Golden Nest

Summary: MDH found the licensee failed to post the required information related to the grievance procedure and reporting contact information for the Office of Ombudsman for Mental Health and Developmental Disabilities (OMHDD), and Office of Health Facility Complaints (OHFC).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to post the required information related to the grievance procedure and reporting contact information for the Office of Ombudsman for Mental Health and Developmental Disabilities (OMHDD), and Office of Health Facility Complaints (OHFC). [...]”

Rule cited: “All facilities must post in a conspicuous place information about the facilities' grievance procedure, and the name, telephone number, and email contact information for the individuals who are responsible for handling resident grievances. [...]”

MDH’s finding, as written: “Based on observation, interview, and record review the licensee failed to display the original current license at the main entrance of the assisted living facility as required. This had the potential to affect all residents, staff, and visitors. [...]”

Rule cited: “The original current license must be displayed at the main entrance of each assisted living facility. The facility must provide a copy of the license to any person who requests it.”

Summary: MDH found the licensee failed to ensure employee records included all required content for one of four employees (unlicensed personnel (ULP)-K).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure employee records included all required content for one of four employees (unlicensed personnel (ULP)-K). [...]”

Rule cited: “(a) The facility must maintain current records of each paid staff member, each regularly scheduled volunteer providing services, and each individual contractor providing services. [...]”

Summary: MDH found the licensee failed to maintain a tuberculosis (TB) prevention and control program, based on the most current guidelines issued by the Centers for Disease Control and Prevention

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to maintain a tuberculosis (TB) prevention and control program, based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC), which included a two-step tuberculin skin test (TST) or other evidence of TB screening such as a blood test for four of four employees (unlicensed personnel (ULP)-A, ULP-B, ULP-F, ULP-K). [...]”

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 maintain a written emergency preparedness plan (EPP) with all the required content as defined in Appendix Z. This had the potential to affect all residents, staff, and visitors.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to maintain a written emergency preparedness plan (EPP) with all the required content as defined in Appendix Z. 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 [...]”

MDH’s finding, as written: “Based on observation and interview, the licensee failed to comply with Minnesota State Fire Code in Minnesota Rules chapter 7511. This deficient condition had the ability to affect all staff and residents. [...]”

Rule cited: “Each assisted living facility must comply with the State Fire Code in Minnesota Rules, chapter 7511, and:”

Summary: MDH found the licensee failed to develop the fire safety and evacuation plan with the required content and provide the required drills.

MDH’s finding, as written: “Based on interview, and record review, the licensee failed to develop the fire safety and evacuation plan with the required content and provide the required 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 and maintain a safe and compliant electrical system. This had the potential to affect all 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 [...]”

Summary: MDH found the licensee failed to comply with all state and local governing laws, and codes for fire safety, building, and zoning requirements.

MDH’s finding, as written: “Based on observation, and interview, the licensee failed to comply with all state and local governing laws, and codes for fire safety, building, and zoning requirements. This had the potential to affect all staff, residents, and visitors. [...]”

Rule cited: “Assisted living facilities shall comply with all applicable state and local governing laws, regulations, standards, ordinances, and codes for fire safety, building, and zoning requirements, except a facility with a licensed resident capacity of six or fewer [...]”

Summary: MDH found the licensee failed to execute a written contract with the required content for two of two residents (R1, R2).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to execute a written contract with the required content for two of two residents (R1, R2). This practice resulted in a level one violation (a violation that will cause only minimal impact on the resident and does not affect health or safety) and was issued at a widespread scope (when problems are pervasive or represent a systemic failure that has affected or has potential to affect a large portion or all of the residents). [...]”

Rule cited: “(a) The contract must include in a conspicuous place and manner on the contract the legal name and the health facility identification of the facility. [...]”

Summary: MDH found the licensee failed to ensure assisted living contracts did not include language waiving the licensee's liability for health, safety, or personal property of a resident for one of one resident (R1).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure assisted living contracts did not include language waiving the licensee's liability for health, safety, or personal property of a resident for one of one resident (R1). [...]”

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 (BGS) was submitted and received in affiliation with the assisted living licensee for one of 17 employees (unlicensed personnel (ULP)-A).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure a background study (BGS) was submitted and received in affiliation with the assisted living licensee for one of 17 employees (unlicensed personnel (ULP)-A). [...]”

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 a registered nurse (RN) provided training and competency evaluations of unlicensed personnel (ULP) providing assisted living services for three of four unlicensed personnel ((ULP)-A, ULP-B, ULP-K).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure a registered nurse (RN) provided training and competency evaluations of unlicensed personnel (ULP) providing assisted living services for three of four unlicensed personnel ((ULP)-A, ULP-B, ULP-K). [...]”

Rule cited: “Instructors and competency evaluators must meet the following requirements: (1) training and competency evaluations of unlicensed personnel who only provide assisted living services specified in section 144G.08, subdivision 9, clauses (1) to (5), must be [...]”

Summary: MDH found the licensee failed to establish and implement a system to communicate up-to-date information to the registered nurse (RN) regarding the current available staff and their competency.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to establish and implement a system to communicate up-to-date information to the registered nurse (RN) regarding the current available staff and their competency. This affected all residents receiving services under the assisted living license. [...]”

Rule cited: “(a) A registered nurse or licensed health professional may delegate tasks only to staff who are competent and possess the knowledge and skills consistent with the complexity of the tasks and according to the appropriate Minnesota practice act. [...]”

MDH’s finding, as written: “Based on observation, interview, and record review, licensee failed to provide training and competency evaluations by a registered nurse (RN) to unlicensed personal (ULP) for delegated catheter cares and full body mechanical lifts for four of four employees (ULP-A, ULP-B, ULP-F, ULP-K). [...]”

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 a registered nurse (RN) conducted direct supervision of staff performing a delegated task within 30 days of providing services for four of four employees (unlicensed personnel (ULP)-A, ULP-B, ULP-F, ULP-K).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure a registered nurse (RN) conducted direct supervision of staff performing a delegated task within 30 days of providing services for four of four employees (unlicensed personnel (ULP)-A, ULP-B, ULP-F, ULP-K). [...]”

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 [...]”

MDH’s finding, as written: “Based on interview and record review, the license failed to complete two hours of initial training on mental illness and de-escalation for employees hired prior to July 1, 2025, for two of four employees (ULP-A, ULP-B). [...]”

Rule cited: “(a) All assisted living facilities must meet the following dementia care, mental illness, and de-escalation training requirements: (1) supervisors of direct-care staff must have at least eight hours of initial training on dementia topics specified under [...]”

Summary: MDH found the licensee failed to ensure all staff received the required content for dementia care training for three of three employees (unlicensed personnel (ULP)-A, ULP-B, ULP-F).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure all staff received the required content for dementia care training for three of three employees (unlicensed personnel (ULP)-A, ULP-B, ULP-F). [...]”

Rule cited: “(5) new staff members may satisfy the initial training requirements by producing written proof of previously completed required training within the past 18 months. [...]”

Summary: MDH found the licensee failed to ensure the registered nurse (RN) completed an assessment on an assistive device, and the potential for it being a restraint for one of one resident (R1).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) completed an assessment on an assistive device, and the potential for it being a restraint for one of one resident (R1). [...]”

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

Summary: MDH found the licensee failed to ensure a current written service plan included a signature or other authentication by the resident, or their representative, documenting agreement on the services to be provided for one of three residents (R1).

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

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 prior to delegating the task of medication administration, the registered nurse (RN) trained unlicensed personnel (ULP) in the proper methods to perform the task or procedure for each resident and evaluate the ULPs' ability to competently perform the task for five of five employees (ULP-F, ULP-J, ULP-K, ULP-L, licensed assisted living director (LALD)-D).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure prior to delegating the task of medication administration, the registered nurse (RN) trained unlicensed personnel (ULP) in the proper methods to perform the task or procedure for each resident and evaluate the ULPs' ability to competently perform the task for five of five employees (ULP-F, ULP-J, ULP-K, ULP-L, licensed assisted living director (LALD)-D). [...]”

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 the registered nurse (RN) developed training and competencies for unlicensed personnel (ULP) providing medications to residents for unplanned time away from home when the licensed nurse was not available for one of one employee (unlicensed personnel (ULP)-K).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the registered nurse (RN) developed training and competencies for unlicensed personnel (ULP) providing medications to residents for unplanned time away from home when the licensed nurse was not available for one of one employee (unlicensed personnel (ULP)-K). [...]”

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 medications including dietary supplements and over-the-counter (OTC) drugs were stored as deemed appropriate by the resident's medication assessment for one of one resident (R3). [...]”

Rule cited: “An assisted living facility providing medication management services for over-the-counter drugs or dietary supplements must retain those items in the original labeled container with directions for use prior to setting up for immediate or later administration. [...]”

Summary: MDH found the licensee failed to ensure a written or electronically recorded prescription for

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure a written or electronically recorded prescription for medications and obtained, and prescriptions were renewed at least every 12 months for two of three residents (R1, R2). [...]”

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 renew complete

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to renew complete prescriptions at least every 12 months 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 [...]”

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 all medications were included in the assessment for medication management or documented in the resident record for one of three residents (R3).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure all medications were included in the assessment for medication management or documented in the resident record for one of three residents (R3). [...]”

Rule cited: “When the assisted living facility is aware of any medications or dietary supplements that are being used by the resident and are not included in the assessment for medication management services, the staff must advise the registered nurse and document that in [...]”

Summary: MDH found the licensee did not train the proper methods for each resident (R2) receiving treatment of therapy services prior to delegating nursing tasks of prescribed treatments, nor did the unlicensed personnel (ULP) demonstrate to the registered nurse (RN), the ability to competently follow the procedure for four of four employees (ULP-A, ULP-B, ULP-F, ULP-K).

MDH’s finding, as written: “Based on interview and record review, the licensee did not train the proper methods for each resident (R2) receiving treatment of therapy services prior to delegating nursing tasks of prescribed treatments, nor did the unlicensed personnel (ULP) demonstrate to the registered nurse (RN), the ability to competently follow the procedure for four of four employees (ULP-A, ULP-B, ULP-F, ULP-K). [...]”

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 treatments or therapies were documented accurately in the medical record for one of one resident (R2) with tube feeding.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure treatments or therapies were documented accurately in the medical record for one of one resident (R2) with tube feeding. [...]”

Rule cited: “Each treatment or therapy administered by an assisted living facility must be in the resident record. [...]”

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure privacy was maintained for three of six residents (R5, R7, R8) while receiving personal cares. In addition, the licensee failed to ensure information regarding the resident's service plan, case discussion, and treatments was kept confidential for all residents receiving assistance with toileting, meal delivery, transportation, shower, face wash, and oral care. [...]”

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. [...]”

Summary: MDH found the licensee failed to ensure a required notice was posted at the main entry way of the facility to display statutory language to disclose electronic monitoring activity.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure a required notice was posted at the main entry way of the facility to display statutory language to disclose electronic monitoring activity. This had the potential to affect all current residents, staff, and 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 [...]”