Lakeside Manor

Summary: MDH found the licensee failed to have a daily program of social and recreational activities based on individual and group interests, physical, mental, and

MDH’s finding, as written: “Based on observation and interview, the licensee failed to have a daily program of social and recreational activities based on individual and group interests, physical, mental, and psychosocial needs. This had the potential to affect all seven 32 residents residing in the facility. [...]”

Rule cited: “(ii) weekly housekeeping; (iii) weekly laundry service; (iv) upon the request of the resident, provide direct or reasonable assistance with arranging for transportation to medical and social services appointments, shopping, and other recreation, and provide [...]”

Summary: MDH found the licensee failed to establish and maintain an infection control program that complies with accepted health care, medical and nursing standards for infection control and current recommendation for COVID-19 regarding wearing appropriate personal protective equipment (PPE).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to establish and maintain an infection control program that complies with accepted health care, medical and nursing standards for infection control and current recommendation for COVID-19 regarding wearing appropriate personal protective equipment (PPE). This had the potential to affect all residents, staff and visitors. [...]”

Rule cited: “(a) All assisted living facilities must establish and maintain an infection control program that complies with accepted health care, medical, and nursing standards for infection control. [...]”

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

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

Summary: MDH found the licensee failed to engage in and maintain documentation of quality management activity appropriate to the size and relevant to the type of services provided by the assisted living.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to engage in and maintain documentation of quality management activity appropriate to the size and relevant to the type of services provided by the assisted living. This had the potential to affect all residents receiving assisted living services. [...]”

Rule cited: “The facility shall engage in quality management appropriate to the size of the facility and relevant to the type of services provided. [...]”

Summary: MDH found the licensee failed to ensure the employee records contained the required content for two of two employees (registered nurse (RN)-A, unlicensed personnel (ULP)-D).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure the employee records contained the required content for two of two employees (registered nurse (RN)-A, unlicensed personnel (ULP)-D). [...]”

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 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 32 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 [...]”

MDH’s finding, as written: “Based on observation and interview the licensee failed to ensure installation and maintenance of portable fire extinguishers at the facility. This had potential to directly affect all residents, staff, and visitors. [...]”

Rule cited: “(2) install and maintain portable fire extinguishers in accordance with the State Fire Code; (3) install portable fire extinguishers having a minimum 2-A:10-B:C rating within Group R-3 occupancies, as defined by the State Fire Code, located so that the travel [...]”

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 observation, interview and record review, the licensee failed to provide the required fire safety training and evacuation plans for residents and staff. This has 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 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 residents. [...]”

Rule cited: “The contract must not include a waiver of facility liability for the health and safety or personal property of a resident. [...]”

MDH’s finding, as written: “Based on interview and record review, licensee failed to provide written notice with required content for an emergency relocation and failed to notify the Office of Ombudsman for Long-Term Care (OOLTC) of the emergency relocation for one or one resident (R6) reviewed for hospitalizations. [...]”

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 staff met all requirements for training and competency evaluations, as identified in 144G.60, Subd. 4, and 144G.61 Subd 1. and 2, for three of three unlicensed personnel (ULP-D, ULP-G, ULP-H).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure staff met all requirements for training and competency evaluations, as identified in 144G.60, Subd. 4, and 144G.61 Subd 1. and 2, for three of three unlicensed personnel (ULP-D, ULP-G, ULP-H). This had the potential to affect all residents receiving assisted living services. [...]”

Rule cited: “(b) Unlicensed personnel performing delegated nursing tasks in an assisted living facility must: (1) have successfully completed training and demonstrated competency by successfully completing a written or oral test of the topics in section 144G.61, [...]”

Summary: MDH found the licensee failed to ensure one of two employees, registered nurse (RN)-B's employee record contained orientation to assisted living facility licensing to include all the required topics.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure one of two employees, registered nurse (RN)-B's employee record contained orientation to assisted living facility licensing to include all the required topics. [...]”

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 three of three employees (unlicensed personnel (ULP)-D, ULP-G, and registered nurse (RN)-B) received the required amount of dementia care training in the required time frame with records reviewed.

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

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 three of three employees (unlicensed personnel (ULP)-D, ULP-G), and registered nurse (RN-B).

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 three of three employees (unlicensed personnel (ULP)-D, ULP-G), and registered nurse (RN-B). This had the potential to affect all residents. [...]”

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. [...]”

MDH’s finding, as written: “Based on interview and record review the licensee failed to ensure the registered nurse (RN) completed a comprehensive assessment not to exceed day 90 for one of three residents (R4). In addition, the RN failed to complete a comprehensive assessment by day 14 from admission for one of three residents (R5). [...]”

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 date time-sensitive medications with an opened or expiration dates for R2, R5, R6, R12, R13.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to date time-sensitive medications with an opened or expiration dates for R2, R5, R6, R12, R13. In addition, the licensee failed to ensure medications were maintained bearing the original prescription label for R13 and further, the licensee failed to monitor for expired medications for R2, R4, R6. [...]”

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 signage was posted at the main entryway of the establishment to display statutory language to disclose electronic monitoring activity, potentially affecting all residents, staff, and visitors of the licensee.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to ensure signage was posted at the main entryway of the establishment to display statutory language to disclose electronic monitoring activity, potentially affecting all residents, staff, and 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 [...]”