Ely Carefree Living by Oxford

Summary: MDH found the licensee failed to execute a written assisted living contract with the required content for three of three residents (R1, R2, R5).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to execute a written assisted living contract with the required content for three of three residents (R1, R2, R5). This had the potential to affect all 39 residents. [...]”

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 ensure an employee received all the required content for annual training for each 12 months of employment for one of one employee (registered nurse (RN)-K).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure an employee received all the required content for annual training for each 12 months of employment for one of one employee (registered nurse (RN)-K). [...]”

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 service plan included a licensee signature or other authentication by the licensee to document agreement on the services to be provided for one of three residents (R2).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure the service plan included a licensee signature or other authentication by the licensee to document agreement on the services to be provided for one of three residents (R2). [...]”

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 service plans included the required content for three of three residents (R1, R3, R5).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure service plans included the required content for three of three residents (R1, R3, 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) and was issued at a widespread scope (when problems are pervasive or represent a systemic failure that has affected or has the potential to affect a large [...]”

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 and maintain a current individualized medication management record to include all required content for three of three residents (R1, R2, R5).

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 to include all required content for three of three residents (R1, R2, R5). [...]”

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 refrigerated medications were maintained at manufacturer recommended temperatures by failing to monitor and document medication refrigerator temperatures for two of three medication refrigerators.

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 by failing to monitor and document medication refrigerator temperatures for two of three medication refrigerators. [...]”

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 medications were maintained bearing the original prescription label for R1, R8.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure medications were maintained bearing the original prescription label for R1, R8. In addition, the licensee failed to date time-sensitive medications with opened or expiration dates for R10. [...]”

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 include a written statement of the treatment or therapy services to be provided on the service plan for one of three residents (R1).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to include a written statement of the treatment or therapy services to be provided on the service plan for one of three residents (R1). [...]”

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 specific written instructions for each resident were documented in three of three resident's records (R1, R7, R8) who received blood glucose monitoring.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure specific written instructions for each resident were documented in three of three resident's records (R1, R7, R8) who received blood glucose monitoring. [...]”

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 hazard vulnerability assessment or safety risk assessment of the physical environment on and around the property for the facility.

MDH’s finding, as written: “Based on record review and interview, the licensee failed to provide hazard vulnerability assessment or safety risk assessment of the physical environment on and around the property for the facility. This deficient practice had the ability to affect all staff, residents, and visitors. [...]”

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 required dementia care policies and procedures were provided to each resident and/or the resident's legal and designated representatives for two of three residents (R1, R5).

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 each resident and/or the resident's legal and designated representatives for two of three residents (R1, R5). [...]”

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 develop a comprehensive evaluation for activities and an individual activity plan (IAP) for one of one resident (R2) who received services under an assisted living with dementia care license.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to develop a comprehensive evaluation for activities and an individual activity plan (IAP) for one of one resident (R2) 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. [...]”