Keystone Bluffs Assisted Livin

Summary: MDH found the licensee failed to maintain a tuberculosis (TB) prevention and control program based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to maintain a tuberculosis (TB) prevention and control program based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC). The licensee failed to complete a TB risk assessment annually. This had the potential to affect all residents. [...]”

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 have a written emergency preparedness plan (EPP) with all the required content and failed to post an emergency preparedness plan prominently.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to have a written emergency preparedness plan (EPP) with all the required content and failed to post an emergency preparedness plan prominently. 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 the Minnesota Fire Code.

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

Rule cited: “for dwellings or sleeping units, as defined in the State Fire Code: (i) provide smoke alarms in each room used for sleeping purposes; (ii) provide smoke alarms outside each separate sleeping area in the immediate vicinity of bedrooms; (iii) provide smoke [...]”

Summary: MDH found the licensee failed to ensure the registered nurse (RN) provided written instructions in the resident's record for the delegated task provided by the unlicensed personnel (ULP) for one of one resident (R10) whose delegated task included catheter care.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) provided written instructions in the resident's record for the delegated task provided by the unlicensed personnel (ULP) for one of one resident (R10) whose delegated task included catheter care. [...]”

Rule cited: “(b) When the registered nurse or licensed health professional delegates tasks to unlicensed personnel, that person must ensure that prior to the delegation the unlicensed personnel is trained in the proper methods to perform the tasks or procedures for each [...]”

Summary: MDH found the licensee failed to ensure two of two employees, (unlicensed personnel (ULP)-D, ULP-F) received the required amount of dementia care training in the required time frame.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure two of two employees, (unlicensed personnel (ULP)-D, ULP-F) received the required amount of dementia care training in the required time frame. [...]”

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 dementia training included all the required content for two of two employees, unlicensed personnel (ULP)-D, ULP-F.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure dementia training included all the required content for two of two employees, unlicensed personnel (ULP)-D, ULP-F. [...]”

Rule cited: “(5) new employees may satisfy the initial training requirements by producing written proof of previously completed required training within the past 18 months. [...]”

Summary: MDH found the licensee failed to ensure service plans were revised/implemented as required for three of four residents (R10, R14, R20).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure service plans were revised/implemented as required for three of four residents (R10, R14, R20). In addition, the licensee failed to ensure service plans were authenticated to confirm agreement of the services to be provided for two of four residents (R17, R18). [...]”

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 registered nurse (RN) conducted a face-to-face medication management reassessment for one of three residents (R17) who received medication management services.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) conducted a face-to-face medication management reassessment for one of three residents (R17) who received medication management services. [...]”

Rule cited: “The assisted living facility must monitor and reassess the resident's medication management services as needed under subdivision 2 when the resident presents with symptoms or other issues that may be medication-related and, at a minimum, annually.”

Summary: MDH found the licensee failed to ensure prior to delegating the nursing task of medication administration, unlicensed personnel (ULP-F) demonstrated competency for administering medication.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure prior to delegating the nursing task of medication administration, unlicensed personnel (ULP-F) demonstrated competency for administering medication. In addition, the licensee failed to ensure the registered nurse (RN) prepared in writing specific instructions for each resident and documented those instructions for three of four residents (R16, R10, R2). [...]”

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 followed registered nurse (RN) written instructions for two of two residents (R2, R17).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure one of two unlicensed personnel (ULP)-D followed registered nurse (RN) written instructions for two of two residents (R2, R17). Additionally, the licensee failed to ensure medications were administered as ordered for three of three residents (R17, R20, R18). Further, the licensee failed to ensure manufacturer's instruction were followed for one of three residents (R17) who received medication management services. [...]”

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 one of four medication carts was secured (medication cart 200).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure one of four medication carts was secured (medication cart 200). 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 was issued at an isolated scope (when one or a limited number of residents are affected or one or a [...]”

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 ensure medications were maintained bearing the original prescription label with legible information, including the expiration date, for time sensitive medications for four of four medication carts: 100, 200, 400, 300 & 500 (combined into one cart).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medications were maintained bearing the original prescription label with legible information, including the expiration date, for time sensitive medications for four of four medication carts: 100, 200, 400, 300 & 500 (combined into one cart). In addition, the licensee failed to monitor for expired medication for one of ten residents (R10). [...]”

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 and implement a treatment or therapy management plan to include all required content for one of three residents (R18) who had treatments managed by the facility.

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 one of three residents (R18) who had treatments managed by the facility. [...]”

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 instructions, specified in writing for each resident, and documented those instructions in the resident's record for three of three residents (R10, R14, R16) receiving treatments.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure instructions, specified in writing for each resident, and documented those instructions in the resident's record for three of three residents (R10, R14, R16) receiving treatments. [...]”

Rule cited: “Ordered or prescribed treatments or therapies must be administered by a nurse, physician, or other licensed health professional authorized to perform the treatment or therapy, or may be delegated or assigned to unlicensed personnel by the licensed health [...]”

Summary: MDH found the licensee failed to ensure treatments or therapies were administered as prescribed for two of three residents (R10, R17) with health monitoring managed by the provider.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure treatments or therapies were administered as prescribed for two of three residents (R10, R17) with health monitoring managed by the provider. [...]”

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 care and services according to acceptable health care, medical, or nursing standards for storage of oxygen for one of two residents (R18) with an oxygen tank.

MDH’s finding, as written: “The licensee failed to provide care and services according to acceptable health care, medical, or nursing standards for storage of oxygen for one of two residents (R18) with an oxygen tank. [...]”

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.”

Summary: MDH found the licensee failed to provide care and services according to acceptable health care, medical, or nursing standards by three of three employees, (unlicensed personnel (ULP)-D, ULP-E, registered nurse (RN)-G) during medication administration for R18.

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 by three of three employees, (unlicensed personnel (ULP)-D, ULP-E, registered nurse (RN)-G) during medication administration for R18. In addition, the licensee failed to ensure a care plan was followed by three of three employees, (ULP-D, ULP-E, RN-G) for R18. [...]”

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 [...]”

Summary: MDH found the facility failed to ensure one of two residents (R10) was treated with dignity and respect when R10's urinary drainage bag was exposed in common areas.

MDH’s finding, as written: “Based on observation, interview, and record review, the facility failed to ensure one of two residents (R10) was treated with dignity and respect when R10's urinary drainage bag was exposed in common areas. [...]”

Rule cited: “Residents have the right to be treated with courtesy and respect, and to have the resident's property treated with respect”

MDH’s finding, as written: “Based on observation, interview, and record review the licensee failed to ensure resident's personal health and medical information was kept private. This had the potential to affect all residents residing at the assisted living facility. [...]”

Rule cited: “(a) Residents have the right to have personal, financial, health, and medical information kept private, to approve or refuse release of information to any outside party, and to be advised of the assisted living facility's policies and procedures regarding [...]”