Maplewood Homes of Faribault, 1st Street Sw

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 the licensee's eight current residents. [...]”

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 [...]”

Summary: MDH found the licensee failed to have a daily program of social and recreational activities that were based upon individual and group interests or physical, mental, and psychosocial needs.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to have a daily program of social and recreational activities that were based upon individual and group interests or physical, mental, and psychosocial needs. [...]”

Rule cited: “(ii) weekly housekeeping; (iii) weekly laundry service; (iv) upon the request of the resident, provide direct or reasonable assistance with arranging for transportation to medical and social services appointments, shopping, and other recreation, and provide [...]”

Summary: MDH found 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.

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 had the potential to affect all 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 post the required information related to the grievance procedure and contact information for the Office of Ombudsman for Long-Term Care and Mental Health and Developmental Disabilities.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to post the required information related to the grievance procedure and contact information for the Office of Ombudsman for Long-Term Care and Mental Health and Developmental Disabilities. This had the potential to affect all of the licensee's 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 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 and interview, 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 all the licensee's current residents, staff and visitors. [...]”

Rule cited: “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 near telephones provided [...]”

Summary: MDH found the licensee failed to ensure employee records contained the required content for one of one employee, (unlicensed personnel (ULP)-C).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure employee records contained the required content for one of one employee, (unlicensed personnel (ULP)-C). [...]”

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 for Disease Control and Prevention (CDC) which included baseline testing for one of one employee (unlicensed personnel (ULP)-C) and a facility TB risk assessment.

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 baseline testing for one of one employee (unlicensed personnel (ULP)-C) and a facility TB risk assessment. [...]”

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 [...]”

Summary: MDH found the licensee failed to have a written emergency preparedness plan with all the required content.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to have a written emergency preparedness plan 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 [...]”

Summary: MDH found the licensee failed to confirm that all smoke alarm devices were installed and operational in accordance to MNSFC provisions.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to confirm that all smoke alarm devices were installed and operational in accordance to MNSFC provisions. 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) [...]”

Summary: MDH found the licensee failed to confirm inspection and maintenance of fire extinguishers in accordance to MNSFC provisions.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to confirm inspection and maintenance of fire extinguishers in accordance to MNSFC provisions. This had the potential to directly affect all residents, staff, and visitors. [...]”

Rule cited: “(2) install and maintain portable fire extinguishers in accordance with the State Fire Code; (3) install portable fire extinguishers having a minimum 2-A:10-B:C rating within Group R-3 occupancies, as defined by the State Fire Code, located so that the travel [...]”

Summary: MDH found the facility failed to maintain the facility in good repair in regards to resident health and safety in accordance with maintenance and repair program.

MDH’s finding, as written: “Based on observation, and staff interview, the facility failed to maintain the facility in good repair in regards to resident health and safety in accordance with maintenance and repair program. This deficient condition has the ability to affect all staff and residents. [...]”

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 [...]”

Summary: MDH found the facility failed have detailed fire safety and evacuation plans and associated confirming documentation.

MDH’s finding, as written: “Based on observation, and staff interview, the facility failed have detailed fire safety and evacuation plans and associated confirming documentation. This deficient condition has the ability to affect all staff and residents. [...]”

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

Summary: MDH found the facility failed to develop and execute an assisted living written contract to include all required content for one of one resident (R1).

MDH’s finding, as written: “Based on interview and record review, the facility failed to develop and execute an assisted living written contract to include all required content for one of one resident (R1). [...]”

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 ensure one of one employee (unlicensed personnel (ULP)-C) completed all training and competency evaluations prior to providing delegated nursing tasks to residents.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure one of one employee (unlicensed personnel (ULP)-C) completed all training and competency evaluations prior to providing delegated nursing tasks to residents. This had the potential to affect all residents receiving assisted living services. [...]”

Rule cited: “(b) Unlicensed personnel performing delegated nursing tasks in an assisted living facility must: (1) have successfully completed training and demonstrated competency by successfully completing a written or oral test of the topics in section 144G.61, [...]”

Summary: MDH found the licensee failed to ensure a registered nurse (RN) conducted direct supervision of staff performing a delegated task within 30 days of providing services for one of one employee (unlicensed personnel (ULP)-C).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure a registered nurse (RN) conducted direct supervision of staff performing a delegated task within 30 days of providing services for one of one employee (unlicensed personnel (ULP)-C). [...]”

Rule cited: “(a) Staff who perform delegated nursing or therapy tasks must be supervised by an appropriate licensed health professional or a registered nurse according to the assisted living facility's policy where the services are being provided to verify that the work [...]”

Summary: MDH found the licensee failed to ensure orientation to assisted living licensing requirements and regulations was provided prior to providing assisted living services to residents for one of one employee (unlicensed personnel (ULP)-C).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure orientation to assisted living licensing requirements and regulations was provided prior to providing assisted living services to residents for one of one employee (unlicensed personnel (ULP)-C). [...]”

Rule cited: “All staff providing and supervising direct services must complete an orientation to assisted living facility licensing requirements and regulations before providing assisted living services to residents. [...]”

Summary: MDH found the licensee failed to ensure employees received at least eight hours of annual training for each 12 months of employment for one of one employee (unlicensed personnel (ULP)-C).

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 for each 12 months of employment for one of one employee (unlicensed personnel (ULP)-C). [...]”

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

Summary: MDH found the licensee failed to ensure employees received eight hours of initial dementia care training within the first 160 hours worked and two additional hours annually for one of one employee (unlicensed personnel (ULP)-C).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure employees received eight hours of initial dementia care training within the first 160 hours worked and two additional hours annually for one of one employee (unlicensed personnel (ULP)-C). [...]”

Rule cited: “(a) All assisted living facilities must meet the following training requirements: (1) supervisors of direct-care staff must have at least eight hours of initial training on topics specified under paragraph (b) within 120 working hours of the employment start [...]”

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 using the uniform assessment tool on or before day 90 for one of one resident (R1). [...]”

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 ensure resident service plans included all the required content for one of one resident (R1).

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

Rule cited: “(f) The service plan must include: (1) a description of the services to be provided, the fees for services, and the frequency of each service, according to the resident's current assessment and resident preferences; (2) the identification of staff or [...]”

Summary: MDH found the licensee failed to ensure a registered nurse (RN) conducted an assessment to determine what medication management services would be provided and how the medication services would be provided for one of one resident (R1).

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

Rule cited: “(a) For each resident who requests medication management services, the facility shall, prior to providing medication management services, have a registered nurse, licensed health professional, or authorized prescriber under section 151.37 conduct an [...]”

Summary: MDH found the licensee failed to ensure the registered nurse (RN) completed annual medication re-assessments for one of one resident (R1).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the registered nurse (RN) completed annual medication re-assessments for one of one resident (R1). 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 [...]”

Rule cited: “The assisted living facility must monitor and reassess the resident's medication management services as needed under subdivision 2 when the resident presents with symptoms or other issues that may be medication-related and, at a minimum, annually.”

Summary: MDH found the licensee failed to complete an individualized medication management plan with required content for one of one resident (R1).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to complete an individualized medication management plan with required content for one of one resident (R1). 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 [...]”

Rule cited: “(a) For each resident receiving medication management services, the assisted living facility must prepare and include in the service plan a written statement of the medication management services that will be provided to the resident. [...]”

Summary: MDH found the licensee failed to dispose of expired medications.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to dispose of expired medications. 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 residents). [...]”

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 ensure the required notice was posted at the main entryway of the establishment to display statutory language to disclose electronic monitoring activity, potentially affecting all current residents in the assisted living facility, staff and any visitors to the facility.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to ensure the required notice was posted at the main entryway of the establishment to display statutory language to disclose electronic monitoring activity, potentially affecting all current residents in the assisted living facility, staff and any visitors to the facility. [...]”

Rule cited: “Subd. 8.Notice to visitors. (a) A facility must post a sign at each facility entrance accessible to visitors that states: "Electronic monitoring devices, including security cameras and audio devices, may be present to record persons and activities." (b) The [...]”