Fairway Pines Senior Living

Summary: MDH found the licensee failed to provide required employee training on fire safety and evacuation.

MDH’s finding, as written: “Based on a record review and interview, the licensee failed to provide required employee training on fire safety and evacuation. This had the potential to affect all staff, residents, 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 resident agreement arbitration requirement did not include a choice of venue provision.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the resident agreement arbitration requirement did not include a choice of venue provision. This practice resulted in a level one violation, 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 the residents). [...]”

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 the registered nurse (RN) provided written instructions in the resident's record for the delegated tasks provided by the unlicensed personnel (ULP) for three of three residents (R6, R8, R5) using Broda Chair (a wheelchair offering tilt-n-space positioning with a seating system which prevents skin breakdown through reducing heat and moisture) motion alarm (special type of sensor that alerts movement) and skin care and catheter care (a tube that is inserted into your bladder, allowing your urine to drain freely.)

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) provided written instructions in the resident's record for the delegated tasks provided by the unlicensed personnel (ULP) for three of three residents (R6, R8, R5) using Broda Chair (a wheelchair offering tilt-n-space positioning with a seating system which prevents skin breakdown through reducing heat and moisture) motion alarm (special type of sensor that alerts movement) and skin care [...]”

Rule cited: “(b) When the registered nurse or licensed health professional delegates tasks to unlicensed personnel, that person must ensure that prior to the delegation the unlicensed personnel is trained in the proper methods to perform the tasks or procedures for each [...]”

Summary: MDH found the licensee failed to ensure a registered nurse (RN) conducted assessments with the uniform assessment tool that included all required content for four of four residents (R2, R3, R4, R7).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure a registered nurse (RN) conducted assessments with the uniform assessment tool that included all required content for four of four residents (R2, R3, R4, R7). [...]”

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 two of four residents (R4, R6) service plans were revised to include provided services.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure two of four residents (R4, R6) service plans were revised to include provided services. [...]”

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) prepared in writing specific instructions for each resident and documented those instructions for one of four residents (R8).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) prepared in writing specific instructions for each resident and documented those instructions for one of four residents (R8). [...]”

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 administered per manufacturer's instructions and the licensee's policy for two of four residents (R7, R5) observed during medication administration.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure medications were administered per manufacturer's instructions and the licensee's policy for two of four residents (R7, R5) observed during medication administration. In addition, the licensee failed to ensure the steps of the medication administration process was followed for one of three employees (unlicensed personnel/ULP-D) observed administering medications for one of five residents (R5). [...]”

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 maintained bearing the original prescription label with legible information including the expiration date for time sensitive medications for one of one resident (R7).

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 with legible information including the expiration date for time sensitive medications for one of one resident (R7). [...]”

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 the registered nurse (RN) specified, in writing,

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 for two of four residents (R2, R3) receiving treatment management services. [...]”

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: “Surveyor: Umlauf, Sara J. Based on observation, interview and record review, the licensee failed to ensure treatment or therapy services were documented for one of one resident (R2). [...]”

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 up-to-date written or electronically recorded orders were maintained for two of four residents (R3, R4) who received treatments managed by the provider.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure up-to-date written or electronically recorded orders were maintained for two of four residents (R3, R4) who received treatments managed by the provider. [...]”

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 written individualized activity evaluation that addressed all six provisions.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to conduct a written individualized activity evaluation that addressed all six provisions. In addition, the licensee failed to develop a complete individual activity plan (IAP) for one of one resident (R6) 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. [...]”

Summary: MDH found the licensee failed to provide care and services according to acceptable health care, medical, or nursing standards for storage of cleaning supplies.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to provide care and services according to acceptable health care, medical, or nursing standards for storage of cleaning supplies. [...]”

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.”