Essence Care Center

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure a menu prepared in advance included all meals and snacks. This had the potential to affect all residents. [...]”

Rule cited: “(13) offer to provide or make available at least the following services to residents: (i) at least three nutritious meals daily with snacks available seven days per week, according to the recommended dietary allowances in the United States Department of [...]”

Summary: MDH found the licensee failed to have a daily program of social and recreational activities.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to have a daily program of social and recreational activities. This had the potential to affect all residents receiving assisted living services. [...]”

Rule cited: “(ii) weekly housekeeping; (iii) weekly laundry service; (iv) upon the request of the resident, provide direct or reasonable assistance with arranging for transportation to medical and social services appointments, shopping, and other recreation, and provide [...]”

Summary: MDH found the licensee failed to establish and maintain an infection control program to comply with accepted health care, medical, and nursing standards for infection control and current recommendations for COVID-19.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to establish and maintain an infection control program to comply with accepted health care, medical, and nursing standards for infection control and current recommendations for COVID-19. This had the potential to affect all residents, staff and visitors. [...]”

Rule cited: “(a) All assisted living facilities must establish and maintain an infection control program that complies with accepted health care, medical, and nursing standards for infection control. [...]”

Summary: MDH found the licensee failed to post information related to the grievance procedure, resident advocacy information, and information for reporting suspected maltreatment.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to post information related to the grievance procedure, resident advocacy information, and information for reporting suspected maltreatment. This had the potential to affect all residents, staff and visitors. [...]”

Rule cited: “All facilities must post in a conspicuous place information about the facilities' grievance procedure, and the name, telephone number, and e-mail contact information for the individuals who are responsible for handling resident grievances. [...]”

Summary: MDH found the licensee failed to ensure an individual abuse prevention plan included statements of the specific measures to be taken to minimize the risk of abuse to that person and other vulnerable adults for identified vulnerabilities for one of one resident (R1) with record reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure an individual abuse prevention plan included statements of the specific measures to be taken to minimize the risk of abuse to that person and other vulnerable adults for identified vulnerabilities for one of one resident (R1) with record 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 ensure employee records included all required content for one of two unlicensed personnel (ULP-C) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure employee records included all required content for one of two unlicensed personnel (ULP-C) 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. [...]”

MDH’s finding, as written: “Based on observation, interview and record review the licensee failed to establish and maintain a TB (tuberculosis) prevention and control program based on the most current guidelines issued by the centers for Disease Control and Prevention (CDC) guidelines. This had the potential to affect all residents, staff and visitors. [...]”

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 ensure emergency exit diagrams were posted, failed to develop an all-hazards emergency preparedness (EP)

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure emergency exit diagrams were posted, failed to develop an all-hazards emergency preparedness (EP) program and plan to include Appendix Z required elements. This had the potential to affect all two (2) residents in the facility, staff and any 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 provide smoke alarms in rooms used for sleeping and ensure smoke alarms are interconnected so that the actuation of one alarm causes all alarms in the dwelling to actuate as

MDH’s finding, as written: “Based on observation and interview, the licensee failed to provide smoke alarms in rooms used for sleeping and ensure smoke alarms are interconnected so that the actuation of one alarm causes all alarms in the dwelling to actuate as required. This had the potential to directly affect all residents, staff, and visitors. [...]”

Rule cited: “(a) Each assisted living facility must comply with the State Fire Code in Minnesota Rules, chapter 7511, and: (1) for dwellings or sleeping units, as defined in the State Fire Code: (i) provide smoke alarms in each room used for sleeping purposes; (ii) [...]”

Summary: MDH found the licensee failed to ensure installation and maintenance of portable fire extinguishers at the facility.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to ensure installation and maintenance of portable fire extinguishers at the facility. This had the potential to directly 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 facility's physical environment in a continuous state of good repair and operation regarding the health, safety, and well-being of the residents.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to maintain the facility's physical environment in a continuous state of good repair and operation regarding the health, safety, and well-being of the residents. This had the potential to directly 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 licensee failed to provide the required fire safety training and evacuation plans for residents and staff.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to provide the required fire safety training and evacuation plans for residents and staff. This has 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 ensure the licensee contract contained terms as required and had provided the Office of Ombudsman for Long-Term Care a complete unsigned copy of its contract.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure the licensee contract contained terms as required and had provided the Office of Ombudsman for Long-Term Care a complete unsigned copy of its contract. This had the potential to affect all current residents. [...]”

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 one of one resident (R1) with record 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 one of one resident (R1) with record reviewed. [...]”

Rule cited: “(a) The contract must include in a conspicuous place and manner on the contract the legal name and the license number of the facility. [...]”

Summary: MDH found the licensee failed to execute a written contract with the required content for one of one resident (R1) with record 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 one of one resident (R1) with record reviewed. [...]”

Rule cited: “(c) The contract must include: (1) a disclosure of the category of assisted living facility license held by the facility and, if the facility is not an assisted living facility with dementia care, a disclosure that it does not hold an assisted living facility [...]”

Summary: MDH found the licensee failed to execute a written contract with the required content for one of one resident (R1) with record 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 one of one resident (R1) with record 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 one of one resident (R1) with record 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 one of one resident (R1) with record 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 execute a written contract with the required content for one of one resident (R1) with record 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 one of one resident (R1) with record reviewed. [...]”

Rule cited: “(a) An assisted living facility must clearly and conspicuously disclose, in writing in an assisted living contract, any arbitration provision in the contract that precludes, limits, or delays the ability of a resident from taking a civil action. [...]”

Summary: MDH found the licensee failed to ensure training and competency evaluations contained all the required training for two of two unlicensed personnel (ULP-C, ULP-D) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure training and competency evaluations contained all the required training for two of two unlicensed personnel (ULP-C, ULP-D) 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 direct supervision of staff performing delegated tasks was provided within 30 calendar days after the date on which the individual begins working for the facility for

MDH’s finding, as written: “Based on interview, and record review, the licensee failed to ensure direct supervision of staff performing delegated tasks was provided within 30 calendar days after the date on which the individual begins working for the facility for one of two unlicensed personnel (ULP-D) 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 licensee failed to ensure staff providing services completed an orientation to assisted living facility licensing requirements and regulations before providing services for two of two unlicensed personnel (ULP-C, ULP-D) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure staff providing services completed an orientation to assisted living facility licensing requirements and regulations before providing services for two of two unlicensed personnel (ULP-C, ULP-D) 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 [...]”

Summary: MDH found the licensee failed to ensure direct care staff completed the required amount of dementia care training in the required time frame for two of four employees (unlicensed personnel (ULP)-C, licensed assisted living director (LALD)-A) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure direct care staff completed the required amount of dementia care training in the required time frame for two of four employees (unlicensed personnel (ULP)-C, licensed assisted living director (LALD)-A) 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 staff completed the required training for all topics for dementia care for two of two employees (unlicensed personnel (ULP)-D, registered nurse (RN)-B), with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure staff completed the required training for all topics for dementia care for two of two employees (unlicensed personnel (ULP)-D, registered nurse (RN)-B), with records reviewed. [...]”

Rule cited: “(5) new employees may satisfy the initial training requirements by producing written proof of previously completed required training within the past 18 months. [...]”

Summary: MDH found the licensee failed to ensure the service plan included a signature or other authentication

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure the service plan included a signature or other authentication by the resident and the facility to document agreement on the services provided for one of one resident (R1) with record 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

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure the service plan included all required content for one of one resident (R1) 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 an assessment for self administration of medication for one of one resident (R1) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure an assessment for self administration of medication for one of one resident (R1) 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) developed written procedures for unplanned time away from home.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) developed written procedures for unplanned time away from home. In addition, the licensee failed to ensure two of two unlicensed personnel (ULP-C, ULP-D) were trained and had demonstrated competency to prepare and give medications for residents having unplanned time away 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 access to

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure access to keys for medication storage was secure. This had the potential to affect all residents. [...]”

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 include in the service plan a written statement of the treatment or therapy services that would be provided, and develop and maintain a current individualized treatment and therapy management record for one of one resident (R1) with record reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to include in the service plan a written statement of the treatment or therapy services that would be provided, and develop and maintain a current individualized treatment and therapy management record for one of one resident (R1) 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 to ensure the registered nurse (RN) specified, in writing, specific instructions and documented those instructions in the resident record for one of one resident (R1) and two of two unlicensed personnel (ULP-C, ULP-D) were instructed in the proper methods and had demonstrated the ability to competently follow the procedures, with records reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) specified, in writing, specific instructions and documented those instructions in the resident record for one of one resident (R1) and two of two unlicensed personnel (ULP-C, ULP-D) were instructed in the proper methods and had demonstrated the ability to competently follow the procedures, with records reviewed. [...]”

Rule cited: “Ordered or prescribed treatments or therapies must be administered by a nurse, physician, or other licensed health professional authorized to perform the treatment or therapy, or may be delegated or assigned to unlicensed personnel by the licensed health [...]”

MDH’s finding, as written: “Based on observation, interview and record review the licensee failed to ensure documentation and administration of treatment as prescribed for one of one resident (R1) with record reviewed. [...]”

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 ensure there were current treatment and therapy orders that

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure there were current treatment and therapy orders that included the frequency, duration, and other required information needed for one of one resident (R1) with record 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 conduct a hazard vulnerability or safety risk assessment on or around the facility property.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to conduct a hazard vulnerability or safety risk assessment on or around the facility property. This had the potential to directly affect all 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 the assisted living facility with dementia care provided the required policies and procedures to one of one resident (R1) with record reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the assisted living facility with dementia care provided the required policies and procedures to one of one resident (R1) with record reviewed. [...]”

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 designate a qualified person to

MDH’s finding, as written: “Based on interview and record review, the licensee failed to designate a qualified person to oversee staff training in the care of individuals with dementia. This had the potential to affect all residents, staff and visitors. [...]”

Rule cited: “Persons providing or overseeing staff training must have experience and knowledge in the care of individuals with dementia, including: (1) two years of work experience related to Alzheimer's disease or other dementias, or in health care, gerontology, or [...]”

Summary: MDH found the licensee failed to ensure evaluation for activities for one of one resident (R1) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure evaluation for activities for one of one resident (R1) 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), 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 portion or all of [...]”

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 behavioral symptoms identified were addressed on the care plan for one of one resident (R1) with record reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure behavioral symptoms identified were addressed on the care plan for one of one resident (R1) with record reviewed. [...]”

Rule cited: “(e) Behavioral symptoms that negatively impact the resident and others in the assisted living facility with dementia care must be evaluated and included on the service or care plan. [...]”

Summary: MDH found the licensee failed to ensure the current Minnesota Bill of Rights for Assisted Living Residents was provided to the resident and a written acknowledgement received for one of one resident (R1) with record reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the current Minnesota Bill of Rights for Assisted Living Residents was provided to the resident and a written acknowledgement received for one of one resident (R1) with record reviewed. This had the potential to affect all residents. [...]”

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 in written or electronic form to residents, families, or other persons who request it, a description of the dementia care training program, the categories of employees trained, the frequency of training, and the basic topics covered with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide in written or electronic form to residents, families, or other persons who request it, a description of the dementia care training program, the categories of employees trained, the frequency of training, and the basic topics covered with records reviewed. [...]”

Rule cited: “An assisted living facility with dementia care shall make available in written or electronic form, to residents and families or other persons who request it, a description of the training program and related training it provides, including the categories of [...]”

Summary: MDH found the licensee failed to ensure the required notice was posted at the main entry way of the establishment to display statutory language to disclose electronic monitoring activity, potentially affecting all current residents in the assisted living facility, staff and any visitors of the licensee.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to ensure the required notice was posted at the main entry way of the establishment to display statutory language to disclose electronic monitoring activity, potentially affecting all current residents in the assisted living facility, staff and any visitors of the licensee. [...]”

Rule cited: “Subd. 8.Notice to visitors. (a) A facility must post a sign at each facility entrance accessible to visitors that states: "Electronic monitoring devices, including security cameras and audio devices, may be present to record persons and activities." (b) The [...]”