Ksms Our House, 14th Street Nw

Summary: MDH found the licensee failed to execute a written contract with the required content for three of three residents (R1, R2, R8).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to execute a written contract with the required content for three of three residents (R1, R2, R8). This practice resulted in a level one violation (a violation that has no potential to cause more than a minimal impact on the resident and does not affect health or safety), and was issued at a widespread scope (when problems are pervasive or represent a systemic failure that has affected or has potential to affect a large portion or all of [...]”

Rule cited: “(d) The contract must include a description of the facility's complaint resolution process available to residents, including the name and contact information of the person representing the facility who is designated to handle and resolve complaints. [...]”

Summary: MDH found the licensee failed to ensure the registered nurse (RN) had completed a comprehensive reassessment for change in condition for two of three residents (R2, R8) related to falls, ER visit and change in status and failed to ensure the RN completed accurate assessment for one of three residents (R8).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) had completed a comprehensive reassessment for change in condition for two of three residents (R2, R8) related to falls, ER visit and change in status and failed to ensure the RN completed accurate assessment for one of three residents (R8). [...]”

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 the service plan was revised with changes in services for two of three residents (R1, R8).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the service plan was revised with changes in services for two of three residents (R1, R8). [...]”

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 three residents (R1, R8).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure the service plan included all required content for two of three residents (R1, R8). 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 [...]”

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 ensure assessment of medication management services included all required content for one of three residents (R8).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure assessment of medication management services included all required content for one of three residents (R8). [...]”

Rule cited: “(a) For each resident who requests medication management services, the facility shall, prior to providing medication management services, have a registered nurse, licensed health professional, or authorized prescriber under section 151.37 conduct an [...]”

MDH’s finding, as written: “Based on observation, interview, and record review the licensee failed to ensure reassessment of medication management services at a minimum annually for two of three residents (R1, R2). [...]”

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 an individualized medication management plan to include all required content for three of three residents (R1, R2, R8).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure an individualized medication management plan to include all required content for three of three residents (R1, R2, R8). [...]”

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 medication was administered as prescribed for one of one resident (R2) who was observed for medication administration.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medication was administered as prescribed for one of one resident (R2) who was observed for medication administration. [...]”

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 an individualized treatment or therapy management record to include all required content for two of three residents (R1, R8).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure an individualized treatment or therapy management record to include all required content for two of three residents (R1, R8). [...]”

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: “Based on observation, interview, and record review the licensee failed to ensure a prescriber's order for treatment or therapy for one of three residents (R1). 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 [...]”

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 develop and implement all required policies and procedures related to dementia care and failed to provide the policies and procedures to residents and the residents' legal and designated representatives at the time of move-in.

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 and failed to provide the policies and procedures to residents and the residents' legal and designated representatives at the time of move-in. [...]”

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 immediately report to the

MDH’s finding, as written: “Based on interview and record review, the licensee failed to immediately report to the Minnesota Adult Abuse Reporting Center (MAARC) suspected abuse for two of two residents (R9, R1). [...]”

Rule cited: “(a) A mandated reporter who has reason to believe that a vulnerable adult is being or has been maltreated, or who has knowledge that a vulnerable adult has sustained a physical injury which is not reasonably explained shall immediately report the information [...]”

Summary: MDH found the licensee failed to post information related to the grievance procedure.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to post information related to the grievance procedure. This had the potential to affect all residents, staff and visitors. [...]”

Rule cited: “All facilities must post in a conspicuous place information about the facilities' grievance procedure, and the name, telephone number, and e-mail contact information for the individuals who are responsible for handling resident grievances. [...]”

MDH’s finding, as written: “Based on observation and interview, the licensee failed to display the original current license at the main entrance of the assisted living facility as required. This had the potential to affect all of the licensee's current residents, staff and visitors. [...]”

Rule cited: “The original current license must be displayed at the main entrance of each assisted living facility. The facility must provide a copy of the license to any person who requests it.”

Summary: MDH found the licensee failed to immediately report to the Minnesota Adult Abuse Reporting Center (MAARC) suspected abuse and failed to complete a thorough investigation for occurrences of suspected abuse for three of three residents (R3, R2, R4).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to immediately report to the Minnesota Adult Abuse Reporting Center (MAARC) suspected abuse and failed to complete a thorough investigation for occurrences of suspected abuse for three of three residents (R3, R2, R4). [...]”

Rule cited: “144G.42 Subd. 6. Compliance with requirements for reporting maltreatment of vulnerable adults; abuse prevention plan. (a) The assisted living facility must comply with the requirements for the reporting of maltreatment of vulnerable adults in section 626.557. [...]”

Summary: MDH found the licensee failed to develop and implement an individual abuse prevention plan that included an individualized review or assessment of the person's susceptibility to abuse by another individual, including other vulnerable adults for two of two residents (R2, R1).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to develop and implement an individual abuse prevention plan that included an individualized review or assessment of the person's susceptibility to abuse by another individual, including other vulnerable adults for two of two residents (R2, R1). [...]”

Rule cited: “(b) The facility must develop and implement an individual abuse prevention plan for each vulnerable adult. [...]”

Summary: MDH found the licensee failed to support protection and safety by not posting information and phone numbers for reporting to the Minnesota Adult Abuse Reporting Center (MAARC) and failed to post the 911 emergency number in common areas and near telephones provided by the assisted living facility.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to support protection and safety by not posting information and phone numbers for reporting to the Minnesota Adult Abuse Reporting Center (MAARC) and failed to post the 911 emergency number in common areas and near telephones provided by the assisted living facility. This had the potential to affect all 17 residents receiving assisted living services, staff, and visitors. [...]”

Rule cited: “The facility shall support protection and safety through access to the state's systems for reporting suspected criminal activity and suspected vulnerable adult maltreatment by: (1) posting the 911 emergency number in common areas and near telephones provided [...]”

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

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

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 an a written emergency disaster plan with required elements and was posted; failed to ensure emergency exit diagrams were posted and provided to residents and failed to ensure a written policy and procedure for missing residents included all required content.

MDH’s finding, as written: “Based on observation, interview and document review, the licensee failed to ensure an a written emergency disaster plan with required elements and was posted; failed to ensure emergency exit diagrams were posted and provided to residents and failed to ensure a written policy and procedure for missing residents included all required content. In addition, the licensee failed to develop an all-hazards emergency preparedness (EP) program and plan to include Appendix Z required elements. [...]”

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 ensure the resident record included a discharge summary with the required content and provided information to the receiving facility as required for one of one discharged resident (R3).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the resident record included a discharge summary with the required content and provided information to the receiving facility as required for one of one discharged resident (R3). In addition, the licensee failed to ensure required content of record for one of two residents (R2). [...]”

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 maintain the facility 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 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 execute a written contract with the required content for two of two residents (R2, R1).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to execute a written contract with the required content for two of two residents (R2, R1). This practice resulted in a level one violation (a violation that has no potential to cause more than a minimal impact on the resident and does not affect health or safety), and was issued at a widespread scope (when problems are pervasive or represent a systemic failure that has affected or has potential to affect a large portion or all of the [...]”

Rule cited: “(d) The contract must include a description of the facility's complaint resolution process available to residents, including the name and contact information of the person representing the facility who is designated to handle and resolve complaints. [...]”

Summary: MDH found the licensee failed to execute a written contract with the required content for two of two residents (R2, R1).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to execute a written contract with the required content for two of two residents (R2, R1). This practice resulted in a level one violation (a violation that has no potential to cause more than a minimal impact on the resident and does not affect health or safety), and was issued at a widespread scope (when problems are pervasive or represent a systemic failure that has affected or has potential to affect a large portion or all of the [...]”

Rule cited: “(5) a description of the facility's policies related to medical assistance waivers under chapter 256S and section 256B.49 and the housing support program under chapter 256I, including: (i) whether the facility is enrolled with the commissioner of human [...]”

Summary: MDH found the licensee failed to ensure the licensee provided the required notice for right to designated representative on a document separate from the contract and failed to ensure the contract included required content for two for two residents (R2, R1).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the licensee provided the required notice for right to designated representative on a document separate from the contract and failed to ensure the contract included required content for two for two residents (R2, R1). [...]”

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 licensee failed to ensure the assisted living 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 licensee failed to ensure the assisted living 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 17 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 the opportunity of a meeting with a representative of the Office of Ombudsman for Long-Term Care before issuing a termination of services for one of one resident (R3).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the opportunity of a meeting with a representative of the Office of Ombudsman for Long-Term Care before issuing a termination of services for one of one resident (R3). [...]”

Rule cited: “(a) Before issuing a notice of termination of an assisted living contract, a facility must schedule and participate in a meeting with the resident and the resident's legal representative and designated representative. [...]”

Summary: MDH found the licensee failed to address if services form another service provider could be obtained to prevent termination of services for one of one discharged resident (R3).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to address if services form another service provider could be obtained to prevent termination of services for one of one discharged resident (R3). [...]”

Rule cited: “A facility may not terminate the assisted living contract if the underlying reason for termination may be resolved by the resident obtaining services from another provider of the resident's choosing and the resident obtains those services.”

Summary: MDH found the licensee failed to send a copy of the termination

MDH’s finding, as written: “Based on interview and record review, the licensee failed to send a copy of the termination notice to the Office of Ombudsman for Long-Term Care for one of one resident (R3). [...]”

Rule cited: “(a) A facility terminating a contract must issue a written notice of termination according to this section. [...]”

Summary: MDH found the facility failed to provide a termination notice which contained all required information for one of one resident (R3).

MDH’s finding, as written: “Based on interview and record review, the facility failed to provide a termination notice which contained all required information for one of one resident (R3). This practice resulted in a level one violation (a violation that has no potential to cause more than a minimal impact on the resident and does not affect health or safety) and was issued at a widespread scope (when problems are pervasive or represent a systemic failure that has affected or has potential to affect a large portion or all [...]”

Rule cited: “The notice required under subdivision 7 must contain, at a minimum: (1) the effective date of the termination of the assisted living contract; (2) a detailed explanation of the basis for the termination, including the clinical or other supporting rationale; [...]”

Summary: MDH found the licensee failed to ensure training and competency evaluations contained all the required training for two of two unlicensed personnel (ULP-E, ULP-F).

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

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 evaluations contained all the required training for one of two unlicensed personnel (ULP-E).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure training and competency evaluations contained all the required training for one of two unlicensed personnel (ULP-E). [...]”

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 the registered nurse (RN) conducted training and competency evaluations for two of two unlicensed personnel (ULP-E, ULP-F) who performed delegated tasks.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) conducted training and competency evaluations for two of two unlicensed personnel (ULP-E, ULP-F) who performed delegated tasks. [...]”

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 direct supervision of staff performing delegated tasks was provided within 30 calendar days after the date on which the individual begins working for the facility for one of two unlicensed personnel (ULP-E).

MDH’s finding, as written: “Based on observation, 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 facility for one of two unlicensed personnel (ULP-E). [...]”

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 the registered nurse (RN) had completed a comprehensive reassessment for change in condition for two of two residents (R2, R1) related to falls, ER visits and change in status and failed to ensure the RN completed accurate assessment for two of two residents (R2, R1).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) had completed a comprehensive reassessment for change in condition for two of two residents (R2, R1) related to falls, ER visits and change in status and failed to ensure the RN completed accurate assessment for two of two residents (R2, 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 the service plan was revised with changes in services for two of two residents (R2, R1).

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

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 (R2, R1).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure the service plan included all required content for two of two residents (R2, R1). 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 [...]”

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: “Based on observation, interview and record review the licensee failed to ensure reassessment of medication management services at a minimum annually for two of two residents (R2, R1). [...]”

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 an individualized medication management plan to include all required content for two of two residents (R2, R1).

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

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, prior to delegating nursing tasks, the one of one unlicensed personnel (ULP-E) was trained in the proper methods to perform the task or procedure for each resident and were able to demonstrate the ability to competently follow the procedure to perform the tasks with employee record reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure, prior to delegating nursing tasks, the one of one unlicensed personnel (ULP-E) was trained in the proper methods to perform the task or procedure for each resident and were able to demonstrate the ability to competently follow the procedure to perform the tasks with employee record reviewed. This resulted in an immediate correction order on September 9, 2022, at approximately 10:40 a.m. [...]”

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 medication was administered as prescribed and direction for administration of medication was transcribed as prescribed for two of two residents (R2, R1).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure medication was administered as prescribed and direction for administration of medication was transcribed as prescribed for two of two residents (R2, R1). In addition, the licensee failed to follow up on as needed (PRN) medication effectiveness for one of one resident (R1). [...]”

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 training and competency evaluations for preparing medications for resident unplanned times away were completed as required for one of one unlicensed personnel (ULP-E) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure training and competency evaluations for preparing medications for resident unplanned times away were completed as required for one of one unlicensed personnel (ULP-E) with records reviewed. [...]”

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: “Based on observation, interview, and record review the licensee failed to ensure prescriber's orders for medications for one of two residents (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, 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: “There must be a current written or electronically recorded prescription as defined in section 151.01, subdivision 16a, for all prescribed medications that the assisted living facility is managing for the resident.”

Summary: MDH found the licensee failed to ensure medications were stored according to manufacturer's instructions in one of one medication refrigerator.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medications were stored according to manufacturer's instructions in one of one medication refrigerator. [...]”

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 an individualized treatment or therapy management record to include all required content for two of two residents (R2, R1).

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

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 an the registered nurse (RN) specified, in writing, specific instructions for each resident and documented those instructions in the resident's records for one of two residents (R2) receiving treatments and had instructed the unlicensed personnel in the proper methods with respect to each resident and two of two unlicensed personnel (ULP-E, ULP-F) has demonstrated the ability to competently follow the procedures.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure an the registered nurse (RN) specified, in writing, specific instructions for each resident and documented those instructions in the resident's records for one of two residents (R2) receiving treatments and had instructed the unlicensed personnel in the proper methods with respect to each resident and two of two unlicensed personnel (ULP-E, ULP-F) has demonstrated the ability to competently follow the procedures. [...]”

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 treatment services were documented for one of two residents (R2).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure treatment services were documented for one of two residents (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, 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: “Each treatment or therapy administered by an assisted living facility must be in the resident record. [...]”

MDH’s finding, as written: “Based on observation, interview, and record review the licensee failed to ensure a prescriber's order for treatment or therapy for two of two residents (R2, R1). 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 a pattern scope (when more than a limited number of residents are affected, [...]”

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 develop and implement all required policies and procedures related to dementia care and failed to provide the policies and procedures to residents and the residents' legal and designated representatives at the time of move-in.

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 and failed to provide the policies and procedures to residents and the residents' legal and designated representatives at the time of move-in. [...]”

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 include a description of the training program for dementia care in written or electronic form to residents, families, or other persons who request it, with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to include a description of the training program for dementia care in written or electronic form to residents, families, or other persons who request it, 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 ensure care and services were provided according to acceptable health care and medical, or nursing standards

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure care and services were provided according to acceptable health care and medical, or nursing standards with bedrails/side rails for one of one resident (R2) with record reviewed. This resulted in an immediate correction order on September 7, 2022, at 1:15 p.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.”

Summary: MDH found the licensee failed to respond to grievances of one of one resident (R2).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to respond to grievances of one of one resident (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, 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 limited number of staff are involved or [...]”

Rule cited: “Residents have the right to make and receive a timely response to a complaint or inquiry, without limitation. [...]”

Summary: MDH found the licensee failed to immediately report to the Minnesota Adult Abuse Reporting Center (MAARC) suspected abuse and failed to complete a thorough investigation for occurrences of suspected abuse for three of three residents (R3, R2, R4).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to immediately report to the Minnesota Adult Abuse Reporting Center (MAARC) suspected abuse and failed to complete a thorough investigation for occurrences of suspected abuse for three of three residents (R3, R2, R4). [...]”

Rule cited: “(a) A mandated reporter who has reason to believe that a vulnerable adult is being or has been maltreated, or who has knowledge that a vulnerable adult has sustained a physical injury which is not reasonably explained shall immediately report the information [...]”

Summary: MDH found the licensee failed to ensure the required notice was posted at the main entry way of the establishment to display statutory language to disclose electronic monitoring activity, potentially affecting all current residents in the assisted living facility, staff and any visitors of the licensee.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to ensure the required notice was posted at the main entry way of the establishment to display statutory language to disclose electronic monitoring activity, potentially affecting all current residents in the assisted living facility, staff and any visitors of the licensee. [...]”

Rule cited: “Subd. 8.Notice to visitors. (a) A facility must post a sign at each facility entrance accessible to visitors that states: "Electronic monitoring devices, including security cameras and audio devices, may be present to record persons and activities." (b) The [...]”