Green Lakes Homes

Summary: MDH found the licensee failed to ensure resident records were protected against unauthorized disclosure of electronic records.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to ensure resident records were protected against unauthorized disclosure of electronic records. 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 a widespread scope (when problems are pervasive or represent a systemic failure that has affected or has the potential to affect a large portion or all [...]”

Rule cited: “(b) Resident records, whether written or electronic, must be protected against loss, tampering, or unauthorized disclosure in compliance with chapter 13 and other applicable relevant federal and state laws. [...]”

Summary: MDH found the licensee failed to comply with Minnesota Fire Code, Minnesota Rules 7511.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to comply with Minnesota Fire Code, Minnesota Rules 7511. This had the potential to directly affect two residents and all staff. [...]”

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 ensure the physical environment of the facility was maintained in compliance with the requirements of Minnesota Statute 144G.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to ensure the physical environment of the facility was maintained in compliance with the requirements of Minnesota Statute 144G. [...]”

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 ensure the physical environment of the facility was maintained in compliance with the requirements of Minnesota Statute 144G.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to ensure the physical environment of the facility was maintained in compliance with the requirements of Minnesota Statute 144G. [...]”

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 ensure the physical environment of the facility was maintained in compliance with the requirements of Minnesota Statute 144G.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to ensure the physical environment of the facility was maintained in compliance with the requirements of Minnesota Statute 144G. [...]”

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 ensure the physical environment of the facility was maintained in compliance with the requirements of Minnesota Statute 144G.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to ensure the physical environment of the facility was maintained in compliance with the requirements of Minnesota Statute 144G. [...]”

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

Summary: MDH found the licensee failed to execute a written contract with the required content for two of two residents (R1 and 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 and R2). 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 the potential to affect a large portion or all the [...]”

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 the registered nurse (RN) completed an assessment for safe smoking for one of two residents (R4).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure the registered nurse (RN) completed an assessment for safe smoking for one of two residents (R4). [...]”

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 one of one resident (R2) who self-administered medications, was assessed for self-administration of medications.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure one of one resident (R2) who self-administered medications, was assessed for self-administration of medications. [...]”

Rule cited: “A registered nurse, advanced practice registered nurse, or qualified staff delegated the task by a registered nurse must monitor and reassess the resident's medication management services as needed under subdivision 2 when the resident presents with symptoms [...]”

Summary: MDH found the licensee failed to develop and implement a current individualized medication management plan to include all required content for two of three residents (R1 and R4).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to develop and implement a current individualized medication management plan to include all required content for two of three residents (R1 and R4). [...]”

Rule cited: “(a) For each resident receiving medication management services, a registered nurse, advanced practice registered nurse, or qualified staff delegated the task by a registered nurse must prepare and include in the service plan a written statement of the [...]”

MDH’s finding, as written: “Based on observation, interview and record review, the license failed to ensure medication administration was documented accurately for one of one resident (R2) who had medication management services and failed to ensure prescriber orders were transcribed correctly for three of three residents (R1, R2 and 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 [...]”

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 current written or electronically recorded prescriptions were obtained for all medications the licensee managed for two of three residents (R2 and R4).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure current written or electronically recorded prescriptions were obtained for all medications the licensee managed for two of three residents (R2 and R4). [...]”

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 all medications were securely locked in substantially constructed compartments and permitted only authorized personnel had access.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to ensure all medications were securely locked in substantially constructed compartments and permitted only authorized personnel had access. [...]”

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 date time-sensitive medications with an opened or expired date for three of three residents (R1, R2 and R3) and the licensee failed to discard expired medications for

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to date time-sensitive medications with an opened or expired date for three of three residents (R1, R2 and R3) and the licensee failed to discard expired medications for two of three residents (R1 and R3). [...]”

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 include on the service plan a written statement of the treatment or therapy services provided and failed to develop

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to include on the service plan a written statement of the treatment or therapy services provided and failed to develop and implement a treatment or therapy management plan to include all required content for two of two residents (R2 and R4). [...]”

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 [...]”

MDH’s finding, as written: “Based on interview and record review the licensee failed to ensure up-to-date written or electronically recorded orders were maintained for one of two residents (R2) receiving treatments. [...]”

Rule cited: “There must be an up-to-date written or electronically recorded order from an authorized prescriber for all treatments and therapies. [...]”

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 (R1) who utilized consumer bed rails. [...]”

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.”