Foxdale

Summary: MDH found the licensee failed to have a daily program of social and recreational activities based on individual and group interests, physical, mental, and psychosocial needs, that create opportunities for active participation in the community at large.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to have a daily program of social and recreational activities based on individual and group interests, physical, mental, and psychosocial needs, that create opportunities for active participation in the community at large. This had the potential to affect all of the licensee's current residents. [...]”

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 [...]”

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 for current recommendations for COVID-19. [...]”

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.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to post information related to the grievance procedure. 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 immediately report to the Minnesota Adult Abuse Reporting Center (MAARC) suspected abuse; failed to notify emergency contact of resident to resident sexual abuse and failed to complete a thorough investigation for occurrences of suspected abuse for five of five residents (R14, R15, R6, R17, R16).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to immediately report to the Minnesota Adult Abuse Reporting Center (MAARC) suspected abuse; failed to notify emergency contact of resident to resident sexual abuse and failed to complete a thorough investigation for occurrences of suspected abuse for five of five residents (R14, R15, R6, R17, R16). [...]”

Rule cited: “144G.42 Subd. 6. Compliance with requirements for reporting maltreatment of vulnerable adults; abuse prevention plan. (a) The assisted living facility must comply with the requirements for the reporting of maltreatment of vulnerable adults in section 626.557. [...]”

Summary: MDH found the licensee failed to support protection and safety by not posting information and phone numbers for reporting to the Minnesota Adult Abuse Reporting Center (MAARC) and failed to post the 911 emergency number in common areas and near telephones provided by the assisted living facility.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to support protection and safety by not posting information and phone numbers for reporting to the Minnesota Adult Abuse Reporting Center (MAARC) and failed to post the 911 emergency number in common areas and near telephones provided by the assisted living facility. This had the potential to affect all 17 residents receiving assisted living services, staff, and visitors. [...]”

Rule cited: “The facility shall support protection and safety through access to the state's systems for reporting suspected criminal activity and suspected vulnerable adult maltreatment by: (1) posting the 911 emergency number in common areas and near telephones provided [...]”

Summary: MDH found 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.

MDH’s finding, as written: “Based on 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 develop an all-hazards emergency preparedness (EP) program and plan to include Appendix Z required elements.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee 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 17 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 ensure the resident record included a discharge summary with the required content for one of one discharged resident (R5).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the resident record included a discharge summary with the required content for one of one discharged resident (R5). [...]”

Rule cited: “Contents of a resident record include the following for each resident: (1) identifying information, including the resident's name, date of birth, address, and telephone number; (2) the name, address, and telephone number of the resident's emergency contact, [...]”

Summary: MDH found the licensee failed to develop a fire safety and evacuation plan with required elements, failed to provide required employee and resident training on fire safety and evacuation, and failed to conduct the required evacuation drills.

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, failed to provide required employee and resident training on fire safety and evacuation, and failed to conduct the required evacuation drills. 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 licensee's contract included a disclosure of the category of assisted living facility license held by the facility for two for two residents (R1, R2) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the licensee's contract included a disclosure of the category of assisted living facility license held by the facility for two for two residents (R1, R2) with records 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 ensure the licensee provided the required notice for right to designated representative on a document separate from the contract for two for two residents (R1, R2) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the licensee provided the required notice for right to designated representative on a document separate from the contract for two for two residents (R1, R2) with records reviewed. [...]”

Rule cited: “(a) Before or at the time of execution of an assisted living contract, an assisted living facility must offer the resident the opportunity to identify a designated representative in writing in the contract and must provide the following verbatim notice on a [...]”

MDH’s finding, as written: “Based on interview and record review the licensee failed to ensure one of four registered nurse (RN-F) who was providing services as an employee of the licensed facility had a current Minnesota license or registration to practice which had the potential to affect all residents and staff. [...]”

Rule cited: “(a) Licensed health professionals and nurses providing services as employees of a licensed facility must possess a current Minnesota license or registration to practice. [...]”

Summary: MDH found the licensee failed to ensure the registered nurse (RN) had documented instructions for a delegated task in the resident's

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure the registered nurse (RN) had documented instructions for a delegated task in the resident's record and ensured prior to the delegation the unlicensed personnel (ULP-D, ULP-E) was trained in the proper methods and was able to demonstrate the ability to follow the procedures for one of one resident (R1). [...]”

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 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-E) with records reviewed.

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-E) 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 the registered nurse (RN) had completed and/or documented a comprehensive assessment for change in condition for one of one resident (R4) related to falls and failed to ensure the RN completed comprehensive reassessment for two of two residents (R1, R2).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) had completed and/or documented a comprehensive assessment for change in condition for one of one resident (R4) related to falls and failed to ensure the RN completed comprehensive reassessment for two of two residents (R1, R2). [...]”

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 signature by the resident/responsible party when the service plan was revised by the licensee and failed to ensure the service plan was revised, based on resident assessment for two of two residents (R1, R2).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure signature by the resident/responsible party when the service plan was revised by the licensee and failed to ensure the service plan was revised, based on resident assessment for two of two residents (R1, R2). [...]”

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 plan included all required content for two of two residents (R1, R2).

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 two of two residents (R1, R2). 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, but was not likely to cause serious injury, impairment, or death) and was issued at a pattern scope (when more than a limited number of residents are affected, [...]”

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 develop, implement, and maintain up-to-date written medication management policies and procedures.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop, implement, and maintain up-to-date written medication management policies and procedures. 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, but was not likely to cause serious injury, impairment, or death), and was issued at a widespread scope (when problems are pervasive or represent a systemic [...]”

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

MDH’s finding, as written: “Based on observation, interview and record review the licensee failed to ensure assessment of medication management services for two of two residents (R1, R2). 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, but was not likely to cause serious injury, impairment, or death) and was issued at a pattern scope (when more than a limited number of residents are affected, [...]”

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 an individualized medication management plan was developed to include all required content for two of two residents (R1, R2).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure an individualized medication management plan was developed to include all required content for two of two residents (R1, 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 documented dosage for medications for one of three residents (R1) and failed to notify the physician and address if there was a negative outcome for omission (not given as prescribed) of medication for one of one resident (R4).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure documented dosage for medications for one of three residents (R1) and failed to notify the physician and address if there was a negative outcome for omission (not given as prescribed) of medication for one of one resident (R4). [...]”

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 documented dosage for medications setup for one of three residents (R1).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure documented dosage for medications setup for one of three residents (R1). 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, but was not likely to cause serious injury, impairment, or death), and was issued at an isolated scope (when one or a limited number of residents are affected or one or [...]”

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 implement policies and procedures for giving accurate and current medications for those residents who received

MDH’s finding, as written: “Based on interview and record review, the licensee failed to implement policies and procedures for giving accurate and current medications for those residents who received medication management services during planned or unplanned times away from home. This has the potential to affect all residents. [...]”

Rule cited: “(a) An assisted living facility that is providing medication management services to the resident must develop and implement policies and procedures for giving accurate and current medications to residents for planned or unplanned times away from home [...]”

Summary: MDH found the licensee failed to implement policies and procedures for medication management services during unplanned times away from home.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to implement policies and procedures for medication management services during unplanned times away from home. This has the potential to affect all residents. In addition, the licensee failed to ensure training and competency evaluations for preparing medications for resident unplanned times away were completed as required for two of two unlicensed personnel (ULP-D, ULP-E) 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 [...]”

MDH’s finding, as written: “Based on observation, interview and record review the licensee failed to ensure prescriber's orders included the medication dose for one of three residents (R1). 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, but was not likely to cause serious injury, impairment, or death), and was issued at an isolated scope (when one or a limited number of residents are affected [...]”

Rule cited: “There must be a current written or electronically recorded prescription as defined in section 151.01, subdivision 16a, for all prescribed medications that the assisted living facility is managing for the resident.”

Summary: MDH found the licensee failed to ensure medications were stored according to manufacturer's instructions in one of one medication refrigerator.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medications were stored according to manufacturer's instructions in one of one medication refrigerator. [...]”

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 keep medication in the original container dispensed by the pharmacy which was stored in one of two medication carts (north side).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to keep medication in the original container dispensed by the pharmacy which was stored in one of two medication carts (north side). [...]”

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 expired medications were disposed in two of two medication carts (north and south) and medication storage cupboards.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure expired medications were disposed in two of two medication carts (north and south) and medication storage cupboards. In addition, the licensee failed to document all required content of disposition of medications for one of one discharged resident (R5). [...]”

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, implement, and

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop, implement, and maintain up-to-date written treatment or therapy management policies and procedures. [...]”

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 ensure an individualized treatment or therapy management record to include all required content for two of

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure an individualized treatment or therapy management record to include all required content for two of two residents (R1, R2). [...]”

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 for each resident and documented those instructions in the resident's records for two of two residents (R1, R2) receiving treatments and had instructed the unlicensed personnel in the proper methods with respect to each resident and two of two unlicensed personnel (ULP-D, ULP-E) has demonstrated the ability to competently follow the procedures.

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 each resident and documented those instructions in the resident's records for two of two residents (R1, R2) receiving treatments and had instructed the unlicensed personnel in the proper methods with respect to each resident and two of two unlicensed personnel (ULP-D, ULP-E) has demonstrated the ability to competently follow the procedures. [...]”

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 treatment services were documented for two of two residents (R1, R2).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure treatment services were documented for two of two residents (R1, R2). 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, but was not likely to cause serious injury, impairment, or death) and was issued at a pattern scope (when more than a limited number of residents are affected, more than [...]”

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 a prescriber's order for treatment or therapy for one of one resident (R1).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure a prescriber's order for treatment or therapy for one of one resident (R1). 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, but was not likely to cause serious injury, impairment, or death), and was issued at an isolated scope (when one or a limited number of residents are affected or one [...]”

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 develop and implement all required policies and procedures related to dementia care and failed to provide the policies and procedures to residents and the residents' legal and designated representatives at the time of move-in.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop and implement all required policies and procedures related to dementia care and failed to provide the policies and procedures to residents and the residents' legal and designated representatives at the time of move-in. [...]”

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 oversee staff training in the care of individuals with dementia.

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 and an individualized activity plan was developed for two of two residents (R1, R2).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure evaluation for activities and an individualized activity plan was developed for two of two residents (R1, R2). [...]”

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 include a description of the training program for dementia care in written or electronic form to residents, families, or other persons who request it, with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to include a description of the training program for dementia care in written or electronic form to residents, families, or other persons who request it, 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 resident's personal health and medical information was kept private.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure resident's personal health and medical information was kept private. This has the potential to affect all 17 residents residing at the facility. [...]”

Rule cited: “(a) Residents have the right to have personal, financial, health, and medical information kept private, to approve or refuse release of information to any outside party, and to be advised of the assisted living facility's policies and procedures regarding [...]”

Summary: MDH found the licensee failed to immediately report to the Minnesota Adult Abuse Reporting Center (MAARC) suspected abuse; failed to notify emergency contact of resident to resident sexual abuse and failed to complete a thorough investigation for occurrences of suspected abuse

MDH’s finding, as written: “Based on interview and record review, the licensee failed to immediately report to the Minnesota Adult Abuse Reporting Center (MAARC) suspected abuse; failed to notify emergency contact of resident to resident sexual abuse and failed to complete a thorough investigation for occurrences of suspected abuse for five of five residents (R14, R15, R6, R17, R16). [...]”

Rule cited: “(a) A mandated reporter who has reason to believe that a vulnerable adult is being or has been maltreated, or who has knowledge that a vulnerable adult has sustained a physical injury which is not reasonably explained shall immediately report the information [...]”