Hallowstone of Winona

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: “(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: “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 was submitted and received in affiliation with the assisted living license for one of 20 unlicensed personnel (ULP-F).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure a background study was submitted and received in affiliation with the assisted living license for one of 20 unlicensed personnel (ULP-F). In addition, the licensee failed to ensure background studies were affiliated with the correct health facility identification (HFID) for one of 20 employees (ULP-G). This had the potential to affect all residents residing within the facility. [...]”

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. [...]”

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

Rule cited: “(c) Resident reassessment and monitoring must be conducted no more than 14 calendar days after initiation of services. [...]”

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

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

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 [...]”

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

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 further action required”

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: “No further action required”

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: “No further action required”

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. [...]”

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

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: “No further action required”

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

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

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

Summary: MDH found the licensee failed to ensure one of one discharged resident's record (R3) included a discharge summary.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure one of one discharged resident's record (R3) included a discharge summary. 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 an isolated scope (when one or a limited number of residents are affected or one or a limited number of staff are involved, or the situation has occurred only [...]”

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 smoke in compliance with Minnesota Fire Code.

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

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 maintain the facility's physical environment in a continuous state of good repair and operation regarding the health, safety, and well-being of the residents.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to maintain the facility's physical environment in a continuous state of good repair and operation regarding the health, safety, and well-being of the residents. This had the potential to directly affect all residents, staff, 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 ensure the assisted living contract did not include language waiving the licensee's liability for health, safety, or personal property of a resident.

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 health, safety, or personal property of a resident. This had the potential to affect all residents. [...]”

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 was submitted and received in affiliation with the assisted living license for one of two unlicensed personnel (ULP-C).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure a background study was submitted and received in affiliation with the assisted living license for one of two unlicensed personnel (ULP-C). This had the potential to affect all residents residing in the facility. This resulted in an immediate order on July 1, 2024. [...]”

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 the registered nurse (RN) conducted ongoing nursing assessments not to exceed 14 days from admission for one of one resident (R2) and failed to conduct ongoing nursing assessments not to exceed 90 days for one of one resident (R1).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the registered nurse (RN) conducted ongoing nursing assessments not to exceed 14 days from admission for one of one resident (R2) and failed to conduct ongoing nursing assessments not to exceed 90 days for one of one resident (R1). [...]”

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 a written service plan was signed and revised to reflect the current services provided for two of two residents (R1 and R2).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure a written service plan was signed and revised to reflect the current services provided for two of two residents (R1 and R2). [...]”

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 the service plan included all 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 ensure the service plan included all required content for two of two residents (R1 and R2). 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: “(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 plan with the required content for two of two residents (R1 and R2).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to develop an individualized medication management plan with the required content for two of two residents (R1 and R2). [...]”

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 one of two unlicensed personnel (ULP-D) was determined competent by a registered nurse (RN) to administer medications.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure one of two unlicensed personnel (ULP-D) was determined competent by a registered nurse (RN) to administer medications. This had the potential to affect all residents receiving medication administration. [...]”

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

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

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 [...]”

Summary: MDH found the licensee failed to document in the resident's record the disposition of the medication including the prescription numbers as applicable, and to whom the medications were given for one of one discharged resident (R3).

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 prescription numbers as applicable, and to whom the medications were given for one of one discharged resident (R3). [...]”

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 develop and implement a treatment or therapy management plan to include all required content for two of two residents (R1 and R2).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to develop and implement a treatment or therapy management plan to include all required content for two of two residents (R1 and R2). [...]”

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 [...]”

Summary: MDH found the licensee failed to ensure treatment or therapies were administered as prescribed, or to document the reason they were not provided, for two of two residents (R1, R2).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure treatment or therapies were administered as prescribed, or to document the reason they were not provided, for two of two residents (R1, R2). [...]”

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 ensure up-to-date written or electronically recorded orders were maintained for two of two residents (R1 and R2) receiving treatments.

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 two of two residents (R1 and 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. [...]”