Edgewood Hermantown I Sr Living

Summary: MDH found the licensee failed to establish and maintain an infection control program that complied with accepted health care, medical and nursing standards for infection control and current recommendations for COVID-19.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to establish and maintain an infection control program that complied with accepted health care, medical and nursing standards for infection control and current recommendations for COVID-19. This had the potential to affect all 159 residents and staff. [...]”

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 engage in and maintain documentation of quality management activity appropriate to the size of the facility and relevant to the type of services provided.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to engage in and maintain documentation of quality management activity appropriate to the size of the facility and relevant to the type of services provided. This had the potential to affect all 159 residents. [...]”

Rule cited: “The facility shall engage in quality management appropriate to the size of the facility and relevant to the type of services provided. [...]”

Summary: MDH found the licensee failed to maintain a tuberculosis (TB) prevention and control program based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to maintain a tuberculosis (TB) prevention and control program based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC). The licensee failed to complete a TB risk assessment every two years. In addition, the licensee failed to ensure history and symptom screenings were completed and documented for two of five employees (unlicensed personnel (ULP)-J and ULP-K) with employee records reviewed. [...]”

Rule cited: “(a) The facility must establish and maintain a comprehensive tuberculosis infection control program according to the most current tuberculosis infection control guidelines issued by the United States Centers for Disease Control and Prevention (CDC), Division [...]”

Summary: MDH found the licensee failed to have a written emergency disaster plan that included all required content and failed to post an emergency plan prominently.

MDH’s finding, as written: “Based on interview, the licensee failed to have a written emergency disaster plan that included all required content and failed to post an emergency plan prominently. This had the potential to affect all 159 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 document 30 minute safety checks in the resident record for three of three residents (R4, R9 and R10) in memory care with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to document 30 minute safety checks in the resident record for three of three residents (R4, R9 and R10) in memory care with records reviewed. [...]”

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, [...]”

MDH’s finding, as written: “No further action required.”

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) [...]”

MDH’s finding, as written: “No further action required.”

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 [...]”

MDH’s finding, as written: “No further action required.”

Rule cited: “(b) Each assisted living facility shall develop and maintain fire safety and evacuation plans. [...]”

Summary: MDH found the licensee failed to ensure employees received orientation to assisted living facility licensing requirements and regulations for three of three unlicensed personnel (ULP)-F, ULP-J, and ULP-K) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure employees received orientation to assisted living facility licensing requirements and regulations for three of three unlicensed personnel (ULP)-F, ULP-J, and ULP-K) with records reviewed. This had the potential to affect all 159 residents. [...]”

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) developed written procedures for unplanned time away from home.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the Registered Nurse (RN) developed written procedures for unplanned time away from home. In addition, the licensee failed to ensure three of three unlicensed personnel (ULP)-F, ULP-H, and ULP-J) were trained and had demonstrated competency to prepare and give medications for clients having unplanned time away. This had the potential to affect all 159 residents. [...]”

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 [...]”

MDH’s finding, as written: “No further action required.”

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 [...]”

MDH’s finding, as written: “Based on interview and record review, licensee failed to ensure policies and procedures required in the licensing of assisted living facilities with dementia care were developed and failed to provided the policies and procedures to residents and the residents' legal and designated representatives at the time of move-in. This had the potential to affect all 159 residents in the memory care units. [...]”

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 establish and maintain an infection control program that complied with accepted health care, medical and nursing standards for infection control and current recommendations for COVID-19.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to establish and maintain an infection control program that complied with accepted health care, medical and nursing standards for infection control and current recommendations for COVID-19. This had the potential to affect all residents and staff. [...]”

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 in a conspicuous place, information about the facility's grievance procedure and the name, telephone number, and e-mail contact information for the individuals who are responsible for handling resident grievances.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to post in a conspicuous place, information about the facility's grievance procedure and the name, telephone number, and e-mail contact information for the individuals who are responsible for handling resident grievances. This had the potential to affect all residents. [...]”

Rule cited: “All facilities must post in a conspicuous place information about the facilities' grievance procedure, and the name, telephone number, and e-mail contact information for the individuals who are responsible for handling resident grievances. [...]”

Summary: MDH found the licensee failed to display the current assisted living with dementia license at the main entrance of one of two assisted living buildings.

MDH’s finding, as written: “Based on observation, and interview, the licensee failed to display the current assisted living with dementia license at the main entrance of one of two assisted living buildings. [...]”

Rule cited: “The original current license must be displayed at the main entrance of each assisted living facility. The facility must provide a copy of the license to any person who requests it.”

Summary: MDH found the licensee failed to engage in and maintain documentation of quality management activity appropriate to the size of the facility and relevant to the type of services provided.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to engage in and maintain documentation of quality management activity appropriate to the size of the facility and relevant to the type of services provided. This had the potential to affect all residents. [...]”

Rule cited: “The facility shall engage in quality management appropriate to the size of the facility and relevant to the type of services provided. [...]”

Summary: MDH found the licensee failed to support protection and safety by not posting information and phone numbers for reporting to the Minnesota Adult Abuse Reporting Center (MAARC) and failed to post the 911 emergency number in common areas and near telephones provided by the assisted living facility.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to support protection and safety by not posting information and phone numbers for reporting to the Minnesota Adult Abuse Reporting Center (MAARC) and failed to post the 911 emergency number in common areas and near telephones provided by the assisted living facility. This had the potential to affect all 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 [...]”

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to maintain a tuberculosis (TB) prevention and control program based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC). The licensee failed to complete a TB risk assessment every two years. [...]”

Rule cited: “(a) The facility must establish and maintain a comprehensive tuberculosis infection control program according to the most current tuberculosis infection control guidelines issued by the United States Centers for Disease Control and Prevention (CDC), Division [...]”

Summary: MDH found the licensee failed to have a written emergency disaster plan that included all required content and failed to post an emergency plan prominently.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to have a written emergency disaster plan that included all required content and failed to post an emergency plan prominently. This had the potential to affect all 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 entries on safety check flow sheets were authenticated by the name and title of the person making the entry.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure entries on safety check flow sheets were authenticated by the name and title of the person making the entry. This had the potential to affect all residents in the memory care unit. [...]”

Rule cited: “(a) Assisted living facilities must maintain records for each resident for whom it is providing services. [...]”

Summary: MDH found the licensee failed to ensure unauthorized persons did not have access to resident records for one of two residents (R1) reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure unauthorized persons did not have access to resident records for one of two residents (R1) reviewed. [...]”

Rule cited: “(b) Resident records, whether written or electronic, must be protected against loss, tampering, or unauthorized disclosure in compliance with chapter 13 and other applicable relevant federal and state laws. [...]”

Summary: MDH found the licensee failed to document 30 minute safety checks in the resident record for two of two residents (R3 and R4) in memory care with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to document 30 minute safety checks in the resident record for two of two residents (R3 and R4) in memory care with records reviewed. [...]”

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 facility failed to maintain two smoke alarms in resident rooms.

MDH’s finding, as written: “Based on observation and interview, the facility failed to maintain two smoke alarms in resident rooms. This had the potential to affect all residents and staff. 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 is issued at an isolated scope (when one or a limited number of clients are affected or [...]”

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 facility failed to maintain the physical environment in a continuous state of good repair and operation.

MDH’s finding, as written: “Based on observation and interview, the facility failed to maintain the physical environment in a continuous state of good repair and operation. 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 [...]”

MDH’s finding, as written: “Based on observation, record review and interview, facility failed to provide the required training and plans for fire safety and evacuation. This had the potential to 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 develop and execute a written Assisted Living Contract with the required content for three of six residents (R1, R9 and R10) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to develop and execute a written Assisted Living Contract with the required content for three of six residents (R1, R9 and R10) 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 ensure the Assisted Living Contract included the required content for

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure the Assisted Living Contract included the required content for one of six residents (R1) with records reviewed. [...]”

Rule cited: “(a) The contract must include in a conspicuous place and manner on the contract the legal name and the license number of the facility. [...]”

Summary: MDH found the licensee failed to develop and execute a written assisted living contract with the required content to two of six residents (R1, R2) with records reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to develop and execute a written assisted living contract with the required content to two of six residents (R1, R2) with records reviewed. [...]”

Rule cited: “(c) The contract must include: (1) a disclosure of the category of assisted living facility license held by the facility and, if the facility is not an assisted living facility with dementia care, a disclosure that it does not hold an assisted living facility [...]”

Summary: MDH found the licensee failed to develop and execute a written contract with the required content to provide assisted living services for four of six residents (R1, R2, R9 and R10) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to develop and execute a written contract with the required content to provide assisted living services for four of six residents (R1, R2, R9 and R10) with records reviewed. [...]”

Rule cited: “(d) The contract must include a description of the facility's complaint resolution process available to residents, including the name and contact information of the person representing the facility who is designated to handle and resolve complaints. [...]”

Summary: MDH found the licensee failed to develop and execute a written Assisted Living Contract with the required content for two of six residents (R1, R2) with records reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to develop and execute a written Assisted Living Contract with the required content for two of six residents (R1, R2) with records reviewed. [...]”

Rule cited: “(5) a description of the facility's policies related to medical assistance waivers under chapter 256S and section 256B.49 and the housing support program under chapter 256I, including: (i) whether the facility is enrolled with the commissioner of human [...]”

Summary: MDH found the licensee failed to ensure employees received orientation to assisted living facility licensing requirements and regulations for four of six unlicensed personnel ((ULP)-F, ULP-I, ULP-J, and ULP-K) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure employees received orientation to assisted living facility licensing requirements and regulations for four of six unlicensed personnel ((ULP)-F, ULP-I, ULP-J, and ULP-K) with records reviewed. [...]”

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 re-assessment following a change of condition for two of six residents (R3 and R4) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure the Registered Nurse (RN) completed a comprehensive re-assessment following a change of condition for two of six residents (R3 and R4) 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 service plans were revised for two of six residents (R3 and R4) and failed to ensure service plans were developed for two of eight residents (R9 and R10) with records revied.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure service plans were revised for two of six residents (R3 and R4) and failed to ensure service plans were developed for two of eight residents (R9 and R10) with records revied. [...]”

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 individual medication management plans contain all the required content for two of eight residents (R3 and R4) with records reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure individual medication management plans contain all the required content for two of eight residents (R3 and R4) with records reviewed. [...]”

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 documented after administration for one of six residents (R2), failed to ensure medications were administered as ordered for three of six (R4, R9 and R10), and failed to ensure the effectiveness of as needed (PRN) medications were documented for one of six residents (R10) with records reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medications were documented after administration for one of six residents (R2), failed to ensure medications were administered as ordered for three of six (R4, R9 and R10), and failed to ensure the effectiveness of as needed (PRN) medications were documented for one of six residents (R10) with 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. [...]”

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure three of three unlicensed personnel ((ULP)-F, ULP-H, and ULP-J) were trained and had demonstrated competency to prepare and give medications for clients having unplanned time away. In addition, the licensee failed to ensure the Registered Nurse (RN) developed written procedures for unplanned time away from home. This had the potential to affect all the residents. [...]”

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 medications were stored according to manufacturer's recommendations.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medications were stored according to manufacturer's recommendations. 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 a pattern scope (when more than a limited number of residents are affected, more than [...]”

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 time sensitive medications were labeled with the open date for one of two residents (R1) with records reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure time sensitive medications were labeled with the open date for one of two residents (R1) with records reviewed. In addition, the licensee adminstered an expired medication to one of six residents (R2) reviewed. [...]”

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 develop a treatment management plan to include all required content for one of six residents (R4) receiving treatment management services with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to develop a treatment management plan to include all required content for one of six residents (R4) receiving treatment management services 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 the Registered Nurse (RN) specified, in writing, specific instructions for one of six residents (R4) receiving treatment management services with records reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the Registered Nurse (RN) specified, in writing, specific instructions for one of six residents (R4) receiving treatment management services with records reviewed. [...]”

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 document treatments for one of six residents (R3) with records reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to document treatments for one of six residents (R3) with records reviewed. 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: “Each treatment or therapy administered by an assisted living facility must be in the resident record. [...]”

MDH’s finding, as written: “Based on observation, record 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 hazards to protect residents from harm was not included in the plan. This had the potential to affect all dementia care residents. [...]”

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 [...]”

MDH’s finding, as written: “Based on interview and record review, licensee failed to ensure policies and procedures required in the licensing of assisted living facilities with dementia care were developed and failed to provided the policies and procedures to residents and the residents' legal and designated representatives at the time of move-in. This had the potential to affect all the residents in the memory care units. [...]”

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 all residents received the complete new Assisted Living Bill of Rights.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure all residents received the complete new Assisted Living Bill of Rights. This had the potential to affect all residents. [...]”

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. [...]”

Summary: MDH found the licensee failed to provide care and services according to acceptable health care standards, medical or nursing standards in two of two rooms (A6 and 121) where oxygen was stored.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to provide care and services according to acceptable health care standards, medical or nursing standards in two of two rooms (A6 and 121) where oxygen was stored. [...]”

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.”

Summary: MDH found the licensee failed to ensure privacy was maintained during medication administration for two of six residents (R9 and R10) with records reviewed.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to ensure privacy was maintained during medication administration for two of six residents (R9 and R10) with records reviewed. [...]”

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. [...]”