Golden Horizons

Summary: MDH found the licensee failed to post, in a conspicuous place, the required information related to the grievance procedure and contact information for the Office of Ombudsman for Long-Term Care and Mental Health and Developmental Disabilities.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to post, in a conspicuous place, the required information related to the grievance procedure and contact information for the Office of Ombudsman for Long-Term Care and Mental Health and Developmental Disabilities. This had the potential to affect all the licensee's current 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 support protection and safety by not posting information and phone numbers for

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 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 employee records included all required content for three of three employees (licensed assisted living director/registered nurse (LALD/RN)-A and unlicensed personnel (ULP)-B and ULP-C) with employee records reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure employee records included all required content for three of three employees (licensed assisted living director/registered nurse (LALD/RN)-A and unlicensed personnel (ULP)-B and ULP-C) with employee records 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 and 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, (unlicensed personnel (ULP)-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 and 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, (unlicensed personnel (ULP)-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

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 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 ability 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 a fire safety and evacuation plan with required elements and failed to provide required employee training on fire safety and evacuation and failed to conduct required evacuation drills.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to develop a fire safety and evacuation plan with required elements and failed to provide required employee training on fire safety and evacuation and failed to conduct 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 develop and execute a written contract with the required content for two of two residents (R1 and R2) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to develop and execute a written contract with the required content for two of two residents (R1 and R2) with records reviewed. [...]”

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 orientation to assisted living licensing requirements and regulations was provided for three of three employees (licensed assisted living director/registered nurse (LALD/RN)-A, unlicensed personnel (ULP-B and ULP-C) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure orientation to assisted living licensing requirements and regulations was provided for three of three employees (licensed assisted living director/registered nurse (LALD/RN)-A, unlicensed personnel (ULP-B and ULP-C) with records reviewed. [...]”

Rule cited: “All staff providing and supervising direct services must complete an orientation to assisted living facility licensing requirements and regulations before providing assisted living services to residents. [...]”

Summary: MDH found the licensee failed to ensure a registered nurse (RN) conducted an initial assessment for one of one resident (R3) with record reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure a registered nurse (RN) conducted an initial assessment for one of one resident (R3) with record reviewed. [...]”

Rule cited: “(a) Residents who are not receiving any services shall not be required to undergo an initial nursing assessment. [...]”

Summary: MDH found the licensee failed to ensure ongoing comprehensive assessments were completed every 90 days for two of three residents (R1 and R2) and failed to complete a change in condition assessment was completed for one of one resident (R12) with record reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure ongoing comprehensive assessments were completed every 90 days for two of three residents (R1 and R2) and failed to complete a change in condition assessment was completed for one of one resident (R12) 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 one of one resident (R12) service plan was revised to reflect the current services provided after a change in condition.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure one of one resident (R12) service plan was revised to reflect the current services provided after a change in condition. [...]”

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 medications not administered were documented as not administered and the reason they were not administered for one of one resident (R11).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medications not administered were documented as not administered and the reason they were not administered for one of one resident (R11). In addition, staff failed to complete an air shot prior to administering insulin from an insulin pen for one of one resident (R1) observed during two separate observations. [...]”

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 not administered were documented as not administered and the reason they were not administered for one of one resident (R11).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medications not administered were documented as not administered and the reason they were not administered for one of one resident (R11). [...]”

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 one of one medication cart, in the memory care unit, was securely locked in substantially constructed compartments and permitted only authorized personnel to have access with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure one of one medication cart, in the memory care unit, was securely locked in substantially constructed compartments and permitted only authorized personnel to have access with records reviewed. This had the potential to affect all 12 of 12 residents residing in the memory care unit. [...]”

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 time sensitive medications were dated when opened and had a pharmacy label for three of four residents (R6, R15, and R1) with insulin, and 2 of 2 residents (R16 and R13) with eye drops, 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 three of four residents (R6, R15, and R1) with insulin, and 2 of 2 residents (R16 and R13) with eye drops, with records reviewed. The licensee failed to ensure medication that was not administered and was no longer in the original container, labeled by the pharmacy, was placed in a separate area for destruction. [...]”

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 a prescription for blood glucose

MDH’s finding, as written: “Based on observation and interview, the licensee failed to ensure a prescription for blood glucose test strips for one resident was not being used for another resident with blood glucose monitoring. [...]”

Rule cited: “No prescription drug supply for one resident may be used or saved for use by anyone other than the resident.”

Summary: MDH found the licensee failed to document in the resident's record the disposition of the medication including the medication's name, strength, prescription number as applicable, quantity, to whom the

MDH’s finding, as written: “Based on interview and record review, the licensee failed to document in the resident's record the disposition of the medication including the medication's name, strength, prescription number as applicable, quantity, to whom the medications were given, date of disposition, and names of staff and other individuals involved in the disposition for one of one discharged resident (R5) 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 provide hazard vulnerability assessment or safety risk assessment of the physical environment on and around the property for the facility.

MDH’s finding, as written: “Based on record review and interview, the licensee failed to provide hazard vulnerability assessment or safety risk assessment of the physical environment on and around the property for the facility. This deficient practice had the ability to affect all staff, residents, and visitors. [...]”

Rule cited: “An assisted living facility with dementia care that has a secured dementia care unit must meet the requirements of section 144G.45 and the following additional requirements: (1) a hazard vulnerability assessment or safety risk must be performed on and around [...]”

Summary: MDH found the licensee failed to provide a copy of the assisted living bill of rights to two of two residents (R1 and R2) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide a copy of the assisted living bill of rights to two of two residents (R1 and R2) with records reviewed. [...]”

Rule cited: “(a) An assisted living facility must provide the resident a written notice of the rights under section 144G.91 before the initiation of services to that resident. [...]”

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 (R10) with bedrails, 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 (R10) with bedrails, with record reviewed. This resulted in an immediate correction order on March 29, 2022, at 4:10 p.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.”

Summary: MDH found the licensee failed to ensure the required notice was posted at the main entry way of the

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

Rule cited: “Subd. 8.Notice to visitors. (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 [...]”