Duluth Heights Lodge Senior Li

MDH’s finding, as written: “Based on document review and interview, the licensee failed to provide the required plans and training for fire safety and evacuation. This had the potential to directly affect all residents and staff. [...]”

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 four of eight residents (R1, R3, R6, R9) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to execute a written contract with the required content for four of eight residents (R1, R3, R6, R9) with records reviewed. In addition, the licensee had three variations of the contract with a final contract under review. This had the potential to affect all 61 residents. [...]”

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 current employee records contained all the required content to include background studies for two of four employees (unlicensed personnel (ULP)-C, ULP-E).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure current employee records contained all the required content to include background studies for two of four employees (unlicensed personnel (ULP)-C, 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 staff providing and supervising direct services completed an orientation to assisted living facility licensing requirements and regulations before providing services for one of one employee (registered nurse (RN)-B) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure staff providing and supervising direct services completed an orientation to assisted living facility licensing requirements and regulations before providing services for one of one employee (registered nurse (RN)-B) 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 the registered nurse (RN) conducted reassessment and monitoring following resident's falls for two of six residents (R2, R3) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the registered nurse (RN) conducted reassessment and monitoring following resident's falls for two of six residents (R2, R3) 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 a service plan was revised to reflect the current services provided for one of six residents (R6), with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure a service plan was revised to reflect the current services provided for one of six residents (R6), with records reviewed. [...]”

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 service plans included the required content for six of six residents (R1, R2, R3, R5, R6, R7) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure service plans included the required content for six of six residents (R1, R2, R3, R5, R6, R7) with records reviewed. [...]”

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 medication management assessments were completed by the registered nurse (RN) to include a review of medications in all required areas for four of five residents (R1, R2, R5, R6) who received medication management services with records reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medication management assessments were completed by the registered nurse (RN) to include a review of medications in all required areas for four of five residents (R1, R2, R5, R6) who received medication management services with records reviewed. [...]”

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 [...]”

MDH’s finding, as written: “Based on observation, interview, and record review the licensee failed to ensure physician orders were transcribed accurately for two of four residents (R5, R6), failed to ensure as needed (PRN) medications had documentation of effectiveness after administration for one of four residents (R6), failed to document follow-up procedures when the licensee did not administer medications as prescribed and failed to ensure staff followed procedure for documentation of administered medications for one [...]”

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 the registered nurse (RN) developed a written procedure for the unlicensed personnel (ULP) providing medications for residents having unplanned time away when the licensed nurse was not available.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the registered nurse (RN) developed a written procedure for the unlicensed personnel (ULP) providing medications for residents having unplanned time away when the licensed nurse was not available. [...]”

Rule cited: “(2) for unplanned time away, when the pharmacy is not able to provide the medications, a licensed nurse or unlicensed personnel shall provide medications in amounts and dosages needed for the length of the anticipated absence, not to exceed seven calendar [...]”

Summary: MDH found the licensee failed to ensure written or electronically recorded prescriptions were obtained for two of six residents (R5, R6) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure written or electronically recorded prescriptions were obtained for two of six residents (R5, R6) with records reviewed. [...]”

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 develop and implement a treatment or therapy management plan for one of three residents (R1) with records reviewed.

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 for one of three residents (R1) with 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 prior to delegating treatments, the registered nurse (RN) trained unlicensed personnel (ULP) in the proper methods to perform the treatments for one of one employee (ULP-E) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure prior to delegating treatments, the registered nurse (RN) trained unlicensed personnel (ULP) in the proper methods to perform the treatments for one of one employee (ULP-E) with records reviewed. In addition, the licensee failed to ensure specific written instructions for each resident were documented in two of two resident's records (R3, R6) who received therapy or treatment services. [...]”

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 ensure there were current treatment and therapy orders for one of three residents (R1) with records reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure there were current treatment and therapy orders for one of three residents (R1) with records reviewed. [...]”

Rule cited: “There must be an up-to-date written or electronically recorded order from an authorized prescriber for all treatments and therapies. [...]”