Maple Hill Senior Living

Survey completed May 18, 2022: 7 correction orders

• Tag 480: 144G.41 Subd 1 (13) (i) (B) Minimum requirements (re-issued) scope/level letter F
  Details

  MDH’s finding, as written: “No futher action required.”

  Rule cited: “(13) offer to provide or make available at least the following services to residents: (i) at least three nutritious meals daily with snacks available seven days per week, according to the recommended dietary allowances in the United States Department of [...]”

• Tag 510: 144G.41 Subd. 3 Infection control program (re-issued) Level 2, widespread scope, scope/level letter F · fine: $500.00 assessed
  Details

  Summary: MDH found the licensee failed to establish and maintain an infection control program that complied with accepted health care, medical and nursing standards related to COVID-19.

  MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to establish and maintain an infection control program that complied with accepted health care, medical and nursing standards related to COVID-19. [...]”

  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 660: 144G.42 Subd. 9 Tuberculosis prevention and control Level 2, isolated scope, scope/level letter D · correction period: Twenty One (21) Days
  Details

  MDH’s finding, as written: “Based on observation, interview and record review, the license failed to maintain a tuberculosis (TB) infection control program based on guidelines by the Center for Disease Control (CDC) and Minnesota Department of Health and ensure the TB infection control program covered all paid and unpaid employees for one of one employee (unlicensed personnel (ULP)-Q) with employee record 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 810: 144G.45 Subd. 2 (b)-(f) Fire protection and physical environment (re-issued) scope/level letter F
  Details

  MDH’s finding, as written: “No futher action required.”

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

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

  Summary: MDH found the licensee failed to ensure one of one employee (unlicensed personal (ULP)-Q) received the required amount 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 one employee (unlicensed personal (ULP)-Q) received the required amount 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. [...]”

• Tag 1890: 144G.71 Subd. 20 Prescription drugs (re-issued) Level 2, isolated scope, scope/level letter D
  Details

  Summary: MDH found the licensee failed to dispose of expired medications and ensure medications had labels with legible information including the expiration or beyond-use date of a time-dated drug for two of two residents (R20, R21) with records reviewed.

  MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to dispose of expired medications and ensure medications had labels with legible information including the expiration or beyond-use date of a time-dated drug for two of two residents (R20, R21) 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 [...]”

• Tag 2040: 144G.81 Subdivision 1 Fire protection and physical environment (re-issued) scope/level letter F
  Details

  MDH’s finding, as written: “No futher action required.”

  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 [...]”

Survey completed December 17, 2021: 30 correction orders

• Tag 250: 144G.20 Subdivision 1. Conditions Level 2, widespread scope, scope/level letter F · correction period: Twenty-One (21) days
  Details

  Summary: MDH found the licensee failed to ensure the management officials who were in charge of the day-to-day operations, and responsible for the resident's assisted living services, understood all of the assisted living facility with dementia care regulations.

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the management officials who were in charge of the day-to-day operations, and responsible for the resident's assisted living services, understood all of the assisted living facility with dementia care regulations. This has 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 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 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: (i) at least three nutritious meals daily with snacks available seven days per week, according to the recommended dietary allowances in the United States Department of [...]”

• Tag 510: 144G.41 Subd. 3 Infection control program Level 2, widespread scope, scope/level letter F · correction period: Seven (7) days · fine: $500.00 assessed
  Details

  Summary: MDH found the licensee failed to establish and maintain an infection control program that complied with accepted health care, medical and nursing standards related to COVID-19; and failed to ensure appropriate infection control practices were implemented during personal cares and delegated treatments/therapies for two of two residents (R1 and R2); and failed to ensure food items were maintained at appropriate and safe temperatures to minimize the potential for foodborne illness for three of twelve residents (R1, R11 and R12) who received meals in their rooms.

  MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to establish and maintain an infection control program that complied with accepted health care, medical and nursing standards related to COVID-19; and failed to ensure appropriate infection control practices were implemented during personal cares and delegated treatments/therapies for two of two residents (R1 and R2); and failed to ensure food items were maintained at appropriate and safe temperatures to minimize the [...]”

  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 620: 144G.42 Subd. 6 Compliance with requirements for reporting ma Level 3, isolated scope, scope/level letter G · correction period: Seven (7) days · fine: $3,000.00 assessed
  Details

  Summary: MDH found the licensee failed to immediately report to the Minnesota Adult Abuse Reporting Center (MAARC) suspected maltreatment, and complete a thorough investigation for one of five residents (R2) with records reviewed.

  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, and complete a thorough investigation for one of five residents (R2) with records reviewed. In addition, the licensee failed to implement written procedures pertaining to allegations of maltreatment. [...]”

  Rule cited: “144G.42 Subd. 6. Compliance with requirements for reporting maltreatment of vulnerable adults; abuse prevention plan. (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 Compliance with requirements for reporting ma Level 2, pattern scope, scope/level letter E · correction period: Seven (7) days
  Details

  Summary: MDH found the licensee failed to develop and implement individual abuse prevention plans that included individualized assessments of the resident's susceptibility to abuse by another individual, including other vulnerable adults and self-abuse; the resident's risk of abusing other vulnerable adults; and statements of the specific measures to be taken to minimize the risk of abuse for three

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop and implement individual abuse prevention plans that included individualized assessments of the resident's susceptibility to abuse by another individual, including other vulnerable adults and self-abuse; the resident's risk of abusing other vulnerable adults; and statements of the specific measures to be taken to minimize the risk of abuse for three of five residents (R1, R2, and R5) with records reviewed. [...]”

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

MDH letters in this report

• May 23, 2022: Notice Of Removal Of Conditional License

From MDH’s letter: the letter says the facility is in substantial compliance.

Fines assessed by MDH

• Tag 510 (144g.41 Subd. 3 - Infection Control Program): $500.00
• Tag 620 (144g.42 Subd. 6 - Compliance With Requirements For Reporting Ma): $3,000.00
• Tag 1760 (144g.71 Subd. 8 - Documentation Of Administration Of Medication): $3,000.00
• Tag 1950 (144g.72 Subd. 4 - Administration Of Treatments And Therapy): $3,000.00
• Tag 2310 (144g.91 Subd. 4 - Appropriate Care And Services): $3,000.00

Total fines assessed, as printed in the letter: $500.00.

Total fines assessed, as printed in the letter: $12,500.00.

Allegation, as written: “The facility neglected the resident when staff failed to provide incontinent care, leading to open wounds. Facility staff also failed to administer medication according to hospital discharge orders, requiring rehospitalization.”

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

Summary: MDH looked into an allegation and found: neglect inconclusive.

MDH’s conclusion, as written: “The Minnesota Department of Health determined neglect was inconclusive. Due to lack of documentation and conflicting information, it is unable to be determined if the resident sustained open wounds due to a lack of incontinence care. When staff observed a change in the resident's condition, the resident was assessed and sent to the hospital for further evaluation. The resident admitted to the intensive care unit (ICU) and discharged back to the facility. No documentation was available to identify the resident's condition or care provided following her return to the facility. Three days later, the resident was readmitted to the hospital. It is unable to be determined if the cause of the rehospitalization was directly related to the facility not administering the resident's medications. An equal opportunity employer.”

Action taken by facility: “None”

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

Survey completed May 4, 2023: 1 correction order

• Tag 2320: 144G.91 Subd. 4 (b) Appropriate care and services Level 3, isolated scope, scope/level letter G
  Details

  Summary: MDH found the licensee failed to ensure care and services were provided according to acceptable health care and medical, or nursing standards and supervision for two of two residents (R1, R2) with records reviewed.

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure care and services were provided according to acceptable health care and medical, or nursing standards and supervision for two of two residents (R1, R2) with records reviewed. The licensee did not have a system in place to ensure coordination of care upon R1 and R2's return to the facility following hospitalization. The licensee failed to complete an assessment upon R1 and R2's return to the facility. [...]”

  Rule cited: “(b) Residents have the right to receive health care and other assisted living services with continuity from people who are properly trained and competent to perform their duties and in sufficient numbers to adequately provide the services agreed to in the [...]”

Allegation, as written: “The facility neglected the resident when scheduled safety checks were not completed and the resident was found on the floor with a nose fracture.”

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

Summary: MDH looked into an allegation and found: neglect inconclusive.

MDH’s conclusion, as written: “The Minnesota Department of Health determined neglect was inconclusive. Due to conflicting information and documentation, it is unable to be determined if maltreatment occurred. Although the resident's last scheduled safety check was not completed, the safety check was scheduled six hours prior to the time the resident was found on the floor. The time of the resident's fall is unknown, and it is unable to be determined if completion of the safety check would have prevented the resident's fall or injury.”

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

Action taken by MDH: “No further action taken at this time.”

Survey completed May 4, 2023: 1 correction order

• Tag 2320: 144G.91 Subd. 4 (b) Appropriate care and services Level 3, isolated scope, scope/level letter G
  Details

  Summary: MDH found the licensee failed to ensure care and services were provided according to acceptable health care and medical, or nursing standards and supervision for two of two residents (R1, R2) with records reviewed.

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure care and services were provided according to acceptable health care and medical, or nursing standards and supervision for two of two residents (R1, R2) with records reviewed. The licensee did not have a system in place to ensure coordination of care upon R1 and R2's return to the facility following hospitalization. The licensee failed to complete an assessment upon R1 and R2's return to the facility. [...]”

  Rule cited: “(b) Residents have the right to receive health care and other assisted living services with continuity from people who are properly trained and competent to perform their duties and in sufficient numbers to adequately provide the services agreed to in the [...]”

Allegation, as written: “The alleged perpetrators (AP #1 and AP #2), unlicensed staff, emotionally abused the resident when AP #1 and AP #2 took the resident's cell phone resulting in aggressive behavior.”

“The Minnesota Department of Health determined emotional abuse was not substantiated.”

Summary: MDH looked into an allegation and found: emotional abuse not substantiated.

MDH’s conclusion, as written: “The Minnesota Department of Health determined emotional abuse was not substantiated. AP #1 and AP #2 were not responsible for maltreatment. While AP #1 took the resident's phone away and AP #2 was aware of the phone being taken, it does not rise to the level of abuse. The resident also has history of agitation towards staff and other residents.”

Action taken by facility: “The facility terminated AP #1 and AP #2.”

Action taken by MDH: “No further action taken at this time.”

Survey completed July 13, 2026: no correction orders issued.

Allegation, as written: “The alleged perpetrator (AP), a facility staff member neglected the resident when the AP failed to provide care and supervision during an incident when the resident fell.”

“The Minnesota Department of Health determined neglect was not substantiated.”

Summary: MDH looked into an allegation and found: neglect not substantiated.

MDH’s conclusion, as written: “The Minnesota Department of Health determined neglect was not substantiated. At the time of the incident, the AP was following the resident's plan of care. The resident sustained a fall and was transported to the hospital.”

Action taken by facility: “Once the facility learned the resident was no longer at the facility, the facility began an investigation. The facility installed additional cameras. The AP is no longer employed by the facility.”

Action taken by MDH: “No further action taken at this time.”

Survey completed December 30, 2024: no correction orders issued.

Allegation, as written: “The facility neglected the resident when the resident fell, requested to go to the hospital, and facility staff refused to send her. She was bedridden for two days and facility staff did not respond her pendent calls for help.”

“The Minnesota Department of Health determined neglect was not substantiated.”

Summary: MDH looked into an allegation and found: neglect not substantiated.

MDH’s conclusion, as written: “The Minnesota Department of Health determined neglect was not substantiated. Although the resident fell, facility nursing staff assessed the resident, completed safety checks, and updated the medical provider. The resident was sent to the ER three days after the fall.”

Action taken by facility: “The facility assessed the resident, administered pain medication, updated the provider, and sent the resident to the emergency room when a change in condition occurred.”

Action taken by MDH: “No further action taken at this time.”

Survey completed April 16, 2024: no correction orders issued.

Allegation, as written: “The alleged perpetrator (AP) neglected a resident when she administered medication to the resident that was not ordered for the resident by the provider.”

“The Minnesota Department of Health determined neglect was not substantiated.”

Summary: MDH looked into an allegation and found: neglect not substantiated.

MDH’s conclusion, as written: “The Minnesota Department of Health determined neglect was not substantiated. The AP administered insulin to the resident. The insulin was meant for another resident with a similar name. Although the wrong medication was given, the error was an isolated incident. The resident sustained nausea and vomiting, received increased monitoring, anti-nausea medication and returned to their baseline health condition.”

Action taken by facility: “The facility immediately reported the incident to the provider and provided the follow up medical care as ordered by the provider. The facility provided retraining to staff.”

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

Survey completed October 30, 2023: 2 correction orders

• Tag 620: 144G.42 Subd. 6 (a) / 626.557, Subd. 3 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 document review the licensee failed to report potential neglect to Minnesota Adult Abuse Reporting (MAARC) immediately, within 24 hours, as required for 1 of 1 residents (R1) 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 1650: 144G.70 Subd. 4 (f) 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 include medication services in the service plan, as required for 1 of 1 residents (R1) reviewed.

  MDH’s finding, as written: “Based on interview and document review, the licensee failed to include medication services in the service plan, as required for 1 of 1 residents (R1) reviewed. 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, but was not likely to cause serious injury, impairment, or death) and was issued at an isolated scope (when one or a limited number of residents are affected or [...]”

  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 [...]”