Encore at Mahtomedi

Summary: MDH found the licensee failed to provide working emergency lighting, emergency power to exit signs, and access to the public was from the first-floor patio.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to provide working emergency lighting, emergency power to exit signs, and access to the public was from the first-floor patio. This deficient condition had the ability to affect all staff and residents. [...]”

Rule cited: “for dwellings or sleeping units, as defined in the State Fire Code: (i) provide smoke alarms in each room used for sleeping purposes; (ii) provide smoke alarms outside each separate sleeping area in the immediate vicinity of bedrooms; (iii) provide smoke [...]”

Summary: MDH found the licensee failed to maintain the portable fire extinguishers.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to maintain the portable fire extinguishers. This deficient condition had the potential to affect all staff, residents, 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 develop the fire safety and evacuation plan with the required content and provide the required training and drills.

MDH’s finding, as written: “Based on interview, and record review, the licensee failed to develop the fire safety and evacuation plan with the required content and provide the required training and drills. This had the potential to directly affect all 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 develop and execute a written contract with the required content upon implementation of Assisted Living Licensure for one of three residents (R2).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop and execute a written contract with the required content upon implementation of Assisted Living Licensure for one of three residents (R2). [...]”

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 ensure training and competency evaluations were completed in all required skill areas, prior to providing services, for two of two unlicensed personnel ((ULP)-D, ULP-E).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure training and competency evaluations were completed in all required skill areas, prior to providing services, for two of two unlicensed personnel ((ULP)-D, ULP-E). [...]”

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 a registered nurse (RN) conducted direct supervision of staff performing a delegated task within 30 days of providing services for two of two unlicensed personnel ((ULP)-D, ULP-E).

MDH’s finding, as written: “Based on 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 for two of two unlicensed personnel ((ULP)-D, ULP-E). [...]”

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 licensee failed to ensure employees received at least eight hours of annual training for each 12 months of employment in the required annual training topics for two of two employees (clinical nurse supervisor (CNS)-B, and unlicensed personnel (ULP)-E).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure employees received at least eight hours of annual training for each 12 months of employment in the required annual training topics for two of two employees (clinical nurse supervisor (CNS)-B, and unlicensed personnel (ULP)-E). [...]”

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

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the registered nurse (RN) completed ongoing resident reassessments not exceed 90 days for two of three residents (R2, R6). [...]”

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 current service plans included a signature or other authentication by the resident to document agreement on the services to be provided for three of three residents (R2, R6, R7).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure current service plans included a signature or other authentication by the resident to document agreement on the services to be provided for three of three residents (R2, R6, R7). [...]”

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 registered nurse (RN) completed face-to-face medication management re-assessments at least annually for one of three residents (R7) with record reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) completed face-to-face medication management re-assessments at least annually for one of three residents (R7) with record 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 documentation of medication setup included all the required content for two of two residents (R9, R10).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure documentation of medication setup included all the required content for two of two residents (R9, R10). [...]”

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 prescription medications were securely locked in a substantially constructed compartment and permitted only authorized personnel to have access.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure prescription medications were securely locked in a substantially constructed compartment and permitted only authorized personnel to have access. This had the potential to affect all residents in the facility. [...]”

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 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 beyond-use date of a time-dated drug.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medications were 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 beyond-use date of a time-dated drug. In addition, the licensee failed to dispose of expired medications. This had a potential to affect all residents. [...]”

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 ensure policies and procedures for assisted living with dementia care (ALFDC) were provided to residents or the resident's legal and / or designated representative at the time of move-in or at the time they began receiving

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure policies and procedures for assisted living with dementia care (ALFDC) were provided to residents or the resident's legal and / or designated representative at the time of move-in or at the time they began receiving assisted living services for three of four residents (R2, R6, R7). [...]”

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 a written acknowledgement of receipt of the current assisted living bill of rights was obtained for three

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure a written acknowledgement of receipt of the current assisted living bill of rights was obtained for three of three residents (R2, R6, and R7). [...]”

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 care and services according to acceptable health care, medical or nursing standards for two of two residents (R2, R6) who utilized hospital bed rails.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to provide care and services according to acceptable health care, medical or nursing standards for two of two residents (R2, R6) who utilized hospital bed rails. Additionally, the licensee failed to provide care and services according to acceptable health care standards, medical, or nursing standards for one of one resident (R6) who utilized oxygen. [...]”

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.”