Elysian Senior Homes of Lake C

Summary: MDH found the licensee failed to ensure the assisted living contract did not include language waiving the facility's liability for health, safety or personal property of a resident.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the assisted living contract did not include language waiving the facility's liability for health, safety or personal property of a resident. This had the potential to affect all residents. [...]”

Rule cited: “The contract must not include a waiver of facility liability for the health and safety or personal property of a resident. [...]”

Summary: MDH found the licensee failed to ensure the service plan included the required content for four of four residents (R10, R2, R4 and R11) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure the service plan included the required content for four of four residents (R10, R2, R4 and R11) 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 document the site of injection for one of two residents (R2) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to document the site of injection for one of two residents (R2) 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 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 three of three residents (R16, R17, and R18) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure documentation of medication setup included all the required content for three of three residents (R16, R17, and R18) with records reviewed. [...]”

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.”

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 [...]”

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 two of five residents (R15, R7) with bedrails, 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 acceptable health care and medical, or nursing standards for two of five residents (R15, R7) with bedrails, 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 have a written emergency preparedness plan with all of the required content.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to have a written emergency preparedness plan with all of the required content. This had the potential to affect all 44 current 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 maintain permanently recorded records for medication setup for one of one resident (R7) with record reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to maintain permanently recorded records for medication setup for one of one resident (R7) with record reviewed. [...]”

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 resident records contained all records of communication pertinent to resident services for two of four residents (R1, R4) with records reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure resident records contained all records of communication pertinent to resident services for two of four residents (R1, R4) 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: “Based on interview and record review, the facility failed to provide documentation of procedures for resident movement, evacuation, or relocation during a fire or similar emergency including the identification of unique or unusual resident needs for movement or evacuation. This had the potential to affect all current residents, staff, and visitors. [...]”

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

Summary: MDH found the licensee failed to execute a written contract prior to providing assisted living services for three of four residents (R1, R3, R4) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to execute a written contract prior to providing assisted living services for three of four residents (R1, R3, R4) 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 execute a written contract with the required content for four of four residents (R1, R2, R3, R4) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to execute a written contract with the required content for four of four residents (R1, R2, R3, R4) 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 execute a written contract with the required content for four of four residents (R1, R2, R3, R4) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to execute a written contract with the required content for four of four residents (R1, R2, R3, R4) 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 the service plan included the required content for four of four residents (R1, R2, R3 and R4) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure the service plan included the required content for four of four residents (R1, R2, R3 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) conducted an individualized assessment to determine what medication management services would be provided, and how the services would be provided for four of four residents (R1, R2, R3 and R4) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the registered nurse (RN) conducted an individualized assessment to determine what medication management services would be provided, and how the services would be provided for four of four residents (R1, R2, R3 and R4) with records reviewed. [...]”

Rule cited: “(a) For each resident who requests medication management services, the facility shall, prior to providing medication management services, have a registered nurse, licensed health professional, or authorized prescriber under section 151.37 conduct an [...]”

Summary: MDH found the licensee failed to ensure the registered nurse (RN) conducted reassessment of medications, which included all the required information for one of four residents (R2) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the registered nurse (RN) conducted reassessment of medications, which included all the required information for one of four residents (R2) 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 ensure medications were administered according to manufacturer's instructions for one of two residents (R8) observed with insulin administration via a prefilled insulin pen; failed to ensure medications were administered as prescribed for two of five residents (R8, R2) and failed to ensure documented site of injection for one of two residents (R2) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure medications were administered according to manufacturer's instructions for one of two residents (R8) observed with insulin administration via a prefilled insulin pen; failed to ensure medications were administered as prescribed for two of five residents (R8, R2) and failed to ensure documented site of injection for one of two residents (R2) 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 ensure documentation of medication setup as required for one of one resident (R7) with record reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure documentation of medication setup as required for one of one resident (R7) with record reviewed. [...]”

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 the registered nurse (RN) developed comprehensive written procedures for the unlicensed personnel (ULP) providing medications for residents having unplanned time away when the licensed nurse was not available, with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the registered nurse (RN) developed comprehensive written procedures for the unlicensed personnel (ULP) providing medications for residents having unplanned time away when the licensed nurse was not available, with records reviewed. [...]”

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 a prescription drug had the original prescription label as required.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure a prescription drug had the original prescription label as required. 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 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 the medications as required for one of one resident (R6) upon discharge, with records reviewed.

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 medications as required for one of one resident (R6) upon discharge, with records reviewed. [...]”

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 develop and implement a treatment or therapy management plan to include all required content and failed to include a written statement in the service plan of the treatment or therapy service being provided for one of three residents (R3) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop and implement a treatment or therapy management plan to include all required content and failed to include a written statement in the service plan of the treatment or therapy service being provided for one of three residents (R3) with records reviewed. In addition, the licensee failed to ensure notification of the registered nurse (RN) for out-of-range blood sugars for one of two residents (R2) 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 prescriber was notified of out-of-range blood sugars for one of two residents (R2) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the prescriber was notified of out-of-range blood sugars for one of two residents (R2) with records reviewed. [...]”

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 interview and record review the licensee failed to ensure up-to-date written or electronically recorded orders were maintained for one of three residents (R3) receiving treatments, with records review. [...]”

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 facility failed to provide the proper documentation that a hazard vulnerability or safety risk assessment had been performed on and around the property.

MDH’s finding, as written: “Based on interview and record review, the facility failed to provide the proper documentation that a hazard vulnerability or safety risk assessment had been performed on and around the property. This has 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 [...]”

Summary: MDH found the licensee failed to develop and implement all required policies and procedures related to dementia care.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop and implement all required policies and procedures related to dementia care. 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 a widespread scope (when problems are pervasive or represent a systemic failure that has [...]”

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 dignity with the provision of cares, failed to utilize nonpharmacological interventions for behaviors and failed to document behavioral symptoms for changes in psychotropic medications for one of two residents (R2) in the memory care unit, with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure dignity with the provision of cares, failed to utilize nonpharmacological interventions for behaviors and failed to document behavioral symptoms for changes in psychotropic medications for one of two residents (R2) in the memory care unit, with records reviewed. [...]”

Rule cited: “(a) In addition to the minimum services required in section 144G.41, an assisted living facility with dementia care must also provide the following services: (1) assistance with activities of daily living that address the needs of each resident with dementia [...]”

Summary: MDH found the licensee failed to ensure an individualized activity plan was developed for two of two residents (R1, R2) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure an individualized activity plan was developed for two of two residents (R1, R2) with records reviewed. [...]”

Rule cited: “(b) Each resident must be evaluated for activities according to the licensing rules of the facility. [...]”

Summary: MDH found the licensee failed to ensure a written acknowledgment of receipt of the current assisted living bill of rights was obtained prior to initiating services for three of four residents (R3, R4, R1) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure a written acknowledgment of receipt of the current assisted living bill of rights was obtained prior to initiating services for three of four residents (R3, R4, R1) 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 three of four residents (R1, R3 and R4) with bedrails, one of one resident (R3) with oxygen storage, and one of two residents (R4) with catheter placement during cares, 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 acceptable health care and medical, or nursing standards for three of four residents (R1, R3 and R4) with bedrails, one of one resident (R3) with oxygen storage, and one of two residents (R4) with catheter placement during cares, 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.”