Liberty Mathan Health Care Ser, Sprague Avenue

Survey completed December 14, 2023: 7 correction orders

• Tag 480: 144G.41 Subd 1 (13) (i) (B) Minimum requirements Level 2, widespread scope, scope/level letter F · correction period: Please refer to the FBEIR for any compliance dates
  Details

  Summary: MDH found the licensee failed to ensure food was prepared and served according to the Minnesota Food Code.

  MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure food was prepared and served according to the Minnesota Food Code. 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 portion or all the [...]”

  Rule cited: “(13) offer to provide or make available at least the following services to residents: (B) food must be prepared and served according to the Minnesota Food Code, Minnesota Rules, chapter 4626; and”

• Tag 680: 144G.42 Subd. 10 Disaster planning and emergency preparedness Level 2, widespread scope, scope/level letter F · correction period: Twenty-one (21) days
  Details

  MDH’s finding, as written: “Based on interview and record review the licensee failed to maintain a written emergency preparedness plan (EPP) with all the required content. This had the potential to affect all staff, visitors, and residents of the assisted living. [...]”

  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 [...]”

• Tag 780: 144G.45 Subd. 2 (a) (1) Fire protection and physical environment Level 2, widespread scope, scope/level letter F · correction period: Seven (7) day
  Details

  Summary: MDH found the licensee failed to provide smoke alarms outside all sleeping rooms and interconnected smoke alarms throughout the facility.

  MDH’s finding, as written: “Based on observation and interview, the licensee failed to provide smoke alarms outside all sleeping rooms and interconnected smoke alarms throughout the facility. This had the potential to directly affect all residents, staff, and visitors. [...]”

  Rule cited: “(a) Each assisted living facility must comply with the State Fire Code in Minnesota Rules, chapter 7511, and: (1) for dwellings or sleeping units, as defined in the State Fire Code: (i) provide smoke alarms in each room used for sleeping purposes; (ii) [...]”

• Tag 910: 144G.50 Subd. 2 (a-b) Contract information Level 1, widespread scope, scope/level letter C · correction period: Twenty-one (21) days
  Details

  Summary: MDH found the licensee failed to execute a written contract with the required content for one of one resident (R2).

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to execute a written contract with the required content for one of one resident (R2). This had the potential to affect all residents living in the assisted living facility. [...]”

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

• Tag 1500: 144G.63 Subd. 5 Required annual training Level 2, widespread scope, scope/level letter F · correction period: Twenty-one (21) days
  Details

  Summary: MDH found the licensee failed to ensure employees received at least eight hours of annual training to include required topics for each 12 months of employment for two of two employees (unlicensed personnel (ULP)-B, ULP-D).

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure employees received at least eight hours of annual training to include required topics for each 12 months of employment for two of two employees (unlicensed personnel (ULP)-B, ULP-D). [...]”

  Rule cited: “(a) All staff that perform direct services must complete at least eight hours of annual training for each 12 months of employment. [...]”

• Tag 1890: 144G.71 Subd. 20 Prescription drugs Level 2, isolated scope, scope/level letter D · correction period: Seven (7) days
  Details

  Summary: MDH found the licensee failed to discard expired medication for one of three residents (R5).

  MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to discard expired medication for one of three residents (R5). 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 an isolated scope (when one or a limited number of residents are affected or one or a limited number of staff are involved, or the situation has occurred only [...]”

  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 [...]”

• Tag 1910: 144G.71 Subd. 22 Disposition of medications Level 2, widespread scope, scope/level letter F · correction period: Seven (7)
  Details

  Summary: MDH found the licensee failed to provide documentation in the resident's record regarding the disposition of medication with all the required content for one of one discharged resident (R1).

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide documentation in the resident's record regarding the disposition of medication with all the required content for one of one discharged resident (R1). [...]”

  Rule cited: “(a) Any current medications being managed by the assisted living facility must be provided to the resident when the resident's service plan ends or medication management services are no longer part of the service plan. [...]”

From MDH’s letter: the letter says the facility is in substantial compliance; no immediate fines.

Allegation, as written: “The alleged perpetrator (AP) neglected the resident when he left the resident on the floor for five hours after the resident fell.”

“The Minnesota Department of Health determined neglect was inconclusive.”

Summary: MDH looked into an allegation and found: neglect inconclusive (individual responsibility).

MDH’s conclusion, as written: “Upon reconsideration, the findings of this report were changed to substantiated. The Minnesota Department of Health determined neglect was inconclusive. The resident experienced a fall in the bathroom and the AP, an unlicensed personnel (ULP), moved the resident back to his bed prior to contacting the nurse. The resident had sustained a left leg fracture. The AP reported conflicting versions of the incident events. The resident's physician stated with the resident's medical history, spontaneous fractures could occur. The investigation determined there was an unreasonable delay in treatment of the VA due to the actions of AP and ULP-1.”

Action taken by facility: “The facility staff administered Tylenol for pain and sent the resident to the hospital.”

Action taken by MDH: “The facility was found to be in noncompliance.”

Survey completed April 3, 2024: 1 correction order

• Tag 2310: 144G.91 Subd. 4 (a) Appropriate care and services Level 3, widespread scope, scope/level letter I · correction period: Seven (7) days
  Details

  MDH’s finding, as written: “Based on interview and document review the licensee failed to implement a process aligned with nursing standards of care to require unlicensed personnel (ULP) to consult with a nurse for directive in response to falls prior to providing intervention for one of one residents reviewed (R1). R1 experienced a fall and the fall policy directed ULP to evaluate and help a resident up if it was safe to do so, without consulting with a nurse. [...]”

  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.”