a) The Department of Health is the exclusive state agency charged with the responsibility and duty of surveying and investigating all assisted living facilities required to be licensed under this chapter. [...]”

• Tag 620: 144G.42 Subd. 6 (a) Compliance with requirements for reporting ma Level 2, isolated scope, scope/level letter D
  Details

  Summary: MDH found the facility failed to comply with the requirements for reporting suspected maltreatment within 24 hours for one of seven residents (R1) with records reviewed.

  MDH’s finding, as written: “Based on interview and record review, the facility failed to comply with the requirements for reporting suspected maltreatment within 24 hours for one of seven residents (R1) with records reviewed. R1 admitted to the hospital after staff found him with critically low oxygen levels. Staff were unable to administer R1's oxygen due to his oxygen tanks were empty. The facility failed to reported the incident to the Minnesota Adult Abuse Reporting Agency (MAARC). [...]”

  Rule cited: “144G.42 Subd. 6. Compliance with requirements for reporting maltreatment of vulnerable adults; abuse prevention plan. (a) The assisted living facility must comply with the requirements for the reporting of maltreatment of vulnerable adults in section 626.557. [...]”

• Tag 730: 144G.43 Subd. 3 Contents of resident record Level 2, widespread scope, scope/level letter F
  Details

  Summary: MDH found the licensee failed to ensure unlicensed personnel (ULP) accurately documented and provided scheduled services for four of seven residents (R1, R5, R6, R7) with records reviewed.

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure unlicensed personnel (ULP) accurately documented and provided scheduled services for four of seven residents (R1, R5, R6, R7) with records reviewed. ULP inaccurately documented they performed R1 and R7's scheduled services during the time they were hospitalized, and inaccurately documented scheduled services were provided for R5 and R6 after they were deceased. [...]”

  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, [...]”

• Tag 1420: 144G.62 Subd. 2 Delegation of assisted living services Level 3, isolated scope, scope/level letter G
  Details

  Summary: MDH found the licensee failed to ensure unlicensed personnel (ULP) were competently trained on how to refill oxygen tanks for four of five ULP (ULP-P, ULP-Q, ULP-R, ULP-S) employee files reviewed.

  MDH’s finding, as written: “Based on record review and interviews, the licensee failed to ensure unlicensed personnel (ULP) were competently trained on how to refill oxygen tanks for four of five ULP (ULP-P, ULP-Q, ULP-R, ULP-S) employee files reviewed. R1's oxygen tanks were not filled, and unable to go be used when R1 was found with critically low 02 levels of 46% (normal 90-100%). [...]”

  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 [...]”

• Tag 1470: 144G.63 Subd. 2 Content of required orientation Level 2, pattern scope, scope/level letter E
  Details

  Summary: MDH found the licensee failed to ensure two of eight direct care staff, registered nurse (RN)-M and unlicensed personnel (ULP)-R, with records reviewed, received orientation to include all required content as specified in Minnesota Statute 144G.63, Subd. 1, 2.

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure two of eight direct care staff, registered nurse (RN)-M and unlicensed personnel (ULP)-R, with records reviewed, received orientation to include all required content as specified in Minnesota Statute 144G.63, Subd. 1, 2. [...]”

  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 [...]”

Allegation, as written: “The facility abused the resident when the facility would limit repositioning or transfers to only one every two hours and did not provide the resident with three meals per day.”

“The Minnesota Department of Health determined abuse was not substantiated.”

Summary: MDH looked into an allegation and found: abuse not substantiated.

MDH’s conclusion, as written: “The Minnesota Department of Health determined abuse was not substantiated. The resident's concerns were addressed, and new interventions were added that better met the resident's needs. The new interventions were found to be effective.”

Action taken by facility: “Care conference was held where new interventions were added to better meet the resident's needs, caregivers were re-educated and situation improved with updated service plan.”

Action taken by MDH: “No further action taken at this time.”

Survey completed January 7, 2026: no correction orders issued.