Midwest Homes

Summary: MDH found the licensee failed to provide a discharge summary with required content for one of one resident (R3) discharged from the licensee.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide a discharge summary with required content for one of one resident (R3) discharged from the licensee. [...]”

Rule cited: “Contents of a resident record include the following for each resident: (1) identifying information, including the resident's name, date of birth, address, and telephone number; (2) the name, address, and telephone number of the resident's emergency contact, [...]”

Summary: MDH found the licensee failed to comply with the current State Fire Code in Minnesota Rules, chapter 7511.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to comply with the current State Fire Code in Minnesota Rules, chapter 7511. This had the potential to directly affect all residents, staff, and visitors. [...]”

Rule cited: “Each assisted living facility must comply with the State Fire Code in Minnesota Rules, chapter 7511, and:”

Summary: MDH found the licensee failed to provide smoke alarms inside all levels of the facility and that were interconnected so that the actuation of one alarm caused 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 inside all levels of the facility and that were interconnected so that the actuation of one alarm caused all alarms in the dwelling unit to actuate. This had the potential to directly affect all residents, staff, and visitors. [...]”

Rule cited: “for dwellings or sleeping units, as defined in the State Fire Code: (i) provide smoke alarms in each room used for sleeping purposes; (ii) provide smoke alarms outside each separate sleeping area in the immediate vicinity of bedrooms; (iii) provide smoke [...]”

Summary: MDH found the licensee failed to develop the fire safety and evacuation plan with the required content and provide the required training and drills.

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

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

Summary: MDH found the licensee failed to develop and execute a written assisted living contract with the required content for one of three residents (R3).

MDH’s finding, as written: “Based on observation and interview, the licensee failed to develop and execute a written assisted living contract with the required content for one of three residents (R3). [...]”

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

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

MDH’s finding, as written: “Based on interview and record review, the licensee failed to execute a written contract with the required content for one of one resident (R1). This practice resulted in a level one violation (a violation that has no potential to cause more than a minimal impact on the resident and does not affect health or safety) and was issued at a widespread scope (when problems are pervasive or represent a systemic failure that has affected or has potential to affect a large portion or all the residents). [...]”

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

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 three employees (unlicensed personnel (ULP)-A).

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 three employees (unlicensed personnel (ULP)-A). [...]”

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 three of three employees (unlicensed personnel (ULP)-A, ULP-B, ULP-E) received at least eight hours of initial dementia care training within 160 working hours of their employment start date, and two hours of dementia training annually.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure three of three employees (unlicensed personnel (ULP)-A, ULP-B, ULP-E) received at least eight hours of initial dementia care training within 160 working hours of their employment start date, and two hours of dementia training annually. [...]”

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 [...]”

Summary: MDH found the licensee failed to ensure the registered nurse (RN) conducted ongoing resident assessment and reassessment, not to exceed 90 calendar days from the last date of the assessment for one of three residents (R1).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the registered nurse (RN) conducted ongoing resident assessment and reassessment, not to exceed 90 calendar days from the last date of the assessment for one of three residents (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 initiate a temporary service plan for one of three residents (R3).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to initiate a temporary service plan for one of three residents (R3). 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 a widespread scope (when problems are pervasive or represent a systemic failure that has affected or has [...]”

Rule cited: “When a facility initiates services and the individualized assessment required in subdivision 2 has not been completed, the facility must complete a temporary plan and agreement with the resident for services. [...]”

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to develop and maintain a current individualized medication management record for each resident to include all required content for one of three residents (R3). [...]”

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 document medication administration for one of three residents (R1).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to document medication administration for one of three residents (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, 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 one or a limited number of [...]”

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. [...]”

Summary: MDH found the licensee failed to provide documentation of disposition of medications for one of one discharged resident (R3).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide documentation of disposition of medications for one of one discharged resident (R3). 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 a widespread scope (when problems are pervasive or represent a systemic failure [...]”

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

Summary: MDH found the licensee included language within a posting on a bulletin board located in common area in the living room which limited the rights of all residents residing within the facility.

MDH’s finding, as written: “Based on interview and record review, the licensee included language within a posting on a bulletin board located in common area in the living room which limited the rights of all residents residing within the facility. [...]”

Rule cited: “The rights established under this section for the benefit of residents do not limit any other rights available under law. [...]”

Summary: MDH found the licensee failed to ensure the required notice was posted at the main entryway of the facility to display statutory language to disclose electronic monitoring activity.

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 facility to display statutory language to disclose electronic monitoring activity. This had the potential to affect all of the licensee's residents, staff, and visitors. [...]”

Rule cited: “(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 facility is responsible for [...]”