Falls Landing Assisted Living

Summary: MDH found the licensee failed to ensure the employee record contained the required content for three of three employees (unlicensed personnel (ULP)-C and ULP-D, and registered nurse (RN)-B reviewed.

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

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 develop and have available a written emergency disaster plan with all required content outlined in Appendix Z. This had the potential to affect all current residents, staff, and visitors.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to develop and have available a written emergency disaster plan with all required content outlined in Appendix Z. This had the potential to affect all 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 ensure resident records were protected against unauthorized disclosure of both electronic and written records.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure resident records were protected against unauthorized disclosure of both electronic and written records. [...]”

Rule cited: “(b) Resident records, whether written or electronic, must be protected against loss, tampering, or unauthorized disclosure in compliance with chapter 13 and other applicable relevant federal and state laws. [...]”

Summary: MDH found the licensee failed provide smoke alarms in all sleeping rooms throughout the facility.

MDH’s finding, as written: “Based on observation and interview, the licensee failed provide smoke alarms in all sleeping rooms throughout the facility. This deficient condition had the ability to affect all staff and residents. [...]”

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 develop a fire safety and evacuation plan with required elements.

MDH’s finding, as written: “Based on a record review and interview, the licensee failed to develop a fire safety and evacuation plan with required elements. 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 two of two unlicensed personnel (ULP)-C and ULP-D) completed training and competency evaluations in all required training topics.

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

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 two of two unlicensed personnel (ULP)-C and ULP-D completed training and competency evaluations in all required training topics.

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

Rule cited: “(b) In addition to paragraph (a), training and competency evaluation for unlicensed personnel providing assisted living services must include: (1) observing, reporting, and documenting resident status; (2) basic knowledge of body functioning and changes in [...]”

Summary: MDH found the licensee failed to ensure the registered nurse (RN) conducted direct

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure the registered nurse (RN) conducted direct supervision of staff performing delegated nursing or therapy tasks within 30 days of first providing those services for one of two unlicensed personnel (ULP)-F with employee 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 orientation to assisted living facility statutes included all the required content for three of three employees (unlicensed personnel (ULP)-C, ULP-D, and registered nurse (RN)-B) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure orientation to assisted living facility statutes included all the required content for three of three employees (unlicensed personnel (ULP)-C, ULP-D, and registered nurse (RN)-B) 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 three of three employees (unlicensed personnel (ULP)-C, ULP-D and registered nurse (RN)-B) received the required amount of dementia care training, in the required time frame in accordance with 144G.64 with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure three of three employees (unlicensed personnel (ULP)-C, ULP-D and registered nurse (RN)-B) received the required amount of dementia care training, in the required time frame in accordance with 144G.64 with records reviewed. [...]”

Rule cited: “(a) All assisted living facilities must meet the following training requirements: (1) supervisors of direct-care staff must have at least eight hours of initial training on topics specified under paragraph (b) within 120 working hours of the employment start [...]”

Summary: MDH found the licensee failed to ensure ongoing comprehensive assessments were completed timely for six of six residents (R5, R4, R6, R7, R8 and R2), and failed to complete a change in condition assessment was for one of one resident (R2) with record

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure ongoing comprehensive assessments were completed timely for six of six residents (R5, R4, R6, R7, R8 and R2), and failed to complete a change in condition assessment was for one of one resident (R2) with record 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 the service plan included the required content for two of three residents (R4, R5) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the service plan included the required content for two of three residents (R4, R5) 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 have a medication assessment for three of three residents (R2, R5, and R7) that included interventions needed in management of medications to prevent diversion of medication by the resident or others who may have access to the medications and provide instructions to the resident and legal or designated representatives on interventions to manage the resident's medications to prevent diversion of medications.

MDH’s finding, as written: “Based on interview and document review, the licensee failed to have a medication assessment for three of three residents (R2, R5, and R7) that included interventions needed in management of medications to prevent diversion of medication by the resident or others who may have access to the medications and provide instructions to the resident and legal or designated representatives on interventions to manage the resident's medications to prevent diversion of medications. [...]”

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) completed annual medication re-assessments 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 registered nurse (RN) completed annual medication re-assessments for one of two 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 develop an individualized medication management record with the required content for three of three residents (R2, R5, and R6) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to develop an individualized medication management record with the required content for three of three residents (R2, R5, and R6) with records reviewed. [...]”

Rule cited: “(a) For each resident receiving medication management services, the assisted living facility must prepare and include in the service plan a written statement of the medication management services that will be provided to the resident. [...]”

Summary: MDH found the licensee failed to ensure one of one unlicensed personnel (ULP-C) completed training and competency evaluations in all required training topics.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure one of one unlicensed personnel (ULP-C) completed training and competency evaluations in all required training topics. This resulted in an immediate order issued on July 15, 2022, at approximately 1:40 p.m. [...]”

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 facility failed to renew prescriptions at least every 12 months for three of three residents (R2, R4, and R7) with record reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the facility failed to renew prescriptions at least every 12 months for three of three residents (R2, R4, and R7) with record reviewed. [...]”

Rule cited: “Prescriptions must be renewed at least every 12 months or more frequently as indicated by the assessment in subdivision 2. Prescriptions for controlled substances must comply with chapter 152.”

Summary: MDH found the licensee failed to ensure time sensitive medications were dated when opened and had a pharmacy label for two of two residents (R2 and R3) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure time sensitive medications were dated when opened and had a pharmacy label for two of two residents (R2 and R3) with records reviewed. [...]”

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 upon disposition, document in the resident's record the disposition of the medication including the medication's prescription number as applicable for one of one discharged resident (R9) with record review.

MDH’s finding, as written: “Based on interview and record review, the licensee failed upon disposition, document in the resident's record the disposition of the medication including the medication's prescription number as applicable for one of one discharged resident (R9) with record review. [...]”

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 record to include all required content for five of five residents (R2, R4, R5, R6, and R8) 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 record to include all required content for five of five residents (R2, R4, R5, R6, and R8) 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 unlicensed personnel were trained and demonstrated competency in treatments to a registered nurse

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure unlicensed personnel were trained and demonstrated competency in treatments to a registered nurse (RN) for three of three unlicensed personnel (ULP-C, ULP-D and ULP-E) 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 [...]”

Summary: MDH found the licensee failed to ensure a written prescriber's order for a treatment was obtained for two of five residents (R2 and R6) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure a written prescriber's order for a treatment was obtained for two of five residents (R2 and R6) with records 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 ensure the care and services were provided according to acceptable health care and medical, or nursing standards for one of one resident (R2) with bilateral half siderails, with record 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 one of one resident (R2) with bilateral half siderails, with record reviewed. This resulted in an immediate correction order on June 6, 2022, at 10:00 a.m. [...]”

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.”