Hills Crossing Senior Living

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure training and competency was completed for one of two employees, (unlicensed personnel (ULP)-E), to include all required content with records 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 direct supervision of staff performing delegated tasks was provided within 30 calendar days after the date on which the individual begins working for the licensee for two of two unlicensed personnel (ULP)-E, ULP-J with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure direct supervision of staff performing delegated tasks was provided within 30 calendar days after the date on which the individual begins working for the licensee for two of two unlicensed personnel (ULP)-E, ULP-J with records 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 [...]”

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

Rule cited: “An assisted living facility with dementia care that has a secured dementia care unit must meet the requirements of section 144G.45 and the following additional requirements: (1) a hazard vulnerability assessment or safety risk must be performed on and around [...]”

MDH’s finding, as written: “Based on interview and record review, the licensee failed to have an evaluation for an activity plan for four of four residents (R1, R3, R4, R9) who received services under an assisted living with dementia care license. [...]”

Rule cited: “(b) Each resident must be evaluated for activities according to the licensing rules of the facility. [...]”

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

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 provide the required plans and resident training for fire safety and evacuation.

MDH’s finding, as written: “Based on document review and interview, the licensee failed to provide the required plans and resident training for fire safety and evacuation. This had the potential to directly affect all residents and staff. [...]”

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

Summary: MDH found the licensee failed to offer the resident the opportunity to identify a designated representative in writing for three of three residents (R1, R3, R4) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to offer the resident the opportunity to identify a designated representative in writing for three of three residents (R1, R3, R4) with records 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 facility failed to ensure the contract did not include language waiving the facility's liability for health, safety, or personal property of a resident.

MDH’s finding, as written: “Based on interview and record review, the facility failed to ensure the contract did not include language waiving the facility'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 with dementia care license for three of three employees (registered nurse (RN)-D, unlicensed personnel (ULP)-C, and ULP-E) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure a background study was submitted and received in affiliation with the assisted living with dementia care license for three of three employees (registered nurse (RN)-D, unlicensed personnel (ULP)-C, and ULP-E) with records reviewed. [...]”

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 training and competency was completed for one of two employees, (unlicensed personnel (ULP)-E), to include all required content with records 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 two employees, (unlicensed personnel (ULP)-E), to include all required content with records 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 two employees, (unlicensed personnel (ULP)-E), to include all required content with records 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 two employees, (unlicensed personnel (ULP)-E), to include all required content with records 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 direct supervision of staff performing delegated tasks was provided within 30 calendar days after the date on which the individual begins working for the licensee for one of one unlicensed personnel (ULP)-E with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure direct supervision of staff performing delegated tasks was provided within 30 calendar days after the date on which the individual begins working for the licensee for one of one unlicensed personnel (ULP)-E with records 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 one of two employees (registered nurse (RN)-D) received orientation to assisted living facility licensing to include all the required topics with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure one of two employees (registered nurse (RN)-D) received orientation to assisted living facility licensing to include all the required topics 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 amount of dementia care training in the required time frame for three of three employees (registered nurse (RN)-D, unlicensed personnel (ULP)-C, ULP-E) with records reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure employees received the required amount of dementia care training in the required time frame for three of three employees (registered nurse (RN)-D, unlicensed personnel (ULP)-C, ULP-E) with records reviewed. [...]”

Rule cited: “(3) for assisted living facilities with dementia care, direct-care employees must have completed at least eight hours of initial training on topics specified under paragraph (b) within 80 working hours of the employment start date. [...]”

Summary: MDH found the licensee failed to ensure documentation of medication setup included all the required content for one of one resident (R3) 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 (R3) 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 two of two medication refrigerators (memory care and assisted living) maintained an acceptable temperature to ensure the medications were stored according to manufacturer's recommendations.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure two of two medication refrigerators (memory care and assisted living) maintained an acceptable temperature to ensure the medications were stored according to manufacturer's recommendations. [...]”

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 monitor for expired medication dates for two of two residents (R3, R7) and stock medications.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to monitor for expired medication dates for two of two residents (R3, R7) and stock medications. [...]”

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 ensure one of one

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure one of one resident's (R1) dressing change was provided as directed by the prescriber with records reviewed. [...]”

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 a hazard vulnerability or safety risk assessment that included hazards identified on and around the property.

MDH’s finding, as written: “Based on document review and interview, the licensee failed to provide a hazard vulnerability or safety risk assessment that included hazards identified on and around the property. This had the potential to directly affect all residents and staff. [...]”

Rule cited: “An assisted living facility with dementia care that has a secured dementia care unit must meet the requirements of section 144G.45 and the following additional requirements: (1) a hazard vulnerability assessment or safety risk must be performed on and around [...]”

Summary: MDH found the licensee failed to develop and implement all required policies and procedures related to dementia care.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop and implement all required policies and procedures related to dementia care. 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 is issued at a widespread scope (when problems are pervasive or represent a systemic failure that has [...]”

Rule cited: “(a) In addition to the policies and procedures required in the licensing of all facilities, the assisted living facility with dementia care licensee must develop and implement policies and procedures that address the: (1) philosophy of how services are [...]”

Summary: MDH found the licensee failed to have an evaluation for an activity plan for three of three residents (R1, R3, R4) who received services under an assisted living with dementia care license.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to have an evaluation for an activity plan for three of three residents (R1, R3, R4) who received services under an assisted living with dementia care license. [...]”

Rule cited: “(b) Each resident must be evaluated for activities according to the licensing rules of the facility. [...]”

Summary: MDH found the licensee failed to provide in written or electronic form to residents, families, or other persons who request it, a description of the dementia care training program, the categories of employees trained and the frequency of training with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide in written or electronic form to residents, families, or other persons who request it, a description of the dementia care training program, the categories of employees trained and the frequency of training with records reviewed. [...]”

Rule cited: “An assisted living facility with dementia care shall make available in written or electronic form, to residents and families or other persons who request it, a description of the training program and related training it provides, including the categories of [...]”

Summary: MDH found the licensee failed to provide care and services according to acceptable health care, medical, or nursing standards for one of three residents (R5) with bedrails and one of one residents (R1) with restraints.

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 three residents (R5) with bedrails and one of one residents (R1) with restraints. This resulted in an immediate correction order on March 15, 2022, at approximately 10:40 a.m. [...]”

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.”