Legacy Care Home, 14900 Crown Drive

MDH’s finding, as written: “Based on observation, interview and record review the licensee failed to establish and maintain an effective infection control program to comply with accepted health care, medical, and nursing standards for infection control and current recommendations for COVID-19. This deficient practice had the potential to affect all of the licensee's current 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 provide a resident council, and

MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide a resident council, and develop a process to consider resident council recommendations and grievances. This had the potential to affect all four residents receiving assisted living services. [...]”

Rule cited: “The facility must provide a resident council with space and privacy for meetings, where doing so is reasonably achievable. Staff, visitors, and other guests may attend a resident council meeting only at the council's invitation. [...]”

Summary: MDH found the licensee failed to provide a family council, and develop a process to consider family council recommendations and grievances.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide a family council, and develop a process to consider family council recommendations and grievances. This had the potential to affect all four residents receiving assisted living services, and their families. [...]”

Rule cited: “The facility must provide a family council with space and privacy for meetings, where doing so is reasonably achievable. [...]”

Summary: MDH found the licensee failed to post in a conspicuous place information about the facility's grievance procedure with the required content.

MDH’s finding, as written: “Based on observation, and interview and record review, the licensee failed to post in a conspicuous place information about the facility's grievance procedure with the required content. This had the potential to affect the licensee's four 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 display the original current license at the main entrance of the assisted living facility as required.

MDH’s finding, as written: “Based on observation, interview and record review, 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 support protection and safety through access to the state's systems for reporting suspected criminal activity and suspected vulnerable adult maltreatment as required.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to support protection and safety through access to the state's systems for reporting suspected criminal activity and suspected vulnerable adult maltreatment as required. This had the potential to affect the licensee's four current residents, staff and visitors. [...]”

Rule cited: “reporting suspected c 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 [...]”

Summary: MDH found the licensee failed to ensure the employee record contained the required content for one of two employees (registered nurse (RN)-A) with records reviewed.

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

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 establish and maintain a tuberculosis (TB) prevention program, based on the most current guidelines issued by the Centers

MDH’s finding, as written: “Based on interview and record review, the licensee failed to establish and maintain a tuberculosis (TB) prevention program, based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC), which included a current facility TB risk assessment, and completion of a two-step tuberculin skin test (TST) or other evidence of TB screening such as a blood test, for two of two employees (registered nurse (RN)-A and unlicensed personnel (ULP)- B) with records reviewed. [...]”

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 [...]”

MDH’s finding, as written: “Based on observation, interview, and record review the licensee failed to have a written emergency preparedness (EP) plan with all of the required content and failed to post an emergency preparedness plan prominently. This had the potential to affect all residents receiving services under the assisted living license, 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 facility failed to provide documentation of policy, schedule, and log of staff training for fire safety and evacuation procedures.

MDH’s finding, as written: “Based on interview and record review, the facility failed to provide documentation of policy, schedule, and log of staff training for fire safety and evacuation procedures. It also failed to provide documentation of required staff evacuation drills. This had the potential to affect all current 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 provide to the Office of Ombudsman for Long-Term Care a complete unsigned copy of its contract.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to provide to the Office of Ombudsman for Long-Term Care a complete unsigned copy of its contract. This had the potential to affect all current residents. [...]”

Rule cited: “(a) An assisted living facility may not offer or provide housing or assisted living services to any individual unless it has executed a written contract with the resident. [...]”

Summary: MDH found the licensee failed to execute a written contract with the required content for one of one resident (R1) with record reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to execute a written contract with the required content for one of one resident (R1) with record reviewed. [...]”

Rule cited: “(a) The contract must include in a conspicuous place and manner on the contract the legal name and the license number of the facility. [...]”

Summary: MDH found the licensee failed to execute a written contract with the required content for one of one resident (R1) with record reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to execute a written contract with the required content for one of one resident (R1) with record reviewed. [...]”

Rule cited: “(c) The contract must include: (1) a disclosure of the category of assisted living facility license held by the facility and, if the facility is not an assisted living facility with dementia care, a disclosure that it does not hold an assisted living facility [...]”

Summary: MDH found the licensee failed to execute a written contract with the required content for one of one resident (R1) with record reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to execute a written contract with the required content for one of one resident (R1) with record reviewed. [...]”

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 one of one resident (R1) with record reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to execute a written contract with the required content for one of one resident (R1) with record reviewed. [...]”

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 employees received orientation to include the required content for two of two employees (registered nurse (RN)-A and unlicensed personnel (ULP)-B) with records reviewed.

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

Rule cited: “(a) The orientation must contain the following topics: (1) an overview of this chapter; (2) an introduction and review of the facility's policies and procedures related to the provision of assisted living services by the individual staff person; (3) handling [...]”

Summary: MDH found the licensee failed to ensure direct-care staff completed the required amount of dementia care training in the required time frame for two of two employees (registered nurse (RN)-A and unlicensed personnel (ULP)-B) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure direct-care staff completed the required amount of dementia care training in the required time frame for two of two employees (registered nurse (RN)-A and unlicensed personnel (ULP)-B) with records reviewed. [...]”

Rule cited: “(3) for assisted living facilities with dementia care, direct-care employees must have completed at least eight hours of initial training on topics specified under paragraph (b) within 80 working hours of the employment start date. [...]”

Summary: MDH found the licensee failed to ensure the service plan included the required content for one of one resident (R1) with record reviewed.

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

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 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 assessment to determine what medication management services would be

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure the registered nurse (RN) conducted an individualized assessment to determine what medication management services would be provided, and how the services would be provided for one of one resident (R1) 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 documentation of

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure documentation of medications provided for residents having planned time away was completed as required and per the licensee's policy for one of two residents (R3) with records reviewed. [...]”

Rule cited: “(a) An assisted living facility that is providing medication management services to the resident must develop and implement policies and procedures for giving accurate and current medications to residents for planned or unplanned times away from home [...]”

Summary: MDH found the licensee failed to ensure medications were maintained bearing the original prescription label with legible information for one of four residents (R5) with medication storage reviewed.

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 for one of four residents (R5) with medication storage 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 current treatment 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 treatment 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 facility failed to provide the proper documentation that a hazard vulnerability or safety risk assessment had been performed on and around the property.

MDH’s finding, as written: “Based on interview and record review, the facility failed to provide the proper documentation that a hazard vulnerability or safety risk assessment had been performed on and around the property. In addition, the facility failed to provide documentation the existing sprinkler system was an approved supervised automatic sprinkler system. [...]”

Rule cited: “An assisted living facility with dementia care that has a secured dementia care unit must meet the requirements of section 144G.45 and the following additional requirements: (1) a hazard vulnerability assessment or safety risk must be performed on and around [...]”

Summary: MDH found the licensee failed to ensure policies and procedures required in the licensing of assisted living facilities with dementia care were developed or implemented, and provided to each resident and/or the residents legal and designated representative at the time of move-in.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure policies and procedures required in the licensing of assisted living facilities with dementia care were developed or implemented, and provided to each resident and/or the residents legal and designated representative at the time of move-in. This had the potential to affect all dementia care residents, staff and visitors. [...]”

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 ensure access to secured outdoor space and walkways that allow residents with dementia to enter and return without staff assistance as required.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure access to secured outdoor space and walkways that allow residents with dementia to enter and return without staff assistance as required. This had the potential to affect all dementia care residents, staff and visitors. [...]”

Rule cited: “(e) Behavioral symptoms that negatively impact the resident and others in the assisted living facility with dementia care must be evaluated and included on the service or care plan. [...]”

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure a written acknowledgment of receipt of the current home care bill of rights was obtained for one of one resident (R1) with records reviewed. [...]”

Rule cited: “(a) An assisted living facility must provide the resident a written notice of the rights under section 144G.91 before the initiation of services to that resident. [...]”