Good Samaritan Society Luverne

Summary: MDH found the licensee failed to ensure annual training included all required topics for each 12 months of employment for one of one employee (unlicensed personnel (ULP)-D).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure annual training included all required topics for each 12 months of employment for one of one employee (unlicensed personnel (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 complete a comprehensive assessment after a change of condition for one of one resident (R2).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to complete a comprehensive assessment after a change of condition for one of one resident (R2). [...]”

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 service plan modifications were completed and signed when the resident's services changed for three of three residents (R2, R3, R5) as required.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure service plan modifications were completed and signed when the resident's services changed for three of three residents (R2, R3, R5) as required. [...]”

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 one of two unlicensed personnel (ULP)-E) were trained for medication administration and failed to ensure

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure one of two unlicensed personnel (ULP)-E) were trained for medication administration and failed to ensure medications were administered according to policy and accepted standards of practice. [...]”

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 [...]”

MDH’s finding, as written: “Based on observation, interview, and record review, licensee failed to ensure medications were administered according to policy and accepted standards of practice for two of two residents (R6, R7). [...]”

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 was completed for the licensee's one resident (R10) receiving medication set-up services.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure documentation of medication setup was completed for the licensee's one resident (R10) receiving medication set-up services. [...]”

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 obtain signed physician orders for medications administered for one of three residents (R9) and failed to have an order which included all required content for one resident (R6).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to obtain signed physician orders for medications administered for one of three residents (R9) and failed to have an order which included all required content for one resident (R6). [...]”

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 securely locked permitting only authorized personnel to have access.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medications were securely locked permitting only authorized personnel to have access. This had the potential to affect all residents residing within the facility. [...]”

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 labeled with the date opened for three of three residents (R4, R8, R2) with inhalers and failed to ensure all medications had a pharmacy label for two of three residents (R8, R5) with inhalers.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure time sensitive medications were labeled with the date opened for three of three residents (R4, R8, R2) with inhalers and failed to ensure all medications had a pharmacy label for two of three residents (R8, R5) with inhalers. [...]”

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 to include all required information on the disposition of medications for one of one discharged resident (R1).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to to include all required information on the disposition of medications for one of one discharged resident (R1). [...]”

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 ensure a licensed health professional instructed and specified, in

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure a licensed health professional instructed and specified, in writing, specific instructions for administering a treatment for one of one resident (R2), and failed to ensure two of two unlicensed personnel (ULP)-D, ULP-E) were trained and competency tested for R2's treatment. [...]”

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 were administered as ordered for one of one resident (R2) receiving treatments.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure treatments were administered as ordered for one of one resident (R2) receiving treatments. [...]”

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 provide care and services according to acceptable health care, medical, or nursing standards for one of one

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to provide care and services according to acceptable health care, medical, or nursing standards for one of one resident (R12) with a consumer grab bar. This resulted in an immediate order issued on April 1, 2026. [...]”

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 two of two unlicensed personnel (ULP)-D, ULP-E) administered diclofenac gel (pain relief) per manufacturer guidelines and failed to ensure one of one ULP (ULP-E) administered oral medications per accepted health care, medical and nursing standards and per the facility policy.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure two of two unlicensed personnel (ULP)-D, ULP-E) administered diclofenac gel (pain relief) per manufacturer guidelines and failed to ensure one of one ULP (ULP-E) administered oral medications per accepted health care, medical and nursing standards and per the facility policy. [...]”

Rule cited: “(b) Residents have the right to receive health care and other assisted living services with continuity from people who are properly trained and competent to perform their duties and in sufficient numbers to adequately provide the services agreed to in the [...]”