Edgewood Alexandria Senior Liv

Summary: MDH found the licensee failed to ensure infection control standards were followed for one of one unlicensed personnel (ULP-H) during blood pressure monitoring for R4.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure infection control standards were followed for one of one unlicensed personnel (ULP-H) during blood pressure monitoring for R4. [...]”

Rule cited: “(a) All assisted living facilities must establish and maintain an infection control program that complies with accepted health care, medical, and nursing standards for infection control. [...]”

Summary: MDH found the licensee failed to post required content to include 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 to include the 911 emergency number in common areas and near telephones provided by the assisted living. This had the potential to affect all 56 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 develop a written emergency preparedness plan (EPP) with all the required content and failed to post an EPP prominently.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to develop a written emergency preparedness plan (EPP) with all the required content and failed to post an EPP prominently. This had the potential to affect all residents, staff, and visitors of the facility. [...]”

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 maintain the facility physical environment in a continuous state of good repair and operation regarding the health, safety, and well-being of the residents.

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

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 ensure four of four residents (R2, R3, R4, R5) assisted living contract included a notice with the required verbiage for the residents to identify a designated representative.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure four of four residents (R2, R3, R4, R5) assisted living contract included a notice with the required verbiage for the residents to identify a designated representative. This had the potential to affect all 56 residents who received services at the facility. [...]”

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 contracted staff met all requirements required for personnel employed by the licensee for one of one contracted unlicensed personnel (ULP)-J.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure contracted staff met all requirements required for personnel employed by the licensee for one of one contracted unlicensed personnel (ULP)-J. [...]”

Rule cited: “When a facility contracts with a temporary staffing agency, those individuals must meet the same requirements required by this section for personnel employed by the facility and shall be treated as if they are staff of the facility.”

Summary: MDH found the licensee failed to ensure direct supervision of staff performing delegated tasks was provided within 30 calendar days after the

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)-B. [...]”

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 three employees (unlicensed personnel) ULP-B.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure orientation to assisted living statutes included all the required content for one of three employees (unlicensed personnel) ULP-B. [...]”

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 the registered nurse (RN) completed a comprehensive reassessment to include an assessment of current smoking status for one of five residents (R16).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) completed a comprehensive reassessment to include an assessment of current smoking status for one of five residents (R16). [...]”

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 four residents (R15) service plan was revised to include provided services.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure one of four residents (R15) service plan was 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 affected or one or a [...]”

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 registered nurse (RN) conducted a face-to-face medication management reassessment to include all required content for four of four residents (R5, R3, R2, 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 four of four residents (R5, R3, R2, 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 ensure medications were administered as ordered for one of four residents (R5).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medications were administered as ordered for one of four residents (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 an isolated scope (when one or a limited number of residents are affected or 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 documentation of medication setup included all the required content for two of two residents (R15, R3).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure documentation of medication setup included all the required content for two of two residents (R15, R3). [...]”

Rule cited: “Documentation of dates of medication setup, name of medication, quantity of dose, times to be administered, route of administration, and name of person completing medication setup must be done at the time of setup.”

Summary: MDH found the licensee failed to ensure one of two unlicensed personnel (ULP-B) 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 two unlicensed personnel (ULP-B) 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 date time-sensitive medications with an opened or expiration date for six of six residents (R6, R7, R8, R16, R3, R10) and failed to ensure all medication included the original prescription label to include whom the medications was to be administered for two of two residents (R16, R3).

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 six of six residents (R6, R7, R8, R16, R3, R10) and failed to ensure all medication included the original prescription label to include whom the medications was to be administered for two of two residents (R16, R3). In addition, the licensee failed to monitor for expired medications for three of three residents (R5, R13, and R2). [...]”

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 [...]”

MDH’s finding, as written: “Based on observation, interview, and record review, the registered nurse (RN) failed to specify, in writing, specific instructions for catheter (tube placed in the body to drain and collect urine from the bladder) care for one of one resident (R4). [...]”

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 the required dementia care policies and procedures were provided to one of two residents (R3) and/or the resident's legal and designated representative.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the required dementia care policies and procedures were provided to one of two residents (R3) and/or the resident's legal and 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 ensure the steps of the treatment administration process was followed for one of four employees, unlicensed personnel (ULP)-I.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the steps of the treatment administration process was followed for one of four employees, unlicensed personnel (ULP)-I. [...]”

Rule cited: “(b) Residents have the right to receive health care and other assisted living services with continuity from people who are properly trained and competent to perform their duties and in sufficient numbers to adequately provide the services agreed to in the [...]”

Summary: MDH found the licensee failed to ensure two of two resident's (R2, R12) privacy was respected with regards to electronic monitoring.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure two of two resident's (R2, R12) privacy was respected with regards to electronic monitoring. [...]”

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. [...]”

Summary: MDH found the licensee failed to obtain consent for electronic monitoring for one of two residents (R12) who had an electronic monitor device in place.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to obtain consent for electronic monitoring for one of two residents (R12) who had an electronic monitor device in place. [...]”

Rule cited: “Subd. 6.Form requirements. (b) Facilities must make the notification and consent form available to the residents and inform residents of their option to conduct electronic monitoring of their rooms or private living unit.”