Jaris M Pokey Paro Assisted Li

Summary: MDH found the licensee failed to develop and post a written emergency disaster plan with all the required content.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to develop and post a written emergency disaster plan with all the required content. This had the potential to affect all 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 keep the facility in compliance with Minnesota State Fire Code under Minnesota Rule Chapter 7511.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to keep the facility in compliance with Minnesota State Fire Code under Minnesota Rule Chapter 7511. The deficient condition has the ability to affect all staff and residents. [...]”

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 develop the fire safety and evacuation plan with the required content and the licensee failed to document required fire safety evacuation training for employees and residents as well as the required fire drills.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to develop the fire safety and evacuation plan with the required content and the licensee failed to document required fire safety evacuation training for employees and residents as well as the required fire drills. This had 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. [...]”

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to provide written notice with required content to the resident, legal representative, and/or designated representative, and failed to provide the notification to the Office of Ombudsman for Long-Term Care (OOLTC) when the resident did not return from the emergency relocation within four days for one of one resident (R4) reviewed for a hospitalization. [...]”

Rule cited: “(a) A facility may remove a resident from the facility in an emergency if necessary due to a resident's urgent medical needs or an imminent risk the resident poses to the health or safety of another facility resident or facility staff member. [...]”

Summary: MDH found the licensee failed to ensure employees performing direct services completed the required annual training for two of two employees (interim clinical nurse supervisor (ICNS)-B, unlicensed personnel (ULP)-C).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure employees performing direct services completed the required annual training for two of two employees (interim clinical nurse supervisor (ICNS)-B, unlicensed personnel (ULP)-C). This had the potential to affect all residents. [...]”

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: “Bases on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) prepared in writing specific instructions for each resident and documented those instructions for one of one resident (R4) who self-administered eye drops. [...]”

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 one of two unlicensed personnel (ULP-D) was trained by a registered nurse (RN) and had demonstrated competency to prepare and give medications for residents having unplanned time away.

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 trained by a registered nurse (RN) and had demonstrated competency to prepare and give medications for residents having unplanned time away. [...]”

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 date time-sensitive medications with opened and expiration dates for two of two residents (R2, R4) whose medications

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to date time-sensitive medications with opened and expiration dates for two of two residents (R2, R4) whose medications were stored by the licensee. [...]”

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 document in the resident record all of the required content in the disposition of medications for one of one resident (R1) upon discharge.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to document in the resident record all of the required content in the disposition of medications for one of one resident (R1) upon discharge. [...]”

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 provide care and services according to acceptable health care medical or nursing standards for medication administration by unlicensed personnel (ULP)-D for one of one resident (R4) whose medications were not administered as directed.

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 medication administration by unlicensed personnel (ULP)-D for one of one resident (R4) whose medications were not administered as directed. [...]”

Rule cited: “(b) Residents have the right to receive health care and other assisted living services with continuity from people who are properly trained and competent to perform their duties and in sufficient numbers to adequately provide the services agreed to in the [...]”