Ecumen North Branch (Assisted Living and Memory Care)

Summary: MDH found the licensee failed to post required content in common areas to include posting the 911 emergency number in common areas and near telephones provided by the assisted living.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to post required content in common areas to include posting the 911 emergency number in common areas and near telephones provided by the assisted living. This had the potential to affect all 70 residents, staff, and visitors. [...]”

Rule cited: “The facility shall support protection and safety through access to the state's systems for reporting suspected criminal activity and suspected vulnerable adult maltreatment by: (1) posting the 911 emergency number in common areas and near telephones provided [...]”

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 plans and training for fire safety and evacuation.

MDH’s finding, as written: “Based on observation, 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 offer three of three residents (R2, R4, R6) the opportunity to identify or decline a designated representative.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to offer three of three residents (R2, R4, R6) the opportunity to identify or decline a designated representative. [...]”

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 the assisted living with dementia contract did not include language waiving the facility's liability for health, safety, or personal property of a resident.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the assisted living with dementia contract did not include language waiving the facility's liability for health, safety, or personal property of a resident. This had the potential to affect all residents. [...]”

Rule cited: “The contract must not include a waiver of facility liability for the health and safety or personal property of a resident. [...]”

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) prior to providing care for four of four unlicensed personnel (ULP)-F, ULP-H, ULP-I, ULP-N.

MDH’s finding, as written: “Based on observation, 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) prior to providing care for four of four unlicensed personnel (ULP)-F, ULP-H, ULP-I, ULP-N. [...]”

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 was completed for one of one employee, unlicensed personnel (ULP)-F, to include all required content.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure training and competency was completed for one of one employee, unlicensed personnel (ULP)-F, to include all required content. [...]”

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) [...]”

Summary: MDH found the licensee failed to ensure training was completed in all required areas for one of one unlicensed personnel (ULP)-F with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure training was completed in all required areas for one of one unlicensed personnel (ULP)-F 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 [...]”

MDH’s finding, as written: “Based on observation, interview and record review the licensee failed to ensure the registered nurse (RN)-C provided training for unlicensed personnel (ULP)-F and all other ULP on the delegated task of using a Broda chair [a wheelchair offering tilt-n-space positioning with a seating system which prevents skin breakdown through reducing heat and moisture]. [...]”

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 [...]”

Summary: MDH found the licensee failed to ensure direct

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure direct supervision of staff performing delegated tasks was provided within 30 calendar days after the date on which the individual begins working for the licensee for one of one unlicensed personnel (ULP)-F. [...]”

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 orientation to assisted living statutes included all the required content for one of one employee registered nurse (RN)-C.

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

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 one of one employee, unlicensed personnel (ULP)-F received the required amount of dementia care training in the required time frame.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure one of one employee, unlicensed personnel (ULP)-F received the required amount of dementia care training in the required time frame. [...]”

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 comprehensive reassessment after a change of condition for one of one resident (R6).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the registered nurse (RN) completed a comprehensive reassessment after a change of condition for one of one resident (R6). In addition, the licensee failed to ensure the RN completed ongoing resident assessments not to exceed 90 days for one of one resident (R6). [...]”

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 three residents (R3) service plans were revised to include provided services.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure one of three residents (R3) service plans were revised to include provided services. 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 [...]”

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 (R2, R3, R5, R6).

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

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 a medication management assessment was completed by the registered nurse (RN) which reviewed all required areas for two of three residents (R2, R3).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure a medication management assessment was completed by the registered nurse (RN) which reviewed all required areas for two of three residents (R2, R3). [...]”

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) prepared in writing specific instructions for each resident and documented those instructions for one of two residents (R4).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure the registered nurse (RN) prepared in writing specific instructions for each resident and documented those instructions for one of two residents (R4). [...]”

Rule cited: “When administration of medications is delegated to unlicensed personnel, the assisted living facility must ensure that the registered nurse has: (1) instructed the unlicensed personnel in the proper methods to administer the medications, and the unlicensed [...]”

Summary: MDH found the licensee failed to ensure medication was administered according to manufacturer's instructions for residents (R3, R4).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure medication was administered according to manufacturer's instructions for residents (R3, R4). In addition, the licensee failed to ensure medications were administered as ordered for resident (R2). [...]”

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 one of one unlicensed personnel (ULP-F) were trained and had demonstrated competency to prepare and give medications for residents having unplanned time away.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure one of one unlicensed personnel (ULP-F) were trained and had demonstrated competency to prepare and give medications for residents having unplanned time away. [...]”

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 refrigerated medications were maintained at manufacturer recommended temperatures for two of two medication refrigerators (second floor, dementia unit).

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 for two of two medication refrigerators (second floor, dementia unit). [...]”

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 date time-sensitive medications with an opened or expiration date for R3, R4, R11, R17, R18, R20 and an unknown resident.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to date time-sensitive medications with an opened or expiration date for R3, R4, R11, R17, R18, R20 and an unknown resident. In addition, the licensee failed to monitor for expired medications for R5, R10, R17, R19 and further, the licensee failed to ensure medication containers had the original prescription label for R3, R17, R18. [...]”

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 to document in the resident's record the required content on disposition of the medications for one of one resident (R7) upon discharge.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to document in the resident's record the required content on disposition of the medications for one of one resident (R7) upon discharge. [...]”

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 ensure instructions, specified in writing, for each resident were documented in the resident's record for two of two resident (R2, R3) who received blood glucose (sugar) monitoring.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure instructions, specified in writing, for each resident were documented in the resident's record for two of two resident (R2, R3) who received blood glucose (sugar) monitoring. [...]”

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 treatments or therapies were administered as prescribed, or to document the reason they were not provided to meet the resident's needs for one of two residents (R3).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure treatments or therapies were administered as prescribed, or to document the reason they were not provided to meet the resident's needs for one of two residents (R3). [...]”

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

Summary: MDH found the licensee failed to provide a hazard vulnerability or safety risk assessment that included hazards identified on and around the property.

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. 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 the assisted living facility with dementia care provided the required policies and procedures to each resident and/or designated representative.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the assisted living facility with dementia care provided the required policies and procedures to each resident and/or designated representative. [...]”

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 [...]”

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 [...]”

Summary: MDH found the licensee failed to develop a comprehensive evaluation for activities and an individual activity plan for two of two residents (R5, R6) who received services under an assisted living with dementia care license.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop a comprehensive evaluation for activities and an individual activity plan for two of two residents (R5, R6) who received services under an assisted living with dementia care license. [...]”

Rule cited: “(b) Each resident must be evaluated for activities according to the licensing rules of the facility. [...]”

Summary: MDH found the licensee failed to ensure the current Minnesota Bill of Rights for Assisted Living Residents was provided to the resident for four of four residents (R2, R4, R5, R6) upon admission to the assisted living with dementia care facility.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the current Minnesota Bill of Rights for Assisted Living Residents was provided to the resident for four of four residents (R2, R4, R5, R6) upon admission to the assisted living with dementia care facility. [...]”

Rule cited: “(a) An assisted living facility must provide the resident a written notice of the rights under section 144G.91 before the initiation of services to that resident. [...]”