Elderwood of Hinckley

Summary: MDH found the licensee failed to develop an individual abuse prevention plan with the required content for three of three residents (R1, R3, R2) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to develop an individual abuse prevention plan with the required content for three of three residents (R1, R3, R2) with records reviewed. [...]”

Rule cited: “(b) The facility must develop and implement an individual abuse prevention plan for each vulnerable adult. [...]”

Summary: MDH found the licensee failed to post the required information to include: (1) posting the 911 emergency number in common areas and near telephones provided by

MDH’s finding, as written: “Based on observation and interview, the licensee failed to post the required information to include: (1) posting the 911 emergency number in common areas and near telephones provided by the assisted living facility; and (2) posting information and the reporting number for the Minnesota Adult Abuse Reporting Center (MAARC) to report suspected maltreatment of a vulnerable adult under section 626.557. This had the potential to affect all current 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 have a written

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to have a written emergency preparedness plan with all the required content and post an emergency preparedness plan prominently. This had the potential to affect all thirty-three (33) residents receiving services under the assisted living with dementia license. [...]”

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 licensee's staff documented the provision of resident services according to the resident's service plans for three of three residents (R3, R1, R2) with

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure licensee's staff documented the provision of resident services according to the resident's service plans for three of three residents (R3, R1, R2) 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 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, training, and drills 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, training, and drills 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 develop and execute a written contract, prior to the start of services, with the required content to provide assisted living services for three of three residents (R1, R3, 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 contract, prior to the start of services, with the required content to provide assisted living services for three of three residents (R1, R3, R2) 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. [...]”

MDH’s finding, as written: “Based on observation, interview and record review, the registered nurse (RN) failed to ensure the unlicensed personnel (ULP) received training in the proper methods to perform the task or procedure for each resident and were able to demonstrate the ability to competently follow the procedure to perform the tasks for two of two (ULP-C, ULP-D) reviewed for the use of a continuous positive airway pressure (CPAP) and Suprapubic catheter belly bag. [...]”

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 employees

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure employees received orientation to 144G licensing requirements for three of three employees (unlicensed personnel (ULP)-C, ULP-D, ULP-E) with employee records reviewed. This had potential to affect all thirty-three (33) 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 employees received at least eight hours of annual training for each 12 months of employment for two of two employees (unlicensed personnel (ULP)-D, ULP-E) with employee records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure employees received at least eight hours of annual training for each 12 months of employment for two of two employees (unlicensed personnel (ULP)-D, ULP-E) with employee records reviewed. [...]”

Rule cited: “(a) All staff that perform direct services must complete at least eight hours of annual training for each 12 months of employment. [...]”

Summary: MDH found the licensee failed to ensure the registered nurse (RN) completed ongoing resident reassessments and did not exceed 90 days for three of three residents (R3, R1, R2) as required 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 ongoing resident reassessments and did not exceed 90 days for three of three residents (R3, R1, R2) as required 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 the service plan included all required content for three of three residents (R3, R1, R2) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure the service plan included all required content for three of three residents (R3, R1, R2) 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 develop, implement, and maintain current medication management policies and procedures that were developed under the supervision and direction of a registered nurse (RN) consistent with current practice standards and guidelines, with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop, implement, and maintain current medication management policies and procedures that were developed under the supervision and direction of a registered nurse (RN) consistent with current practice standards and guidelines, with records reviewed. [...]”

Rule cited: “(a) This section applies only to assisted living facilities that provide medication management services. [...]”

Summary: MDH found the licensee failed to develop and maintain a current individualized medication management record for each resident to include all required content for three of three residents (R3, R2, R1) with records reviewed.

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 for each resident to include all required content for three of three residents (R3, R2, R1) 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 the registered nurse documented resident-specific instructions for their medications for one of three residents (R1) whose medication administration was delegated to unlicensed personnel.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure the registered nurse documented resident-specific instructions for their medications for one of three residents (R1) whose medication administration was delegated to unlicensed personnel. [...]”

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 staff administered medications as ordered 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 staff administered medications as ordered for one of two residents (R1) 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. [...]”

Summary: MDH found the licensee failed to develop, implement, and maintain up-to-date written treatment or therapy management policies and procedures that were developed under the supervision and direction of a registered nurse (RN) consistent with current practice standards and guidelines, with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop, implement, and maintain up-to-date written treatment or therapy management policies and procedures that were developed under the supervision and direction of a registered nurse (RN) consistent with current practice standards and guidelines, 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 develop individual treatment management plans with all required content for three of three residents (R3, R2, R1)

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to develop individual treatment management plans with all required content for three of three residents (R3, R2, R1) who received ordered treatments. [...]”

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 and documented those instructions in the resident record for three of three residents (R1, R2, 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) specified, in writing, specific instructions and documented those instructions in the resident record for three of three residents (R1, R2, R3) 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 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. Hazards were not assessed and mitigated to protect residents from harm. 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 required in the licensing of assisted living facilities with dementia care were developed and/or implemented.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure policies and procedures required in the licensing of assisted living facilities with dementia care were developed and/or implemented. [...]”

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 current Minnesota Bill of Rights for Assisted Living Residents was provided to the residents and a written acknowledgement received for three of three residents (R1, R2, R3) with records reviewed.

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 residents and a written acknowledgement received for three of three residents (R1, R2, R3) with records reviewed. [...]”

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 ensure the care and services were provided according to acceptable health care and medical, or nursing standards for twelve of thirteen residents (R1, R2, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13) with siderails.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure the care and services were provided according to acceptable health care and medical, or nursing standards for twelve of thirteen residents (R1, R2, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13) with siderails. [...]”

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.”

MDH’s finding, as written: “Based on observation and interview the licensee failed to ensure the required notice to visitors was posted at the main entry way of the establishment to display statutory language to disclose electronic monitoring activity, potentially affecting all 33 current clients, staff, and visitors. [...]”

Rule cited: “Subd. 8.Notice to visitors. (a) A facility must post a sign at each facility entrance accessible to visitors that states: "Electronic monitoring devices, including security cameras and audio devices, may be present to record persons and activities." (b) The [...]”