Gentle Care Homes

Summary: MDH found the licensee failed to implement and maintain a quality management program (QMP) appropriate to the size of the facility and relevant to the type of services provided.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to implement and maintain a quality management program (QMP) appropriate to the size of the facility and relevant to the type of services provided. This had the potential to affect all current residents, staff, and visitors. [...]”

Rule cited: “The facility shall engage in quality management appropriate to the size of the facility and relevant to the type of services provided. [...]”

Summary: MDH found the licensee failed to post the required information and phone numbers for reporting to the Minnesota Adult Abuse Reporting Center (MAARC) as required and failed to post the 911 emergency number in common areas and by telephones.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to post the required information and phone numbers for reporting to the Minnesota Adult Abuse Reporting Center (MAARC) as required and failed to post the 911 emergency number in common areas and by telephones. This had the potential to affect all residents, 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 ensure the employee record contained the required content for three of three employees (unlicensed personnel/assistant manager (ULP/AM)-A, ULP-C, ULP-D).

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/assistant manager (ULP/AM)-A, ULP-C, ULP-D). [...]”

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 maintaining a current Facility TB Risk Assessment and baseline screening and testing for one of two employees (unlicensed personnel (ULP)-D).

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 maintaining a current Facility TB Risk Assessment and baseline screening and testing for one of two employees (unlicensed personnel (ULP)-D). [...]”

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 have a written emergency preparedness (EP) plan with all the required content.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to have a written emergency preparedness (EP) plan with all the required content. This had the potential to affect all 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 provide smoke alarms that functioned and were interconnected so that the actuation of one alarm caused all alarms in the dwelling unit to actuate.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to provide smoke alarms that functioned and were interconnected so that the actuation of one alarm caused all alarms in the dwelling unit to actuate. 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 maintain the portable fire extinguishers.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to maintain the portable fire extinguishers. This deficient condition had the potential to affect all staff, residents, 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 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.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to maintain 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. This deficient condition had the potential to affect all staff, residents, 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 develop the fire safety and evacuation plan with the required content and provide the required training and drills.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to develop the fire safety and evacuation plan with the required content and provide the required training and drills. This had 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 physical facility elements did not constitute a distinct hazard to life.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to ensure physical facility elements did not constitute a distinct hazard to life. The licensee failed to provide resident bedrooms with the minimum window opening meeting the minimum state standard for egress. This had the potential to affect some residents, staff, and visitors. [...]”

Rule cited: “(g) Existing construction or elements, including assisted living facilities that were registered as housing with services establishments under chapter 144D prior to August 1, 2021, shall be permitted to continue in use provided such use does not constitute a [...]”

MDH’s finding, as written: “Based on interview and record review, the licensee failed to execute an assisted living (AL) contract before offering housing and assisted living services for one of three residents (R3). [...]”

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 provide the following verbatim notice to identify a designated representative for two of two residents (R1, R2).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide the following verbatim notice to identify a designated representative for two of two residents (R1, R2). [...]”

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 [...]”

Summary: MDH found the licensee failed to ensure competency testing was completed in all required areas for one of three employees (unlicensed personnel (ULP)-D).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure competency testing was completed in all required areas for one of three employees (unlicensed personnel (ULP)-D). [...]”

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 employees received orientation to include all required content for two of three employees (unlicensed personnel/assistant manager (ULP/AM)-A, ULP-D).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure employees received orientation to include all required content for two of three employees (unlicensed personnel/assistant manager (ULP/AM)-A, ULP-D). [...]”

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 that one of three employees (unlicensed personnel (ULP)-C) completed a minimum of 8 hours of annual training per 12 months of employment.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure that one of three employees (unlicensed personnel (ULP)-C) completed a minimum of 8 hours of annual training per 12 months of employment. The licensee also failed to include all required content in the annual training for three of three employees (unlicensed personnel/assistant manager (ULP/AM)-A, ULP-C, ULP-D). [...]”

Rule cited: “(a) All staff that perform direct services must complete at least eight hours of annual training for each 12 months of employment. [...]”

Summary: MDH found the licensee failed to ensure the required eight (8) hours of dementia care training was completed for three of three employees (unlicensed personnel/assistant manager ((ULP/AM)-A, ULP-C, ULP-D) and failed to ensure two (2) hours of dementia training for each 12 months of employment was completed for two of three

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the required eight (8) hours of dementia care training was completed for three of three employees (unlicensed personnel/assistant manager ((ULP/AM)-A, ULP-C, ULP-D) and failed to ensure two (2) hours of dementia training for each 12 months of employment was completed for two of three employees (ULP-C, ULP-D). [...]”

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 the registered nurse (RN) conducted ongoing resident monitoring and within the required 90-day timeframe for one of two residents (R2).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the registered nurse (RN) conducted ongoing resident monitoring and within the required 90-day timeframe for one of two residents (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 a current written service plan that included a signature or other authentication by the resident or resident's designated representative to document agreement on the services to be provided for three of three residents (R1, R2, R3).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure a current written service plan that included a signature or other authentication by the resident or resident's designated representative to document agreement on the services to be provided for three of three residents (R1, R2, R3). [...]”

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 steps of the medication administration process was followed for one of one employee (unlicensed personnel (ULP)-C) observed administering medications for one of two residents (R2).

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 one employee (unlicensed personnel (ULP)-C) observed administering medications for one of two residents (R2). [...]”

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 written or electronically recorded prescriptions were obtained for one of two residents (R3).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure written or electronically recorded prescriptions were obtained for one of two residents (R3). 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 prescriptions were renewed at least annually, or every 12 months, for one of two residents (R2).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure prescriptions were renewed at least annually, or every 12 months, for one of two residents (R2). [...]”

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 store all prescription medications in securely locked and substantially constructed compartments according to the

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to store all prescription medications in securely locked and substantially constructed compartments according to the manufacturer's directions. [...]”

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 develop and implement a treatment or therapy management plan to include all required content for one of one resident (R2).

MDH’s finding, as written: “Based on 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 one resident (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) instructed and ensured competency on proper treatment procedures for three of three unlicensed personnel (unlicensed personnel/assistant manager (ULP/AM)-A, ULP-C, ULP-D).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) instructed and ensured competency on proper treatment procedures for three of three unlicensed personnel (unlicensed personnel/assistant manager (ULP/AM)-A, ULP-C, ULP-D). The licensee also failed to ensure the RN specified, in writing, specific treatment instructions for each resident, and documented those instructions in the resident record for one of two residents (R2). [...]”

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 document blood glucose monitoring for one of one resident (R2).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to document blood glucose monitoring for one of one resident (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) and was issued at an isolated scope (when one or a limited number of residents are affected or one or a limited number of staff are involved, or the situation has occurred only [...]”

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 the required notice included required statutory language to disclose electronic monitoring activity, potentially affecting all current residents in the assisted living facility, staff, and any visitors to the facility.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the required notice included required statutory language to disclose electronic monitoring activity, potentially affecting all current residents in the assisted living facility, staff, and any visitors to the facility. [...]”

Rule cited: “(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 facility is responsible for [...]”