Family Tree Care Homes

MDH’s finding, as written: “Based on record review and interview, the licensee failed to develop fire safety and evacuation plans with the required elements, failed to provide resident training, and failed to meet the required evacuation drill frequency for employees. These deficient conditions 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 develop and execute a written contract, with the required content for one of one renter (R4) who was residing in the basement apartment of the facility.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to develop and execute a written contract, with the required content for one of one renter (R4) who was residing in the basement apartment of the facility. [...]”

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 the assisted living contract did not include language waiving the facility's liability for health, safety, or personal property of a resident.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the assisted living contract did not include language waiving the facility's liability for health, safety, or personal property of a resident. This had the potential to affect all residents. [...]”

Rule cited: “The contract must not include a waiver of facility liability for the health and safety or personal property of a resident. [...]”

Summary: MDH found the licensee failed to ensure a background study was affiliated with the assisted living license for two of two employees (clinical nurse supervisor/CNS-B, unlicensed personnel/ULP-C).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure a background study was affiliated with the assisted living license for two of two employees (clinical nurse supervisor/CNS-B, unlicensed personnel/ULP-C). [...]”

Rule cited: “(a) Employees, contractors, and regularly scheduled volunteers of the facility are subject to the background study required by section 144.057 and may be disqualified under chapter 245C. [...]”

Summary: MDH found the licensee failed to ensure the security and accountability of controlled substances were maintained for one of one resident (R2).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the security and accountability of controlled substances were maintained for one of one resident (R2). [...]”

Rule cited: “(a) This section applies only to assisted living facilities that provide medication management services. [...]”

Summary: MDH found the licensee failed to ensure a medication management assessment was completed by the registered nurse/RN to determine what medication management services would be provided and included identification and review in all required areas for one of one resident (R2).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure a medication management assessment was completed by the registered nurse/RN to determine what medication management services would be provided and included identification and review in all required areas for one of one resident (R2). [...]”

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 develop and maintain a current individualized medication management plan for each resident to include all required content for one of one resident (R2).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to develop and maintain a current individualized medication management plan for each resident to include all required content for one of one resident (R2). [...]”

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 the steps of the medication administration process was followed for one of two employees (unlicensed personnel/ULP-C) observed administering medications for two of three residents (R2, R3); and failed to ensure medications were administered as ordered for one of three residents (R2) who received medication

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the steps of the medication administration process was followed for one of two employees (unlicensed personnel/ULP-C) observed administering medications for two of three residents (R2, R3); and failed to ensure medications were administered as ordered for one of three residents (R2) who received medication management services. [...]”

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 documentation of medication setup included all the required content for one of one resident (R2).

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 one of one resident (R2). [...]”

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 one of one medication refrigerator maintained an acceptable temperature and medications was stored according to manufacturer's recommended temperature.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure one of one medication refrigerator maintained an acceptable temperature and medications was stored according to manufacturer's recommended temperature. [...]”

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 maintained bearing the original prescription label with legible information including the expiration date for time sensitive medications for two of three residents (R1, R2).

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 two of three residents (R1, R2). [...]”

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, implement, and maintain up-to-date written treatment or therapy management policies and procedures that were developed under the supervision and direction of a registered nurse (RN) consistent with current practice standards and guidelines.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to develop, implement, and maintain up-to-date written treatment or therapy management policies and procedures that were developed under the supervision and direction of a registered nurse (RN) consistent with current practice standards and guidelines. [...]”

Rule cited: “(a) An assisted living facility that provides treatment and therapy management services must develop, implement, and maintain up-to-date written treatment or therapy management policies and procedures. [...]”

Summary: MDH found the licensee failed to develop and implement a treatment or therapy management plan to include all required content for one of two

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 for one of two residents (R2) who had treatments managed by the facility. [...]”

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 care and services were provided according to acceptable health care and medical, or nursing standards with regards to safely storing oxygen for one of two residents (R3).

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 with regards to safely storing oxygen for one of two residents (R3). [...]”

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.”

Summary: MDH found the facility failed to ensure one of one resident (R1) was treated with dignity and respect when unlicensed personnel (ULP)-C provided treatment and medication management services to R1 in a public setting.

MDH’s finding, as written: “Based on observation, interview, and record review, the facility failed to ensure one of one resident (R1) was treated with dignity and respect when unlicensed personnel (ULP)-C provided treatment and medication management services to R1 in a public setting. [...]”

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. [...]”