Emerald Crest of Shakopee

Summary: MDH found the licensee failed to immediately report an incident to the Minnesota Adult Abuse Reporting Center (MAARC) for one of one resident (R3) who did not return to the facility, after being allowed to leave the facility against the family's wishes, with record reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to immediately report an incident to the Minnesota Adult Abuse Reporting Center (MAARC) for one of one resident (R3) who did not return to the facility, after being allowed to leave the facility against the family's wishes, 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 licensee failed to ensure the employee record contained the required content for two of five employees (registered nurse (RN)-B, unlicensed

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the employee record contained the required content for two of five employees (registered nurse (RN)-B, unlicensed personnel (ULP)-A), with records reviewed. [...]”

Rule cited: “(a) The facility must maintain current records of each paid employee, each regularly scheduled volunteer providing services, and each individual contractor providing services. [...]”

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 documentation of a completed health history and symptom screening, including completion of a two-step TST (tuberculin skin test) or other evidence of TB screening such as a blood test for two of five employees (unlicensed personnel (ULP)-B, ULP-A) with records reviewed.

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 documentation of a completed health history and symptom screening, including completion of a two-step TST (tuberculin skin test) or other evidence of TB screening such as a blood test for two of five employees (unlicensed personnel (ULP)-B, ULP-A) with records [...]”

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 facility failed to require evacuation drills twice per year per shift with at least one evacuation drill every other month, as required by MN Statute 144G.45 Subd.2(f).

MDH’s finding, as written: “Based on observation, record review and interview, the facility failed to require evacuation drills twice per year per shift with at least one evacuation drill every other month, as required by MN Statute 144G.45 Subd.2(f). 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 ensure the registered nurse (RN) completed an initial, comprehensive nursing assessment prior to signing the assisted living contract/providing services for one of one resident (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 an initial, comprehensive nursing assessment prior to signing the assisted living contract/providing services for one of one resident (R2) as required, with records reviewed. [...]”

Rule cited: “(a) Residents who are not receiving any services shall not be required to undergo an initial nursing assessment. [...]”

Summary: MDH found the licensee failed to conduct an ongoing resident reassessment and monitoring, as needed based on changes in the needs of the resident 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 conduct an ongoing resident reassessment and monitoring, as needed based on changes in the needs of the resident for two of two residents (R1, R2), 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 services plans were revised to reflect the current services provided for one of two residents (R3) reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure services plans were revised to reflect the current services provided for one of two residents (R3) 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 the service plan included the required content for one of one resident (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 the required content for one of one resident (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 ensure two of three unlicensed personnel (ULP-A, ULP-B) demonstrated competency for administering oral medications to residents.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure two of three unlicensed personnel (ULP-A, ULP-B) demonstrated competency for administering oral medications to residents. [...]”

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 medications were transcribed and administered as prescribed for one of four residents (R6) with records reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medications were transcribed and administered as prescribed for one of four residents (R6) 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 medications were secure and permitted only authorized personnel access, for one of three medication storage areas (House #3) with records reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medications were secure and permitted only authorized personnel access, for one of three medication storage areas (House #3) with records reviewed. [...]”

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 with time sensitive dates were not expired, for one of one resident (R10) reviewed, during observation of medication storage.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medications with time sensitive dates were not expired, for one of one resident (R10) reviewed, during observation of medication storage. [...]”

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

MDH’s finding, as written: “Based on observation, 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 the treatment in the service plan for one of two residents (R3) 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 treatment or therapies were administered as directed, or to document the reason they were not administered, and any follow up procedures that were provided to meet the resident's needs, for one of one resident (R1) receiving blood glucose monitoring with records reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure treatment or therapies were administered as directed, or to document the reason they were not administered, and any follow up procedures that were provided to meet the resident's needs, for one of one resident (R1) receiving blood glucose monitoring with records reviewed. [...]”

Rule cited: “Each treatment or therapy administered by an assisted living facility must be in the resident record. [...]”

Summary: MDH found the facility failed to provide hazard vulnerability assessment or safety risk, as required by MN Statute 144G.81 Subd.1 (a).

MDH’s finding, as written: “Based on record review and interview, the facility failed to provide hazard vulnerability assessment or safety risk, as required by MN Statute 144G.81 Subd.1 (a). This had the potential to affect all current residents, staff 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 dementia cares services provided to residents that promoted dignity for two of two residents (R7, R8) with records reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure dementia cares services provided to residents that promoted dignity for two of two residents (R7, R8) 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 privacy was maintained for one of one resident (R6) observed during medication administration.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure privacy was maintained for one of one resident (R6) observed during medication administration. [...]”

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 an incident to the Minnesota Adult Abuse Reporting Center (MAARC) for one of one resident (R3) who did not return to the facility, after being allowed to leave the facility against the family's wishes, with record reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to immediately report an incident to the Minnesota Adult Abuse Reporting Center (MAARC) for one of one resident (R3) who did not return to the facility, after being allowed to leave the facility against the family's wishes, 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 [...]”