Eagle Street Assisted Living

Summary: MDH found the licensee failed to develop a written emergency preparedness (EP) plan with all the required content.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop a written emergency preparedness (EP) plan with all the required content. This had the potential to affect all 12 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 ensure the resident record included documentation of all provided services for two of two residents (R1, R3).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the resident record included documentation of all provided services for two of two residents (R1, R3). [...]”

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 maintain smoke alarms throughout the facility.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to maintain smoke alarms 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 the physical environment in a continuous state of good repair and operation with regard to the health, safety, and well-being of the residents.

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

Summary: MDH found the licensee failed to provide the required fire safety training for residents and staff, and failed to conduct required evacuation drills.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide the required fire safety training for residents and staff, and failed to conduct required evacuation drills. 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 develop and execute a written assisted living contract with the required content for two of two residents (R1, R3) 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 with the required content for two of two residents (R1, 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 offer the opportunity to identify a designated representative for two of two residents (R1, R3) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to offer the opportunity to identify a designated representative for two of two residents (R1, R3) with records reviewed. [...]”

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 registered nurse (RN) conducted direct supervision of staff performing a

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure a registered nurse (RN) conducted direct supervision of staff performing a delegated task within 30 days of providing services for one of one unlicensed staff (unlicensed personnel (ULP)-C). [...]”

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 one of one employee (registered nurse (RN)-A) received orientation to all required assisted living regulation content.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure one of one employee (registered nurse (RN)-A) received orientation to all required assisted living regulation content. [...]”

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 [...]”

Summary: MDH found the licensee failed to ensure direct-care staff completed the required amount of dementia care training in the required time frame for two of two employees (registered nurse (RN)-A, unlicensed personnel (ULP)-C).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure direct-care staff completed the required amount of dementia care training in the required time frame for two of two employees (registered nurse (RN)-A, unlicensed personnel (ULP)-C). [...]”

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) conducted ongoing resident monitoring and reassessment, utilizing a uniform assessment tool, not to exceed 90 calendar days from the last assessment date, for two of two residents (R1,

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the registered nurse (RN) conducted ongoing resident monitoring and reassessment, utilizing a uniform assessment tool, not to exceed 90 calendar days from the last assessment date, for two of two residents (R1, R3). [...]”

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 resident service plan included the required content for two of two residents (R1, R3) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the resident service plan included the required content for two of two residents (R1, R3) 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 monitor and reassess the resident's medication management services at least annually for two of two residents (R1, R3).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to monitor and reassess the resident's medication management services at least annually for two of two residents (R1, R3). [...]”

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 and maintain a current individualized medication management record to include all required content for one of two residents (R1).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to develop and maintain a current individualized medication management record to include all required content for one of two residents (R1). [...]”

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 per providers orders for two of three residents (R1, R5) with medication administration records reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medications were administered per providers orders for two of three residents (R1, R5) with medication administration records reviewed. [...]”

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 two of two residents (R1, R3).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure written or electronically recorded prescriptions were obtained for two of two residents (R1, R3). [...]”

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 medications were stored under proper temperature controls according to manufacturer instructions.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medications were stored under proper temperature controls according to manufacturer instructions. This had the potential to affect two of two residents (R6, R7) with refrigerated medications. [...]”

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 the policy and procedures for treatments and therapy management services included all the required content and written treatment or therapy management policies and procedures were developed under the supervision and direction of a registered nurse (RN), licensed health professional, or pharmacist consistent with current practice standards, with records reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the policy and procedures for treatments and therapy management services included all the required content and written treatment or therapy management policies and procedures were developed under the supervision and direction of a registered nurse (RN), licensed health professional, or pharmacist consistent with current practice standards, with records reviewed. [...]”

Rule cited: “(a) An assisted living facility that provides treatment and therapy management services must develop, implement, and maintain up-to-date written treatment or therapy management policies and procedures. [...]”

Summary: MDH found the licensee failed to ensure the registered nurse (RN) developed and implemented a treatment or therapy management plan to include all required content for two of two residents (R1, R3) with records reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) developed and implemented a treatment or therapy management plan to include all required content for two of two residents (R1, R3) 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 provide a hazard vulnerability or safety risk assessment that included hazards

MDH’s finding, as written: “Based on document review and interview, the licensee failed to provide a hazard vulnerability or safety risk assessment that included hazards identified on and around the property. Mitigation of property hazards to protect residents from harm was not included. This had the potential to directly affect all residents and staff. [...]”

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 policies and procedures for assisted living with dementia care were provided to residents and the residents' legal and designated representatives at the time of move for residents (R1, R3).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure policies and procedures for assisted living with dementia care were provided to residents and the residents' legal and designated representatives at the time of move for residents (R1, R3). [...]”

Rule cited: “(a) In addition to the policies and procedures required in the licensing of all facilities, the assisted living facility with dementia care licensee must develop and implement policies and procedures that address the: (1) philosophy of how services are [...]”