Millers Landing Senior Living

Survey completed March 2, 2022: 5 correction orders

• Tag 480: 144G.41 Subd 1 (13) (i) (B) Minimum (re-issued)
  Details

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

  Rule cited: “requirements (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 [...]”

• Tag 1760: 144G.71 Subd. 8 Documentation of administration of medication (re-issued) Level 2, isolated scope, scope/level letter D
  Details

  Summary: MDH found the licensee failed to ensure medications were administered as prescribed for one of three residents (R7) with records reviewed.

  MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure medications were administered as prescribed for one of three residents (R7) with records reviewed. [...]”

  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 1950: 144G.72 Subd. 4 Administration of treatments and therapy (re-issued) Level 2, isolated scope, scope/level letter D
  Details

  Summary: MDH found the licensee failed to ensure the registered nurse (RN) specified in writing, specific instructions for each resident and documented those instructions in the resident's record regarding receiving blood glucose monitoring for one of three residents (R7) with records reviewed.

  MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure the registered nurse (RN) specified in writing, specific instructions for each resident and documented those instructions in the resident's record regarding receiving blood glucose monitoring for one of three residents (R7) with records reviewed. [...]”

  Rule cited: “Ordered or prescribed treatments or therapies must be administered by a nurse, physician, or other licensed health professional authorized to perform the treatment or therapy, or may be delegated or assigned to unlicensed personnel by the licensed health [...]”

• Tag 1960: 144G.72 Subd. 5 Documentation of administration of treatments (re-issued) Level 2, isolated scope, scope/level letter D
  Details

  Summary: MDH found the licensee failed to ensure each treatment or therapy was documented, and when not documented as prescribed, the provider must document the reason why and any follow-up procedures that were provided to meet the resident's needs for one of three residents (R7), who received treatments/therapies.

  MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure each treatment or therapy was documented, and when not documented as prescribed, the provider must document the reason why and any follow-up procedures that were provided to meet the resident's needs for one of three residents (R7), who received treatments/therapies. [...]”

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

• Tag 2320: 144G.91 Subd. 4 Appropriate care and services Level 2, isolated scope, scope/level letter D · correction period: Seven (7) days
  Details

  Summary: MDH found the licensee failed to maintain a clean and safe environment, as an assisted living service, and failed to ensure unlicensed personnel (ULP) were trained and competent to perform their duties.

  MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to maintain a clean and safe environment, as an assisted living service, and failed to ensure unlicensed personnel (ULP) were trained and competent to perform their duties. This affected one of four resident (R8). [...]”

  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 [...]”

Survey completed December 11, 2021: 21 correction orders

• Tag 470: 144G.41 Subdivision 1 Minimum requirements Level 2, isolated scope, scope/level letter D · correction period: Seven (7) days
  Details

  Summary: MDH found the licensee failed to ensure staff responded promptly and effectively to individual resident emergencies for one of two residents (R3) with records reviewed.

  MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure staff responded promptly and effectively to individual resident emergencies for one of two residents (R3) with records reviewed. [...]”

  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 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 comply with Minnesota Food Code, chapter 4626.

  MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to comply with Minnesota Food Code, chapter 4626. This had the potential to affect all 34 residents residing at the facility. [...]”

  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 effective infection control program to comply with accepted health care, medical, and nursing standards for infection control.

  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. This deficient practice had the potential to affect all of the licensee's 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. [...]”

• Tag 650: 144G.42 Subd. 8 Employee records Level 2, widespread scope, scope/level letter F · correction period: Twenty-one (21) days
  Details

  Summary: MDH found the licensee failed to ensure employee records included all required content for four of four employees (registered nurse (RN)-A, RN-C, unlicensed personnel (ULP)-E, ULP-F) with employee records reviewed.

  MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure employee records included all required content for four of four employees (registered nurse (RN)-A, RN-C, unlicensed personnel (ULP)-E, ULP-F) with employee records reviewed. [...]”

  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, pattern scope, scope/level letter E · correction period: Twenty-One (21) days
  Details

  Summary: MDH found 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).

  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). [...]”

  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 [...]”

Fines assessed by MDH

• Tag 510 (144g.41 Subd. 3 - Infection Control Program): $500.00
• Tag 2070 (144g.81 Subd. 4 - Awake Staff Requirement): $3,000.00

Total fines assessed, as printed in the letter: $3,500.00.

Allegation, as written: “The alleged perpetrator (AP) financially exploited residents when controlled medications from discharged or deceased residents went missing from the nurse's office.”

“The Minnesota Department of Health determined financial exploitation was inconclusive.”

Summary: MDH looked into an allegation and found: financial exploitation inconclusive.

MDH’s conclusion, as written: “The Minnesota Department of Health determined financial exploitation was inconclusive. While it was true three residents' controlled medications went missing from the nurse's office, it could not be determined who took the medications. The investigation found at least three other staff members besides the AP had access to these medications and the facility system for tracking narcotics for discharged or deceased residents was insufficient. The facility was issued a compliance correction order to address the medication storage concerns.”

Action taken by facility: “The AP is no longer employed by the facility.”

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

Survey completed December 5, 2023: 1 correction order

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

  Summary: MDH found the licensee failed to provide documentation in the resident's record regarding the disposition of medication to include all the required content for 2 of 2 discharged residents (R1 and R2) plus one current resident (R3).

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide documentation in the resident's record regarding the disposition of medication to include all the required content for 2 of 2 discharged residents (R1 and R2) plus one current resident (R3). [...]”

  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. [...]”

Allegation, as written: “The alleged perpetrator (AP) (unknown facility staff) neglected a resident when the AP gave the resident a peer's medications. The facility did not investigate the incident or retrain the AP. The facility also neglected to check on the resident and ensure the resident was eating/drinking.”

“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. The resident experienced altered mental status and the facility sent the resident to the hospital. The hospital reported to the facility the resident had a medication in his system that was not prescribed to him. The facility investigation determined medication counts were accurate and could not find evidence of a medication error. The Minnesota Department of Health investigation could not determine why/how the unprescribed medication was in the resident's system.”

Action taken by facility: “The facility retrained staff on medication administration and verified all the resident's medications.”

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

Survey completed June 8, 2023: 1 correction order

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

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

  MDH’s finding, as written: “The facility failed to ensure one of one resident reviewed (R1) was free from maltreatment. Findings include: The Minnesota Department of Health (MDH) issued a determination maltreatment occurred, and an individual 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 facility neglected a resident when the facility did not provide cares such as blood sugar monitoring.”

“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 resident had blood glucose checked three times a day ordered, and the facility documentation indicated this was being done.”

Action taken by facility: “The facility provides glucometers for caregivers to use when checking blood sugars.”

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

Survey completed December 5, 2023: 1 correction order

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

  Summary: MDH found the licensee failed to provide documentation in the resident's record regarding the disposition of medication to include all the required content for 2 of 2 discharged residents (R1 and R2) plus one current resident (R3).

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide documentation in the resident's record regarding the disposition of medication to include all the required content for 2 of 2 discharged residents (R1 and R2) plus one current resident (R3). [...]”

  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. [...]”