Elmore Assisted Living

Summary: MDH found the licensee failed to execute a written contract prior to providing assisted living services for three of eight residents (R22, R20, R21) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to execute a written contract prior to providing assisted living services for three of eight residents (R22, R20, R21) 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 one of eight residents (R4) the opportunity to identify a designated representative with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to offer one of eight residents (R4) the opportunity to identify a designated representative 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 the registered nurse (RN) completed a change in condition assessment when required for one of four residents (R21).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) completed a change in condition assessment when required for one of four residents (R21). [...]”

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 resident service plan included a signature or other authentication by the resident and the licensee to document the agreement on the services to be provided for two of seven residents (R22, R8) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure resident service plan included a signature or other authentication by the resident and the licensee to document the agreement on the services to be provided for two of seven residents (R22, R8) with records reviewed. [...]”

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 resident service plans included all the required content for seven of seven residents (R5, R23, R20, R22, R4, R3, R21) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure resident service plans included all the required content for seven of seven residents (R5, R23, R20, R22, R4, R3, R21) 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 ensure a current written or electronically recorded prescription was obtained for all medications the provider had managed for two of five residents (R23, R30) with record reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure a current written or electronically recorded prescription was obtained for all medications the provider had managed for two of five residents (R23, R30) with record reviewed. [...]”

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 maintained bearing the original label with legible information for two of two residents (R4, R29) with medication storage reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure medications were maintained bearing the original label with legible information for two of two residents (R4, R29) with medication storage 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 [...]”

MDH’s finding, as written: “Based on interview and record review, the licensee failed to document in the resident's record the disposition of the medication including the medication's name, strength, prescription number as applicable, quantity, to whom the medications were given, date of disposition, and names of staff and other individuals involved in the disposition for two of two discharged residents (R6, R24) with record review. [...]”

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 the care and services were provided according to a suitable, and up-to-date plan, and subject to acceptable health care and medical, or nursing standards for one of three residents (R4) with side rails with records reviewed.

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 a suitable, and up-to-date plan, and subject to acceptable health care and medical, or nursing standards for one of three residents (R4) with side rails with records reviewed. [...]”

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 immediately report to the Minnesota Adult Abuse Reporting Center (MAARC) suspected maltreatment for one of one resident (R1) with record reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to immediately report to the Minnesota Adult Abuse Reporting Center (MAARC) suspected maltreatment for one of one resident (R1) with record reviewed. [...]”

Rule cited: “144G.42 Subd. 6. Compliance with requirements for reporting maltreatment of vulnerable adults; abuse prevention plan. (a) The assisted living facility must comply with the requirements for the reporting of maltreatment of vulnerable adults in section 626.557. [...]”

Summary: MDH found the facility failed to ensure development of an individual abuse prevention plan with the required content for one of four residents (R5) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the facility failed to ensure development of an individual abuse prevention plan with the required content for one of four residents (R5) 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 establish and maintain a tuberculosis (TB) prevention program based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC) which included a facility TB risk assessment.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to establish and maintain a tuberculosis (TB) prevention program based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC) which included a facility TB risk assessment. The licensee failed to ensure one of five employees (unlicensed personnel (ULP)-C) had a TB symptom screen and 2 step Tuberculin Skin Test (TST) with 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 develop an all-hazards emergency preparedness program and plan to include Appendix Z required elements.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop an all-hazards emergency preparedness program and plan to include Appendix Z required elements. 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 facility failed to maintain fire extinguishers in accordance with Minnesota State Fire Code as required by MN Statute 144G.45 subd.2(a)(2).

MDH’s finding, as written: “Based on observation and interview, the facility failed to maintain fire extinguishers in accordance with Minnesota State Fire Code as required by MN Statute 144G.45 subd.2(a)(2). This had the potential to affect all residents, staff and visitors. [...]”

Rule cited: “(2) install and maintain portable fire extinguishers in accordance with the State Fire Code; (3) install portable fire extinguishers having a minimum 2-A:10-B:C rating within Group R-3 occupancies, as defined by the State Fire Code, located so that the travel [...]”

Summary: MDH found the licensee failed to maintain 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 as required by MN Statute 144G.45, subd.2(a)(4).

MDH’s finding, as written: “Based on observation and interview, the licensee failed to maintain 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 as required by MN Statute 144G.45, subd.2(a)(4). This had the potential to 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 facility failed to maintain the physical environment in a condition that does not create a distinct hazard to residents and staff as required by MN Statute 144G.45, subd.2(g).

MDH’s finding, as written: “Based on observation and interview, the facility failed to maintain the physical environment in a condition that does not create a distinct hazard to residents and staff as required by MN Statute 144G.45, subd.2(g). This had the potential to affect all current residents, staff and visitors. [...]”

Rule cited: “(g) Existing construction or elements, including assisted living facilities that were registered as housing with services establishments under chapter 144D prior to August 1, 2021, shall be permitted to continue in use provided such use does not constitute a [...]”

Summary: MDH found the licensee failed to develop and execute a written assisted living contract prior to providing assisted living services for six of six residents (R3, R5, R4, R8, R9, R1) 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 prior to providing assisted living services for six of six residents (R3, R5, R4, R8, R9, R1) 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 facility failed to ensure training and competency evaluations were completed as required prior to providing direct care to residents for three of three unlicensed personnel (ULP-I, ULP-B, ULP-C) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the facility failed to ensure training and competency evaluations were completed as required prior to providing direct care to residents for three of three unlicensed personnel (ULP-I, ULP-B, ULP-C) with records reviewed. [...]”

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 and competency evaluations were completed as required prior to providing direct care to residents for two of three unlicensed personnel (ULP-B, ULP-C) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure training and competency evaluations were completed as required prior to providing direct care to residents for two of three unlicensed personnel (ULP-B, ULP-C) 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 [...]”

Summary: MDH found the licensee failed to ensure a registered nurse (RN) conducted direct supervision of staff performing a delegated task within 30 days of providing services to residents for three of three unlicensed personnel (ULP-I, ULP-B, ULP-C) with records reviewed.

MDH’s finding, as written: “Based on observation, 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 to residents for three of three unlicensed personnel (ULP-I, ULP-B, ULP-C) with records reviewed. [...]”

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 facility failed to ensure employees received orientation to include the required content for four of four employees (unlicensed personnel (ULP)-I, ULP-C, ULP-B, and licensed practical nurse (LPN)-M) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the facility failed to ensure employees received orientation to include the required content for four of four employees (unlicensed personnel (ULP)-I, ULP-C, ULP-B, and licensed practical nurse (LPN)-M) 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 [...]”

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure four of four direct-care staff (unlicensed personnel (ULP)-I, ULP-B, ULP-C, and licensed practical nurse (LPN)-M) completed the required amount of dementia care training in the required time frame with records reviewed. [...]”

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 a change in condition assessment was completed for one of one resident (R4) with record reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure a change in condition assessment was completed for one of one resident (R4) with record 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) and was issued at an isolated scope (when one or a limited number of residents are affected or one or a limited number of staff are involved, or the [...]”

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 resident service plan included a signature or other authentication by the resident and the licensee to document the agreement on the services to be provided for six of six residents (R3, R5, R1, R8, R9, R4) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure resident service plan included a signature or other authentication by the resident and the licensee to document the agreement on the services to be provided for six of six residents (R3, R5, R1, R8, R9, R4) with records reviewed. [...]”

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 facility failed to ensure resident service plans included all the required content for three of four residents (R3, R5, and R4) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the facility failed to ensure resident service plans included all the required content for three of four residents (R3, R5, and R4) 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 ensure the registered nurse (RN) completed annual medication re-assessments for three of three residents (R3, R1, R4) with records reviewed.

MDH’s finding, as written: “Based on observation and record review, the licensee failed to ensure the registered nurse (RN) completed annual medication re-assessments for three of three residents (R3, R1, R4) with records reviewed. [...]”

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 an individualized medication management record with the required content for two of four residents (R3, R7) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to develop an individualized medication management record with the required content for two of four residents (R3, R7) 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 current written or electronically recorded prescriptions were obtained for all medications the provider managed for one of eight residents (R7) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure current written or electronically recorded prescriptions were obtained for all medications the provider managed for one of eight residents (R7) with records reviewed. [...]”

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.”

MDH’s finding, as written: “Based on observation, interview and record review the facility failed to renew prescriptions at least every 12 months for four of five residents (R3, R1, R4 and R8) with records reviewed. [...]”

Rule cited: “Prescriptions must be renewed at least every 12 months or more frequently as indicated by the assessment in subdivision 2. Prescriptions for controlled substances must comply with chapter 152.”

Summary: MDH found the facility failed to label time sensitive medications with a date when opened for two of two residents (R3, R7) who received medication management services.

MDH’s finding, as written: “Based on observation, interview, and record review, the facility failed to label time sensitive medications with a date when opened for two of two residents (R3, R7) who received medication management services. [...]”

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 disposition of medications, including the medication's name, strength, prescription number as applicable, quantity, to whom the medications were given, date of disposition, and names of staff and other individuals involved in the disposition for one of one discharged resident (R2) with record review.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to document in the resident's record the disposition of medications, including the medication's name, strength, prescription number as applicable, quantity, to whom the medications were given, date of disposition, and names of staff and other individuals involved in the disposition for one of one discharged resident (R2) with record review. [...]”

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 have a signed service plan for the treatment or therapy services that will be provided to one of one resident (R7) for diabetic blood sugar monitoring with record reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to have a signed service plan for the treatment or therapy services that will be provided to one of one resident (R7) for diabetic blood sugar monitoring with record 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 ensure up-to-date written or electronically recorded orders were maintained for one of three residents (R7) receiving treatments for records reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed ensure up-to-date written or electronically recorded orders were maintained for one of three residents (R7) receiving treatments for records reviewed. [...]”

Rule cited: “There must be an up-to-date written or electronically recorded order from an authorized prescriber for all treatments and therapies. [...]”

Summary: MDH found the licensee failed to ensure the current Minnesota Bill of Rights for Assisted Living Residents and information about how to make a complaint was provided to residents and a written acknowledgement received for six of six residents (R3, R5, R1, R8, R9, R4) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure the current Minnesota Bill of Rights for Assisted Living Residents and information about how to make a complaint was provided to residents and a written acknowledgement received for six of six residents (R3, R5, R1, R8, R9, R4) 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 provide the care and services according to acceptable health care, medical, or nursing standards for two of two residents (R6 and R1) with side rails with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to provide the care and services according to acceptable health care, medical, or nursing standards for two of two residents (R6 and R1) with side rails with records reviewed. [...]”

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 in double occupancy room for 10 of 46 residents (R6, R10, R12, R13, R14, R15, R16, R17, R18 and R19) with records reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure privacy in double occupancy room for 10 of 46 residents (R6, R10, R12, R13, R14, R15, R16, R17, R18 and R19) 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. [...]”

Summary: MDH found the licensee failed to immediately report to the Minnesota Adult Abuse Reporting Center (MAARC) suspected maltreatment for one of one resident (R1) with record reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to immediately report to the Minnesota Adult Abuse Reporting Center (MAARC) suspected maltreatment for one of one resident (R1) with record reviewed. [...]”

Rule cited: “(a) A mandated reporter who has reason to believe that a vulnerable adult is being or has been maltreated, or who has knowledge that a vulnerable adult has sustained a physical injury which is not reasonably explained shall immediately report the information [...]”