Good Time Care

Summary: MDH found the licensee failed to establish and

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to establish and maintain infection control policies and procedures that complied with accepted health care, medical, and nursing standards for infection control related to the COVID-19 pandemic when the licensee failed to ensure visitors, employees, and residents were screened for COVID-19 with temperature checks and screening questions and failed to develop policies and procedures to guide decision making related to [...]”

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 the required information related to the grievance procedure.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to post the required information related to the grievance procedure. 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. [...]”

MDH’s finding, as written: “No futher action required.”

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 engage in and maintain documentation of ongoing quality management activities relevant to the size and services provided by the assisted living provider.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to engage in and maintain documentation of ongoing quality management activities relevant to the size and services provided by the assisted living provider. [...]”

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 911 emergency number in common areas and near telephones provided by the assisted living facility.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to post the 911 emergency number in common areas and near telephones provided by the assisted living facility. [...]”

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 one of one employee (registered nurse (RN)-A) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the employee record contained the required content for one of one employee (registered nurse (RN)-A) with 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. [...]”

MDH’s finding, as written: “No further action required.”

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, [...]”

MDH’s finding, as written: “No further action required.”

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) [...]”

MDH’s finding, as written: “No further action required.”

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 [...]”

MDH’s finding, as written: “No further action required.”

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 [...]”

MDH’s finding, as written: “No further action required.”

Rule cited: “(b) Each assisted living facility shall develop and maintain fire safety and evacuation plans. [...]”

MDH’s finding, as written: “No further action required.”

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. [...]”

MDH’s finding, as written: “No further action required.”

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

MDH’s finding, as written: “No further action required.”

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 [...]”

MDH’s finding, as written: “No further action required.”

Rule cited: “(d) The contract must include a description of the facility's complaint resolution process available to residents, including the name and contact information of the person representing the facility who is designated to handle and resolve complaints. [...]”

MDH’s finding, as written: “No further action required.”

Rule cited: “(5) a description of the facility's policies related to medical assistance waivers under chapter 256S and section 256B.49 and the housing support program under chapter 256I, including: (i) whether the facility is enrolled with the commissioner of human [...]”

MDH’s finding, as written: “No further action required.”

Rule cited: “(b) Unlicensed personnel performing delegated nursing tasks in an assisted living facility must: (1) have successfully completed training and demonstrated competency by successfully completing a written or oral test of the topics in section 144G.61, [...]”

MDH’s finding, as written: “No further action required.”

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 comprehensive reassessment using the uniform assessment tool not to exceed 90 calendar days for two of two residents (R1, R2) as required with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the registered nurse (RN) conducted ongoing comprehensive reassessment using the uniform assessment tool not to exceed 90 calendar days for two of two residents (R1, R2) as required with records 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 service plans included all the required content for one of one resident (R1) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure service plans included all the required content for one of one resident (R1) with records reviewed. 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 [...]”

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 an individualized medication management record with the required content for one of one resident (R1) with record reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop an individualized medication management record with the required content for one of one resident (R1) with record reviewed. [...]”

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. [...]”

MDH’s finding, as written: “No futher action required.”

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 prescription medications were stored according to the manufacturer's directions.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure prescription medications were stored according to the manufacturer's directions. 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: “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.”

MDH’s finding, as written: “No futher action required.”

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 [...]”

Summary: MDH found the licensee failed to ensure a menu was prepared and provided to residents a week in advance and failed to provide meal substitutions that are nutritious according to the recommended dietary allowances in the United States

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure a menu was prepared and provided to residents a week in advance and failed to provide meal substitutions that are nutritious according to the recommended dietary allowances in the United States Department of Agriculture (USDA) guidelines. This had the potential to affect all residents. [...]”

Rule cited: “(13) offer to provide or make available at least the following services to residents: (i) at least three nutritious meals daily with snacks available seven days per week, according to the recommended dietary allowances in the United States Department of [...]”

Summary: MDH found the licensee failed to establish and maintain infection control policies and procedures that complied with accepted health care, medical, and nursing standards for infection control related to the COVID-19 pandemic when the licensee failed to ensure visitors, employees, and residents were screened for COVID-19 with temperature checks and screening questions and failed to develop policies and procedures to guide decision making related to COVID-19 pandemic.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to establish and maintain infection control policies and procedures that complied with accepted health care, medical, and nursing standards for infection control related to the COVID-19 pandemic when the licensee failed to ensure visitors, employees, and residents were screened for COVID-19 with temperature checks and screening questions and failed to develop policies and procedures to guide decision making related to [...]”

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 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, as well as information for reporting suspected maltreatment to the Minnesota Adult Abuse Reporting Center

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 contact information for the Office of Ombudsman for Long-Term Care and Mental Health and Developmental Disabilities, as well as information for reporting suspected maltreatment to the Minnesota Adult Abuse Reporting Center (MAARC). 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 display the current assisted living license at the main entrance of the assisted living building.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to display the current assisted living license at the main entrance of the assisted living building. This practice resulted in a level one violation (a violation that has no potential to cause more than a 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 [...]”

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 engage in and maintain documentation of ongoing quality management activities relevant to the size and services provided by the assisted living provider.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to engage in and maintain documentation of ongoing quality management activities relevant to the size and services provided by the assisted living provider. [...]”

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 support protection and safety by not posting information and phone

MDH’s finding, as written: “Based on observation, interview and record review, 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. [...]”

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 two of two employees (registered nurse (RN)-A, unlicensed personnel (ULP)-B) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the employee record contained the required content for two of two employees (registered nurse (RN)-A, unlicensed personnel (ULP)-B) with 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 completion of a two-step TST (tuberculin skin test) or other evidence of TB screening such as a blood test for two of two employees (registered nurse (RN)-A, 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 completion of a two-step TST (tuberculin skin test) or other evidence of TB screening such as a blood test for two of two employees (registered nurse (RN)-A, 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 maintain a written emergency disaster plan (EDP) with all required content and failed to post an emergency plan prominently.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to develop and maintain a written emergency disaster plan (EDP) with all required content and failed to post an emergency plan prominently. [...]”

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 that the appropriate records for three of three residents (R1, R2, R3) were readily available for timely access to employees, vendors, and the commissioner authorized to access the records.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure that the appropriate records for three of three residents (R1, R2, R3) were readily available for timely access to employees, vendors, and the commissioner authorized to access the records. [...]”

Rule cited: “The facility must ensure that the appropriate records are readily available to employees and contractors authorized to access the records. Resident records must be maintained in a manner that allows for timely access, printing, or transmission of the records. [...]”

Summary: MDH found the licensee failed to provide written acknowledgement of receipt of the current Minnesota Assisted Living Bill of Rights (BOR) for two of two residents (R1, R2) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide written acknowledgement of receipt of the current Minnesota Assisted Living Bill of Rights (BOR) for two of two residents (R1, R2) with records reviewed. [...]”

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 provide the minimum required working smoke alarms and to have smoke alarms interconnected so that actuation of one alarm causes all alarms in the home to sound.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to provide the minimum required working smoke alarms and to have smoke alarms interconnected so that actuation of one alarm causes all alarms in the home to sound. This has the potential to directly affect staff, visitors, and residents receiving assisted living care. [...]”

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 provide the required minimum size and maintain the portable fire extinguishers in accordance with the State Fire Code as required by MN Statute 144G.45 Subd(a)(2).

MDH’s finding, as written: “Based on observation, record review, and interview, the licensee failed to provide the required minimum size and maintain the portable fire extinguishers in accordance with the State Fire Code as required by MN Statute 144G.45 Subd(a)(2). This had the potential to directly affect all residents and staff. [...]”

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 of the facility in a continuous state of good repair and operation.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to maintain the physical environment of the facility in a continuous state of good repair and operation. This has the potential to directly affect the health, safety, and well-being of residents and staff. [...]”

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 provide the required content of documentation on the fire safety plan, required employee and resident training, and required evacuation drills performed by employees.

MDH’s finding, as written: “Based on document review and interview, the licensee failed to provide the required content of documentation on the fire safety plan, required employee and resident training, and required evacuation drills performed by employees. This has the potential to directly affect the safety of visitors, staff, and all residents receiving assisted living care. [...]”

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 provided the Office of Ombudsman for Long-Term Care a complete unsigned copy of its assisted living contract.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the licensee provided the Office of Ombudsman for Long-Term Care a complete unsigned copy of its assisted living contract. This had the potential to affect all current residents. [...]”

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 execute a written contract with the required content for two of two residents (R1, R2) with records reviewed.

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) with records reviewed. [...]”

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

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

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) with records reviewed. This had the potential to affect all residents. [...]”

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 execute a written contract with the required content for one of one resident (R1) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to execute a written contract with the required content for one of one resident (R1) with records reviewed. This practice resulted in a level one violation (a violation that has no potential to cause more than a 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 [...]”

Rule cited: “(d) The contract must include a description of the facility's complaint resolution process available to residents, including the name and contact information of the person representing the facility who is designated to handle and resolve complaints. [...]”

Summary: MDH found the licensee failed to execute a written contract with the required content for one of one resident (R1) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to execute a written contract with the required content for one of one resident (R1) with records reviewed. This practice resulted in a level one violation (a violation that has no potential to cause more than a 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 [...]”

Rule cited: “(5) a description of the facility's policies related to medical assistance waivers under chapter 256S and section 256B.49 and the housing support program under chapter 256I, including: (i) whether the facility is enrolled with the commissioner of human [...]”

Summary: MDH found the licensee failed to ensure the assisted living contract included the designation of representative statutory language for one of one resident (R1) with record reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the assisted living contract included the designation of representative statutory language for one of one resident (R1) with record 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 [...]”

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

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

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 complete training and competency evaluations in all required training topics for one of one employee (unlicensed personnel (ULP)-B).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to complete training and competency evaluations in all required training topics for one of one employee (unlicensed personnel (ULP)-B). [...]”

Rule cited: “(b) Unlicensed personnel performing delegated nursing tasks in an assisted living facility must: (1) have successfully completed training and demonstrated competency by successfully completing a written or oral test of the topics in section 144G.61, [...]”

Summary: MDH found the licensee failed to ensure training and competency evaluations of unlicensed personnel (ULP) providing assisted living services were conducted by a registered nurse (RN) for one of one unlicensed professional (ULP-B) with record reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure training and competency evaluations of unlicensed personnel (ULP) providing assisted living services were conducted by a registered nurse (RN) for one of one unlicensed professional (ULP-B) with record reviewed. [...]”

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 ensure training and competency was completed for one of one unlicensed personnel (ULP)-B, to include all required content, with training record reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure training and competency was completed for one of one unlicensed personnel (ULP)-B, to include all required content, with training record reviewed. [...]”

Rule cited: “(a) Training and competency evaluations for all unlicensed personnel must include the following: (1) documentation requirements for all services provided; (2) reports of changes in the resident's condition to the supervisor designated by the facility; (3) [...]”

Summary: MDH found the licensee failed to ensure training and competency was completed for one of one unlicensed personnel (ULP)-B), to include all required content, with record reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure training and competency was completed for one of one unlicensed personnel (ULP)-B), to include all required content, with record reviewed. [...]”

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 the registered nurse (RN) conducted training and competency evaluations for one of one unlicensed personnel ((ULP)-B) who performed delegated tasks.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the registered nurse (RN) conducted training and competency evaluations for one of one unlicensed personnel ((ULP)-B) who performed delegated tasks. [...]”

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 delegated tasks within 30 days of providing

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure a registered nurse (RN) conducted direct supervision of staff performing delegated tasks within 30 days of providing services for one of one unlicensed personnel ((ULP)-B) with employee record 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 employees received orientation to include all required content for one of one employee (unlicensed personnel (ULP)-B) with records reviewed.

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 one of one employee (unlicensed personnel (ULP)-B) with records reviewed. [...]”

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 employees received the required hours of dementia care training for one of one unlicensed personnel ((ULP)-B), with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure employees received the required hours of dementia care training for one of one unlicensed personnel ((ULP)-B), with records reviewed. [...]”

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 a registered nurse (RN) conducted an initial assessment prior to move in for two of two residents (R1, R2) 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 prior to move in for two of two residents (R1, R2) 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 the registered nurse (RN) completed a 14 day reassessment and ongoing comprehensive reassessment using the uniform assessment tool not to exceed 90 calendar days for two of two residents (R1, R2) as required with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the registered nurse (RN) completed a 14 day reassessment and ongoing comprehensive reassessment using the uniform assessment tool not to exceed 90 calendar days for two of two residents (R1, R2) as required with records 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 service plans included all the required content for two of two residents (R1, R2) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure service plans included all the required content for two of two residents (R1, R2) with records reviewed. [...]”

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 ensure the registered nurse (RN) conducted an individualized assessment to determine what medication management services would be provided, and how the services would be provided for one of one resident (R1) with record reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the registered nurse (RN) conducted an individualized assessment to determine what medication management services would be provided, and how the services would be provided for one of one resident (R1) with record reviewed. [...]”

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 develop an individualized medication management record with the required content for one of one resident (R1) with record reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop an individualized medication management record with the required content for one of one resident (R1) with record reviewed. [...]”

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 prior to delegating nursing tasks, the unlicensed personnel (ULP) were trained in the proper methods to perform the task or procedure for each client, and were able to demonstrate the ability to competently follow the procedure for one of one employee (ULP-B) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure prior to delegating nursing tasks, the unlicensed personnel (ULP) were trained in the proper methods to perform the task or procedure for each client, and were able to demonstrate the ability to competently follow the procedure for one of one employee (ULP-B) with records reviewed. [...]”

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 documentation of medication setup included all the required content for one of one resident (R1) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure documentation of medication setup included all the required content for one of one resident (R1) with records reviewed. [...]”

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 ensure written or electronically recorded prescriptions were obtained for one of one resident (R1) with record reviewed.

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 one resident (R1) with record reviewed. [...]”

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 prescription medications were stored according to the manufacturer's directions.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure prescription medications were stored according to the manufacturer's directions. 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: “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 a required notice was posted at the main entry way of the licensee's 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 licensee's facility to display statutory language to disclose electronic monitoring activity. [...]”

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 [...]”