Lino Lakes Assisted Living

Summary: MDH found the licensee failed to ensure required training was completed for one of two employees (unlicensed personnel (ULP)-F).

MDH’s finding, as written: “Based on observation, interview and, record review, the licensee failed to ensure required training was completed for one of two employees (unlicensed personnel (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 required training was completed upon hire for one of one employee (unlicensed personnel (ULP)-F).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure required training was completed upon hire for one of one employee (unlicensed personnel (ULP)-F). [...]”

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 [...]”

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure orientation to assisted living facility licensing requirements and regulations included all required content for one of two employees (unlicensed personnel (ULP-F). [...]”

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 staff received dementia training in the required areas for one of two employees (unlicensed personnel (ULP)-F).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure staff received dementia training in the required areas for one of two employees (unlicensed personnel (ULP)-F). [...]”

Rule cited: “All direct care staff and supervisors providing direct services must demonstrate an understanding of the training specified in section 144G.64.”

Summary: MDH found the licensee failed to ensure one of two employees, unlicensed personnel (ULP)-F received the required eight hours of dementia care training in the required time frame.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure one of two employees, unlicensed personnel (ULP)-F received the required eight hours of dementia care training in the required time frame. [...]”

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. [...]”

MDH’s finding, as written: “Based on interview and record review the licensee failed to ensure the registered nurse (RN) completed an ongoing reassessment and monitoring on or before day 90 for two of three residents (R1, R3). [...]”

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 develop a treatment or therapy management plan to include the required content for three of three residents (R1, R3, R4).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to develop a treatment or therapy management plan to include the required content for three of three residents (R1, R3, R4). [...]”

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 provide a hazard vulnerability assessment or safety risk assessment of the physical environment on and around the property.

MDH’s finding, as written: “Based on record review and interview, the licensee failed to provide a hazard vulnerability assessment or safety risk assessment of the physical environment on and around the property. This deficient practice had the ability to affect all staff, residents, and visitors. [...]”

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 provide care and services according to acceptable health care

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 standards, medical, or nursing standards for one of one resident (R2) who utilized oxygen. [...]”

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.”

Survey completed June 27, 2024: 4 correction orders

• Tag 1730: 144G.71 Subd. 5 Individualized medication management plan Level 3, isolated scope, scope/level letter G · correction period: Seven (7) days
  Details

  Summary: MDH found the licensee failed to perform a medication reconciliation to verify medications were administered as physician prescribed for one of five resident (R5) with record review.

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to perform a medication reconciliation to verify medications were administered as physician prescribed for one of five resident (R5) with record review. As a result, for approximately one month, R5 received inaccurate medications, including receiving an antidepressant medication that was discontinued, receiving a higher dose of her antipsychotic medication and sleep aid medication instead of the taper to reduce the dose. [...]”

  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. [...]”

• Tag 1760: 144G.71 Subd. 8 Documentation of administration of medication Level 3, widespread scope, scope/level letter I · correction period: Seven (7) days
  Details

  Summary: MDH found the licensee failed to ensure medications were ordered so each resident received medications as prescribed by their physician, and failed to document medication administration for five of

  MDH’s finding, as written: “Based on observation and record review, the licensee failed to ensure medications were ordered so each resident received medications as prescribed by their physician, and failed to document medication administration for five of five residents (R1, R2, R3, R4, R5) with records reviewed. As a result, harm occurred to R1 and R2. The licensees's lack of oversight in medication management had the potential to affect all residents. [...]”

  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. [...]”

• Tag 1960: 144G.72 Subd. 5 Documentation of administration of treatments Level 2, isolated scope, scope/level letter D · correction period: Seven (7) days
  Details

  Summary: MDH found the licensee failed to ensure lab tests, and therapy services were completed as prescribed by a physician for one of one resident (R5) with record review.

  MDH’s finding, as written: “Based on interview and document review, the licensee failed to ensure lab tests, and therapy services were completed as prescribed by a physician for one of one resident (R5) with record review. [...]”

  Rule cited: “Each treatment or therapy administered by an assisted living facility must be in the resident record. [...]”

• Tag 2360: 144G.91 Subd. 8 Freedom from maltreatment
  Details

  Summary: MDH found the facility failed to ensure two of two residents reviewed (R1, R2) were free from maltreatment.

  MDH’s finding, as written: “The facility failed to ensure two of two residents reviewed (R1, R2) were free from maltreatment. Findings include: The Minnesota Department of Health (MDH) issued a determination maltreatment occurred, and the facility was responsible for the maltreatment, in connection with incidents which occurred at the facility. Please refer to the public maltreatment report for details.”

  Rule cited: “Residents have the right to be free from physical, sexual, and emotional abuse; neglect; financial exploitation; and all forms of maltreatment covered under the Vulnerable Adults Act.”

Allegation, as written: “The alleged perpetrator (AP) neglected the resident when the AP failed to follow the residents care plan and reevaluate the residents low blood sugar after 30 minutes resulting in ongoing low blood sugar, fall and hospitalization.”

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

“The facility was responsible for the maltreatment.”

Summary: MDH looked into an allegation and found: neglect substantiated (facility responsibility).

MDH’s conclusion, as written: “The Minnesota Department of Health determined neglect was substantiated. The facility was responsible for the maltreatment. The AP was not provided with resident specific instructions pertaining to low blood sugar, consequently, the resident had a low blood sugar with inadequate follow-up contributing to the resident falling, becoming unresponsive, and requiring transfer to the emergency room.”

Action taken by facility: “Sent the resident to the hospital.”

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

Survey completed July 25, 2023: 3 correction orders

• Tag 1470: 144G.63 Subd. 2 Content of required orientation Level 2, isolated scope, scope/level letter D · correction period: Twenty-one (21) days
  Details

  Summary: MDH found the licensee failed to ensure employees received orientation training to the assisted living licensing requirements and regulations for one of three employees (licensed practical nurse (LPN)-E) before providing resident care.

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure employees received orientation training to the assisted living licensing requirements and regulations for one of three employees (licensed practical nurse (LPN)-E) before providing resident care. [...]”

  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 [...]”

• Tag 1480: 144G.63 Subd. 3 Orientation to resident Level 2, widespread scope, scope/level letter F · correction period: Twenty-one (21) days
  Details

  Summary: MDH found the licensee failed to ensure staff providing assisted living services were oriented

  MDH’s finding, as written: “Based on observation, record review, and interview, the licensee failed to ensure staff providing assisted living services were oriented specifically to each individual resident and the services to be provided for three of three employees (registered nurse (RN)-A, unlicensed personnel (ULP)-D, and licensed practical nurse (LPN)-E). [...]”

  Rule cited: “Staff providing assisted living services must be oriented specifically to each individual resident and the services to be provided. This orientation may be provided in person, orally, in writing, or electronically.”

• Tag 2360: 144G.91 Subd. 8 Freedom from maltreatment
  Details

  Summary: MDH found the facility failed to ensure one of one resident(s) reviewed (R1) was free from maltreatment.

  MDH’s finding, as written: “The facility failed to ensure one of one resident(s) reviewed (R1) was free from maltreatment. Findings include: The Minnesota Department of Health (MDH) issued a determination maltreatment occurred, and the facility was responsible for the maltreatment, in connection with an incident which occurred at the facility. Please refer to the public maltreatment report for details.”

  Rule cited: “Residents have the right to be free from physical, sexual, and emotional abuse; neglect; financial exploitation; and all forms of maltreatment covered under the Vulnerable Adults Act.”

Allegation, as written: “The facility neglected resident #1 and resident #2 when resident #2 touched resident #1 sexually.”

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

“The facility was responsible for the maltreatment.”

Summary: MDH looked into an allegation and found: neglect substantiated (facility responsibility).

MDH’s conclusion, as written: “The Minnesota Department of Health determined neglect was substantiated. The facility was responsible for the maltreatment. Although concerns regarding the relationship between resident #1 and resident #2 arose on multiple occasions, the facility did not assess nor implement subsequent interventions to address these concerns for either resident. Resident #2 touched resident #1 sexually, which resident #1 said was not welcome.”

Action taken by facility: “Administration spoke with resident #2 that he was not allowed in resident #1's room.”

Action taken by MDH: “The responsible party will be notified of their right to appeal the maltreatment finding. The facility was found to be in noncompliance.”

Survey completed August 17, 2023: 2 correction orders

• Tag 630: 144G.42 Subd. 6 (b) Compliance with requirements for reporting ma Level 3, isolated scope, scope/level letter G · correction period: Seven (7) Days
  Details

  Summary: MDH found the licensee failed to address areas of potential abuse to other vulnerable adults (VA) on the individual abuse prevention plan (IAPP) for two of four residents (R1 and R2) with records reviewed.

  MDH’s finding, as written: “Based on interview, and record review, the licensee failed to address areas of potential abuse to other vulnerable adults (VA) on the individual abuse prevention plan (IAPP) for two of four residents (R1 and R2) with records reviewed. [...]”

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

• Tag 2360: 144G.91 Subd. 8 Freedom from maltreatment
  Details

  MDH’s finding, as written: “Citation Text for Tag 2360, Regulation EF5D Based on observations, interviews, and document review, the facility failed to ensure two of four residents reviewed (R1 and R2) were free from maltreatment. R1 was neglected. Findings include: On August 17, 2023, the Minnesota Department of Health (MDH) issued a determination that neglect occurred, and that the facility was responsible for the maltreatment, in connection with incidents which occurred at the facility. [...]”

  Rule cited: “Residents have the right to be free from physical, sexual, and emotional abuse; neglect; financial exploitation; and all forms of maltreatment covered under the Vulnerable Adults Act.”

Allegation, as written: “The alleged perpetrator (AP) neglected the resident when the AP failed to complete every two-hour safety check for approximately eight hours. The resident fell, crawled around the room, and was unable to get off the floor. When staff members entered the room, approximately four hours after the resident fell, the resident had no clothing on and had stool smeared on herself and all over the carpet. The resident was taken to the hospital for evaluation.”

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

“The AP was responsible for the maltreatment.”

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

MDH’s conclusion, as written: “The Minnesota Department of Health determined neglect was substantiated. The AP was responsible for the maltreatment. The AP failed to complete safety checks on the resident every two hours as indicated on the resident's care plan.”

Action taken by facility: “The facility investigated the incident and sent the resident to the hospital.”

Action taken by MDH: “The facility was issued a correction order regarding the vulnerable adult's right to be free from maltreatment.”

Survey completed April 27, 2023: 14 correction orders

• Tag 480: 144G.41 Subd 1 (13) (i) (B) Minimum requirements Level 2, widespread scope, scope/level letter F · correction period: Twenty-one (21) days
  Details

  Summary: MDH found the licensee failed to ensure food was prepared 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 according to the Minnesota Food Code. This had the potential to affect all 97 residents residing in the facility. [...]”

  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 510: 144G.41 Subd. 3 Infection control program Level 2, widespread scope, scope/level letter F · correction period: Twenty-One (21) days
  Details

  Summary: MDH found the licensee failed to ensure infection control procedures were followed for six of six residents (R6, unidentified resident (UR)1, UR2, UR3, UR4, UR5)) during mealtime.

  MDH’s finding, as written: “Based on record review, observation, and interview, the licensee failed to ensure infection control procedures were followed for six of six residents (R6, unidentified resident (UR)1, UR2, UR3, UR4, UR5)) during mealtime. This had the potential to affect all residents in the dining room at communal mealtimes. [...]”

  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. [...]”

• Tag 580: 144G.42 Subd. 2 Quality management Level 2, widespread scope, scope/level letter F · correction period: Twenty-one (21) days
  Details

  Summary: MDH found the licensee failed to engage in and maintain documentation of quality management activities.

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to engage in and maintain documentation of quality management activities. This had the potential to affect all ninety-seven (97) 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. [...]”

• Tag 650: 144G.42 Subd. 8 Employee records Level 2, widespread scope, scope/level letter F
  Details

  Summary: MDH found the licensee failed to ensure employee records contained the required content for four of four staff (unlicensed personnel (ULP)-D-, (ULP)-E, (ULP)-J and registered nurse (RN)-B) with employee records reviewed.

  MDH’s finding, as written: “Based on observation and record review, the licensee failed to ensure employee records contained the required content for four of four staff (unlicensed personnel (ULP)-D-, (ULP)-E, (ULP)-J and registered nurse (RN)-B) with employee records reviewed. This had the potential to affect all residents in the facility. [...]”

  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. [...]”

• Tag 660: 144G.42 Subd. 9 Tuberculosis prevention and control Level 2, widespread scope, scope/level letter F · correction period: Twenty-one (21) days
  Details

  Summary: MDH found the licensee failed to maintain a tuberculosis (TB)

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to maintain a tuberculosis (TB) prevention and control program, based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC). The licensee failed to ensure history and symptoms screenings and screening for active TB (either a two-step tuberculin skin test (TST) or blood test) were completed and documented for one of one unlicensed personnel (ULP-E) with employee 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 [...]”

• 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 document review, the licensee failed to develop a written emergency disaster plan (EP) with all the required content. This had the potential to affect all 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 [...]”

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

  Summary: MDH found the licensee failed to provide smoke alarms that are interconnected so that actuation of one alarm causes all alarms in the dwelling unit to actuate.

  MDH’s finding, as written: “Based on observation and interview, the licensee failed to provide smoke alarms that are interconnected so that actuation of one alarm causes all alarms in the dwelling unit to actuate. This deficient condition had the ability to affect all staff and residents. [...]”

  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 800: 144G.45 Subd. 2 (a) (4) Fire protection and physical environment Level 2, widespread scope, scope/level letter F · correction period: Seven (7) days
  Details

  Summary: MDH found the licensee failed to maintain 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.

  MDH’s finding, as written: “Based on observation and interview, the licensee failed to maintain 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. This deficient condition had the potential to affect all staff, residents, 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 [...]”

• Tag 810: 144G.45 Subd. 2 (b)-(f) Fire protection and physical environment Level 2, widespread scope, scope/level letter F · correction period: Twenty-one (21) days
  Details

  Summary: MDH found the licensee failed to provide required employee training on fire safety and evacuation and failed to complete required employee

  MDH’s finding, as written: “Based on record review, observation, and interview, the licensee failed to provide required employee training on fire safety and evacuation and failed to complete required employee evacuation drills. This had the potential to affect all staff, residents, and visitors. [...]”

  Rule cited: “(b) Each assisted living facility shall develop and maintain fire safety and evacuation plans. [...]”

• Tag 1460: 144G.63 Subdivision 1 Orientation of staff and supervisors Level 2, isolated scope, scope/level letter D · correction period: Twenty-One (21) days
  Details

  MDH’s finding, as written: “Based on observation and record review, licensee failed to ensure employees received orientation training to the assisted living licensing requirements and regulations for one of six employees (registered nurse [RN]-C) with records reviewed before providing direct care. [...]”

  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. [...]”

• Tag 1540: 144G.64 (a) TRAINING IN DEMENTIA CARE REQUIRED Level 2, isolated scope, scope/level letter D · correction period: Fourteen (14) days
  Details

  Summary: MDH found the licensee failed to ensure employees received the required amount of dementia care training in the required period for one of one employee unlicensed personal (ULP-E) records reviewed.

  MDH’s finding, as written: “Based on observation and record review, the licensee failed to ensure employees received the required amount of dementia care training in the required period for one of one employee unlicensed personal (ULP-E) 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. [...]”

• Tag 1620: 144G.70 Subd. 2 (c-e) Initial reviews, assessments, and monitoring Level 2, isolated scope, scope/level letter D
  Details

  Summary: MDH found the licensee failed to ensure the required comprehensive nursing assessment was completed by a registered nurse (RN) for two of three residents (R5, R9).

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the required comprehensive nursing assessment was completed by a registered nurse (RN) for two of three residents (R5, R9). [...]”

  Rule cited: “(c) Resident reassessment and monitoring must be conducted no more than 14 calendar days after initiation of services. [...]”

• Tag 1640: 144G.70 Subd. 4 (a-e) Service plan, implementation and revisions to Level 2, isolated scope, scope/level letter D · correction period: Twenty-one (21) days
  Details

  Summary: MDH found the licensee failed to complete a service plan within 14 days of admission for one of one residents (R9).

  MDH’s finding, as written: “Based on record review and interview, the licensee failed to complete a service plan within 14 days of admission for one of one residents (R9). 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) 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. [...]”

• Tag 2170: 144G.84 SERVICES FOR RESIDENTS WITH DEMENTIA Level 2, isolated scope, scope/level letter D · correction period: Twenty-one (21) days
  Details

  Summary: MDH found the licensee failed to have a written individual activity plan which reflected the resident's activity preferences and needs and included structured and non-structured activities for one of one resident (R6).

  MDH’s finding, as written: “Based on record review, and interview, the licensee failed to have a written individual activity plan which reflected the resident's activity preferences and needs and included structured and non-structured activities for one of one resident (R6). [...]”

  Rule cited: “(b) Each resident must be evaluated for activities according to the licensing rules of the facility. [...]”

Allegation, as written: “The facility neglected resident #1 when staff failed to provide supervision and monitoring for resident #1 when staff found her naked in her room, bleeding from her head. Resident #1 was transported to the emergency room (ER) for treatment and a sexual assault exam.”

“The Minnesota Department of Health determined sexual abuse was not substantiated, although neglect was substantiated.”

“The facility was responsible for the maltreatment.”

Summary: MDH looked into an allegation and found: sexual abuse not substantiated (facility responsibility).

MDH’s conclusion, as written: “The Minnesota Department of Health determined sexual abuse was not substantiated, although neglect was substantiated. The facility was responsible for the maltreatment. Resident #1 was sent to the ER for treatment and no signs of sexual assault were found. However, the facility neglected resident #1 when it failed to complete and implement an individual abuse prevention plan (IAPP). This led to resident #1 sustaining an injury during a resident-to-resident altercation with resident #2.”

Action taken by facility: “The staff sent resident #1 to the hospital and the facility conducted and internal investigation.”

Action taken by MDH: “The responsible party will be notified of their right to appeal the maltreatment finding. The facility was found to be in noncompliance.”

Survey completed March 14, 2023: 11 correction orders

• Tag 250: 144G.20 Subdivision 1 Conditions Level 2, widespread scope, scope/level letter F · correction period: Two (2) days
  Details

  Summary: MDH found the licensee failed to show they met the requirements of licensure, by attesting the managerial officials who oversaw the day-to-day operations understood applicable statutes and rules; nor developed and/or implemented current policies and procedures as required with records reviewed.

  MDH’s finding, as written: “Based on interview and document review, the licensee failed to show they met the requirements of licensure, by attesting the managerial officials who oversaw the day-to-day operations understood applicable statutes and rules; nor developed and/or implemented current policies and procedures as required with records reviewed. This had the potential to affect all residents, staff, and visitors. [...]”

  Rule cited: “(a) The commissioner may refuse to grant a provisional license, refuse to grant a license as a result of a change in ownership, refuse to renew a license, suspend or revoke a license, or impose a conditional license if the owner, controlling individual, or [...]”

• Tag 470: 144G.41 Subdivision 1 Minimum requirements Level 3, widespread scope, scope/level letter I · correction period: Two (2) days
  Details

  Summary: MDH found the licensee failed to develop a staffing plan based on the individual resident needs.

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop a staffing plan based on the individual resident needs. The facility failed to provide nursing coverage to complete assessments and ensure resident medications and prescribed treatments were provided according to physician orders for four of four (R1, R2, R3 and R4) resident records reviewed. This had the potential to affect all 98 of the residents residing in the facility. [...]”

  Rule cited: “(11) develop and implement a staffing plan for determining its staffing level that: (i) includes an evaluation, to be conducted at least twice a year, of the appropriateness of staffing levels in the facility; (ii) ensures sufficient staffing at all times to [...]”

• Tag 620: 144G.42 Subd. 6 (a) Compliance with requirements for reporting ma Level 2, isolated scope, scope/level letter D · correction period: Seven (7) days
  Details

  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 maltreatment for one of one resident (R5) with records reviewed. [...]”

  Rule cited: “(a) The assisted living facility must comply with the requirements for the reporting of maltreatment of vulnerable adults in section 626.557. [...]”

• Tag 630: 144G.42 Subd. 6 (b) Compliance with requirements for reporting ma Level 3, widespread scope, scope/level letter I · correction period: Seven (7) days
  Details

  MDH’s finding, as written: “Based on interview and record review the licensee failed to develop and implement an individual abuse prevention plan (IAPP) for each vulnerable adult. The plan must include the person's susceptibility to abuse by another individual, the person's risk of abusing others, statements of the specific measure to be taken to minimize the risk of abuse and include self-abuse for four of four residents (R2, R4, R5 and R9) with records reviewed. [...]”

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

• Tag 690: 144G.43 Subdivision 1 Resident record Level 2, widespread scope, scope/level letter F · correction period: Seven (7) days
  Details

  MDH’s finding, as written: “Based on interview record review the licensee failed to ensure entries in the resident records were authenticated with the correct title of the person making the entry for all residents residing in the facility. This could affect all resident records these employees document within. [...]”

  Rule cited: “(a) Assisted living facilities must maintain records for each resident for whom it is providing services. [...]”

• Tag 1600: 144G.70 Subdivision 1 Acceptance of residents Level 3, widespread scope, scope/level letter I · correction period: Two (2) days
  Details

  Summary: MDH found the licensee failed to ensure the facility had sufficient nursing staff to adequately provide the services agreed upon for 4 of 4 residents,.R1, R2, R3, and R4, reviewed with missed medication or wound care.

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the facility had sufficient nursing staff to adequately provide the services agreed upon for 4 of 4 residents,.R1, R2, R3, and R4, reviewed with missed medication or wound care. Due to the lack of nursing staff the medication changes and wound care orders were not implemented or completed. [...]”

  Rule cited: “An assisted living facility may not accept a person as a resident unless the facility has staff, sufficient in qualifications, competency, and numbers, to adequately provide the services agreed to in the assisted living contract.”

• Tag 1700: 144G.71 Subd. 2 Provision of medication management services Level 3, widespread scope, scope/level letter I · correction period: Seven (7) days
  Details

  Summary: MDH found the licensee failed to ensure the registered nurse (RN) conducted a face-to-face medication management assessment, prior to providing medication management services, to include all required content for four of four residents (R1, R2, R4, and R5) 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 a face-to-face medication management assessment, prior to providing medication management services, to include all required content for four of four residents (R1, R2, R4, and R5) 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 [...]”

• Tag 1760: 144G.71 Subd. 8 Documentation of administration of medication Level 3, widespread scope, scope/level letter I · correction period: Two (2) days
  Details

  Summary: MDH found the licensee failed to document the reason medications were not given as prescribed and to document follow-up procedures to ensure the resident's needs were met for four of four (R1, R2, R3, and R4) residents reviewed.

  MDH’s finding, as written: “Based on interview, and record review, the licensee failed to document the reason medications were not given as prescribed and to document follow-up procedures to ensure the resident's needs were met for four of four (R1, R2, R3, and R4) residents reviewed. This had the potential to affect all residents currently receiving medication management services from the licensee. [...]”

  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. [...]”

• Tag 1960: 144G.72 Subd. 5 Documentation of administration of treatments Level 4, isolated scope, scope/level letter J · correction period: 7-days
  Details

  Summary: MDH found the licensee failed to ensure an individualized treatment and therapy management plan was completed, to include all required contents for one of one resident (R4) with records reviewed.

  MDH’s finding, as written: “Based on record review and interview, the licensee failed to ensure an individualized treatment and therapy management plan was completed, to include all required contents for one of one resident (R4) with records reviewed. Additionally, the facility failed to notify the appropriate licensed health professional (the prescriber) when neither the licensee nor an outside home care agency provided the prescribed wound care. [...]”

  Rule cited: “Each treatment or therapy administered by an assisted living facility must be in the resident record. [...]”

• Tag 2360: 144G.91 Subd. 8 Freedom from maltreatment
  Details

  Summary: MDH found the facility failed to ensure two residents reviewed (R4, and R5) were free from maltreatment.

  MDH’s finding, as written: “The facility failed to ensure two residents reviewed (R4, and R5) were free from maltreatment. Findings include: The Minnesota Department of Health (MDH) issued a determination maltreatment occurred, and the facility was responsible for the maltreatment, in connection with incidents which occurred at the facility. Please refer to the public maltreatment report for details.”

  Rule cited: “Residents have the right to be free from physical, sexual, and emotional abuse; neglect; financial exploitation; and all forms of maltreatment covered under the Vulnerable Adults Act.”

• Tag 3000: 626.557 Subd. 3 Timing of report Level 2, isolated scope, scope/level letter D · correction period: Seven (7) days
  Details

  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 maltreatment for one of one resident (R5) with records reviewed. [...]”

  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 [...]”

Allegation, as written: “The facility neglected the resident when the facility failed to complete wound monitoring and assessments. The resident's wound became infected, and the resident became septic (a life-threatening medical emergency related to an extreme response to an infection).”

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

“The facility was responsible for the maltreatment.”

Summary: MDH looked into an allegation and found: neglect substantiated (facility responsibility).

MDH’s conclusion, as written: “The Minnesota Department of Health determined neglect was substantiated. The facility was responsible for the maltreatment. The facility failed to ensure appropriate monitoring and oversight for the residents wound care. Although the facility refers wound care management to external home care agencies, the facility did not oversee wound management services to ensure the resident's wound care was being managed. Eventually, the resident required hospitalization, antibiotics, and surgical interventions. An equal opportunity employer.”

Action taken by facility: “The facility sent the resident to the hospital.”

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

Survey completed March 14, 2023: 11 correction orders

• Tag 250: 144G.20 Subdivision 1 Conditions Level 2, widespread scope, scope/level letter F · correction period: Two (2) days
  Details

  Summary: MDH found the licensee failed to show they met the requirements of licensure, by attesting the managerial officials who oversaw the day-to-day operations understood applicable statutes and rules; nor developed and/or implemented current policies and procedures as required with records reviewed.

  MDH’s finding, as written: “Based on interview and document review, the licensee failed to show they met the requirements of licensure, by attesting the managerial officials who oversaw the day-to-day operations understood applicable statutes and rules; nor developed and/or implemented current policies and procedures as required with records reviewed. This had the potential to affect all residents, staff, and visitors. [...]”

  Rule cited: “(a) The commissioner may refuse to grant a provisional license, refuse to grant a license as a result of a change in ownership, refuse to renew a license, suspend or revoke a license, or impose a conditional license if the owner, controlling individual, or [...]”

• Tag 470: 144G.41 Subdivision 1 Minimum requirements Level 3, widespread scope, scope/level letter I · correction period: Two (2) days
  Details

  Summary: MDH found the licensee failed to develop a staffing plan based on the individual resident needs.

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop a staffing plan based on the individual resident needs. The facility failed to provide nursing coverage to complete assessments and ensure resident medications and prescribed treatments were provided according to physician orders for four of four (R1, R2, R3 and R4) resident records reviewed. This had the potential to affect all 98 of the residents residing in the facility. [...]”

  Rule cited: “(11) develop and implement a staffing plan for determining its staffing level that: (i) includes an evaluation, to be conducted at least twice a year, of the appropriateness of staffing levels in the facility; (ii) ensures sufficient staffing at all times to [...]”

• Tag 620: 144G.42 Subd. 6 (a) Compliance with requirements for reporting ma Level 2, isolated scope, scope/level letter D · correction period: Seven (7) days
  Details

  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 maltreatment for one of one resident (R5) with records reviewed. [...]”

  Rule cited: “(a) The assisted living facility must comply with the requirements for the reporting of maltreatment of vulnerable adults in section 626.557. [...]”

• Tag 630: 144G.42 Subd. 6 (b) Compliance with requirements for reporting ma Level 3, widespread scope, scope/level letter I · correction period: Seven (7) days
  Details

  MDH’s finding, as written: “Based on interview and record review the licensee failed to develop and implement an individual abuse prevention plan (IAPP) for each vulnerable adult. The plan must include the person's susceptibility to abuse by another individual, the person's risk of abusing others, statements of the specific measure to be taken to minimize the risk of abuse and include self-abuse for four of four residents (R2, R4, R5 and R9) with records reviewed. [...]”

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

• Tag 690: 144G.43 Subdivision 1 Resident record Level 2, widespread scope, scope/level letter F · correction period: Seven (7) days
  Details

  MDH’s finding, as written: “Based on interview record review the licensee failed to ensure entries in the resident records were authenticated with the correct title of the person making the entry for all residents residing in the facility. This could affect all resident records these employees document within. [...]”

  Rule cited: “(a) Assisted living facilities must maintain records for each resident for whom it is providing services. [...]”

• Tag 1600: 144G.70 Subdivision 1 Acceptance of residents Level 3, widespread scope, scope/level letter I · correction period: Two (2) days
  Details

  Summary: MDH found the licensee failed to ensure the facility had sufficient nursing staff to adequately provide the services agreed upon for 4 of 4 residents,.R1, R2, R3, and R4, reviewed with missed medication or wound care.

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the facility had sufficient nursing staff to adequately provide the services agreed upon for 4 of 4 residents,.R1, R2, R3, and R4, reviewed with missed medication or wound care. Due to the lack of nursing staff the medication changes and wound care orders were not implemented or completed. [...]”

  Rule cited: “An assisted living facility may not accept a person as a resident unless the facility has staff, sufficient in qualifications, competency, and numbers, to adequately provide the services agreed to in the assisted living contract.”

• Tag 1700: 144G.71 Subd. 2 Provision of medication management services Level 3, widespread scope, scope/level letter I · correction period: Seven (7) days
  Details

  Summary: MDH found the licensee failed to ensure the registered nurse (RN) conducted a face-to-face medication management assessment, prior to providing medication management services, to include all required content for four of four residents (R1, R2, R4, and R5) 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 a face-to-face medication management assessment, prior to providing medication management services, to include all required content for four of four residents (R1, R2, R4, and R5) 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 [...]”

• Tag 1760: 144G.71 Subd. 8 Documentation of administration of medication Level 3, widespread scope, scope/level letter I · correction period: Two (2) days
  Details

  Summary: MDH found the licensee failed to document the reason medications were not given as prescribed and to document follow-up procedures to ensure the resident's needs were met for four of four (R1, R2, R3, and R4) residents reviewed.

  MDH’s finding, as written: “Based on interview, and record review, the licensee failed to document the reason medications were not given as prescribed and to document follow-up procedures to ensure the resident's needs were met for four of four (R1, R2, R3, and R4) residents reviewed. This had the potential to affect all residents currently receiving medication management services from the licensee. [...]”

  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. [...]”

• Tag 1960: 144G.72 Subd. 5 Documentation of administration of treatments Level 4, isolated scope, scope/level letter J · correction period: 7-days
  Details

  Summary: MDH found the licensee failed to ensure an individualized treatment and therapy management plan was completed, to include all required contents for one of one resident (R4) with records reviewed.

  MDH’s finding, as written: “Based on record review and interview, the licensee failed to ensure an individualized treatment and therapy management plan was completed, to include all required contents for one of one resident (R4) with records reviewed. Additionally, the facility failed to notify the appropriate licensed health professional (the prescriber) when neither the licensee nor an outside home care agency provided the prescribed wound care. [...]”

  Rule cited: “Each treatment or therapy administered by an assisted living facility must be in the resident record. [...]”

• Tag 2360: 144G.91 Subd. 8 Freedom from maltreatment
  Details

  Summary: MDH found the facility failed to ensure two residents reviewed (R4, and R5) were free from maltreatment.

  MDH’s finding, as written: “The facility failed to ensure two residents reviewed (R4, and R5) were free from maltreatment. Findings include: The Minnesota Department of Health (MDH) issued a determination maltreatment occurred, and the facility was responsible for the maltreatment, in connection with incidents which occurred at the facility. Please refer to the public maltreatment report for details.”

  Rule cited: “Residents have the right to be free from physical, sexual, and emotional abuse; neglect; financial exploitation; and all forms of maltreatment covered under the Vulnerable Adults Act.”

• Tag 3000: 626.557 Subd. 3 Timing of report Level 2, isolated scope, scope/level letter D · correction period: Seven (7) days
  Details

  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 maltreatment for one of one resident (R5) with records reviewed. [...]”

  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 [...]”

Allegation, as written: “The facility neglected a resident when they failed to monitor and assess the resident's wounds. The resident developed sepsis and was hospitalized.”

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

“The facility was responsible for the maltreatment.”

Summary: MDH looked into an allegation and found: neglect substantiated (facility responsibility).

MDH’s conclusion, as written: “The Minnesota Department of Health determined neglect was substantiated. The facility was responsible for the maltreatment. The resident had multiple wounds and the facility failed to assess, monitor, and provide necessary care to promote healing and/or prevent worsening of the residents' wounds. The residents' wounds worsened resulting in exposed bone and tendon between third and fourth toes.”

Action taken by facility: “No action taken by the facility”

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

Survey completed February 16, 2023: 2 correction orders

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

  Summary: MDH found the licensee failed to ensure care and services were provided according to a suitable and up-to-date plan, and subject to acceptable health care and medical, or nursing standards for one of one resident (R1) reviewed with pressure ulcers and/or wounds.

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure care and services were provided according to a suitable and up-to-date plan, and subject to acceptable health care and medical, or nursing standards for one of one resident (R1) reviewed with pressure ulcers and/or wounds. Facility nursing staff failed to ensure the wounds were monitored, and failed to ensure physician orders were implemented to prevent the wounds from worsening. [...]”

  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.”

• Tag 2360: 144G.91 Subd. 8 Freedom from maltreatment
  Details

  Summary: MDH found the facility failed to ensure one of one residents reviewed (R1) was free from maltreatment.

  MDH’s finding, as written: “The facility failed to ensure one of one residents reviewed (R1) was free from maltreatment. Findings include: The Minnesota Department of Health (MDH) issued a determination maltreatment occurred, and the facility was responsible for the maltreatment, in connection with incidents which occurred at the facility. Please refer to the public maltreatment report for details.”

  Rule cited: “Residents have the right to be free from physical, sexual, and emotional abuse; neglect; financial exploitation; and all forms of maltreatment covered under the Vulnerable Adults Act.”