Lakeview Retirement Residence

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

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 three of three unlicensed personnel ((ULP)-C, ULP-E, ULP-F) with records reviewed. [...]”

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 staff providing and supervising direct services completed an orientation to assisted living facility licensing requirements and regulations before providing services for one of one employee (licensed practical nurse (LPN)-D) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure staff providing and supervising direct services completed an orientation to assisted living facility licensing requirements and regulations before providing services for one of one employee (licensed practical nurse (LPN)-D) 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 service plans included the required content for three of three residents (R1, R2, R3,) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure service plans included the required content for three of three residents (R1, R2, R3,) with records reviewed. This had the potential to affect all 40 residents who received assisted living services from the licensee. [...]”

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 develop, implement, and maintain current medication management policies and procedures that were developed under the supervision and direction of a registered nurse (RN) consistent with current practice standards and guidelines, with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop, implement, and maintain current medication management policies and procedures that were developed under the supervision and direction of a registered nurse (RN) consistent with current practice standards and guidelines, with records reviewed. [...]”

Rule cited: “(a) This section applies only to assisted living facilities that provide medication management services. [...]”

Summary: MDH found the licensee failed to ensure the registered nurse (RN) conducted an individualized medication assessment with the required content for two of three residents (R1, R3) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure the registered nurse (RN) conducted an individualized medication assessment with the required content for two of three residents (R1, R3) with records reviewed. [...]”

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 [...]”

Summary: MDH found the licensee failed to ensure the registered nurse (RN) maintained a current individualized medication management plan following a change in condition and a change in medication management services for one of three residents (R3) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the registered nurse (RN) maintained a current individualized medication management plan following a change in condition and a change in medication management services for one of three residents (R3) with records reviewed. [...]”

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 documentation of medication setup included all the required content for one of one resident (R3) with records reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure documentation of medication setup included all the required content for one of one resident (R3) with records reviewed. [...]”

Rule cited: “Documentation of dates of medication setup, name of medication, quantity of dose, times to be administered, route of administration, and name of person completing medication setup must be done at the time of setup.”

Summary: MDH found the licensee failed to ensure a prescription drug had the original prescription label as required for one of one resident (R2) with records reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure a prescription drug had the original prescription label as required for one of one resident (R2) 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, implement, and maintain up-to-date written treatment or therapy management policies and procedures that were developed under the supervision and direction of a registered nurse (RN) consistent with current practice standards and guidelines with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop, implement, and maintain up-to-date written treatment or therapy management policies and procedures that were developed under the supervision and direction of a registered nurse (RN) consistent with current practice standards and guidelines with records reviewed. [...]”

Rule cited: “(a) An assisted living facility that provides treatment and therapy management services must develop, implement, and maintain up-to-date written treatment or therapy management policies and procedures. [...]”

Summary: MDH found the licensee failed to ensure specific written instructions for each resident were documented in one of one resident's record (R3) who received blood glucose monitoring.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure specific written instructions for each resident were documented in one of one resident's record (R3) who received blood glucose monitoring. [...]”

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 provide care and services according to acceptable health care, medical, or nursing standards for three of three residents (R6, R7, R8) with bedrails who lacked a bed rail assessment and an explanation of risks and benefits of the use of bed rails.

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 three of three residents (R6, R7, R8) with bedrails who lacked a bed rail assessment and an explanation of risks and benefits of the use of bed rails. [...]”

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.”