Ivy Hill Senior Care

Summary: MDH found the licensee failed to ensure an annual performance review was completed, and the licensee failed to ensure a current job description was included as part of the record for one of two employees (registered nurse (RN)-C) with employee record reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure an annual performance review was completed, and the licensee failed to ensure a current job description was included as part of the record for one of two employees (registered nurse (RN)-C) with employee record 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 documentation of a completed health history and symptom screening, including completion of a two-step TST (tuberculin skin test) or other evidence of TB screening such as a blood test for one of one employee (registered nurse (RN)-C).

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 documentation of a completed health history and symptom screening, including completion of a two-step TST (tuberculin skin test) or other evidence of TB screening such as a blood test for one of one employee (registered nurse (RN)-C). [...]”

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 ensure it completed a written emergency disaster plan with all required content outlined in Appendix Z. This had the potential to affect all current residents, staff, and visitors.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure it completed a written emergency disaster plan with all required content outlined in Appendix Z. This had the potential to affect all current residents, staff, and visitors. [...]”

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 fire safety training and evacuation plans for residents and staff.

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

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 the licensee's two of three current residents (R1, R4) 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 the licensee's two of three current residents (R1, R4) with records reviewed. [...]”

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 ensure employees received orientation training to the assisted living licensing requirements and regulations for one of two employees (registered nurse (RN)-C) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure employees received orientation training to the assisted living licensing requirements and regulations for one of two employees (registered nurse (RN)-C) with records reviewed. [...]”

Rule cited: “All staff providing and supervising direct services must complete an orientation to assisted living facility licensing requirements and regulations before providing assisted living services to residents. [...]”

Summary: MDH found the licensee failed to ensure staff received dementia training in the required areas for two of two employees (registered nurse (RN)-C and unlicensed personnel (ULP)-B) with employee records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure staff received dementia training in the required areas for two of two employees (registered nurse (RN)-C and unlicensed personnel (ULP)-B) with employee records reviewed. [...]”

Rule cited: “All direct care staff and supervisors providing direct services must demonstrate an understanding of the training specified in section 144G.64.”

Summary: MDH found the licensee failed to ensure employees received at least eight hours of annual training for each 12 months of employment for one of one employee (registered nurse (RN)-C) with employee record reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure employees received at least eight hours of annual training for each 12 months of employment for one of one employee (registered nurse (RN)-C) with employee record reviewed. [...]”

Rule cited: “(a) All staff that perform direct services must complete at least eight hours of annual training for each 12 months of employment. [...]”

MDH’s finding, as written: “Based on interview and record review the licensee failed to provide evidence of dementia care training on required topics for one of two employees (registered nurse (RN)-C), 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 medications were labeled correctly for one of one resident (R4) with records reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medications were labeled correctly for one of one resident (R4) with records reviewed. [...]”

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 develop a treatment management plan to include all required content for one of two residents (R1) with records reviewed.

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

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 [...]”