Minnehaha Senior Living

Survey completed October 5, 2022: 15 correction orders

• Tag 470: 144G.41 Subdivision 1 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 the 24-hour staffing schedule was posted in a central location for residents, staff and visitors to review as required.

  MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the 24-hour staffing schedule was posted in a central location for residents, staff and visitors to review as required. In addition, the licensee failed to have a system in place to ensure call lights were responded to promptly. This had the potential to affect all residents and staff. [...]”

  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 adhere to the Minnesota Food Code, Minnesota Rules, chapter 4626.

  MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to adhere to the Minnesota Food Code, Minnesota Rules, chapter 4626. This had the potential to affect all residents of 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: Two (2) days
  Details

  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 acceptable 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 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 ensure employee tuberculosis (TB) baseline screenings were completed and documented for two of two employees (unlicensed personnel (ULP)-H, licensed practical nurse (LPN)-J).

  MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure employee tuberculosis (TB) baseline screenings were completed and documented for two of two employees (unlicensed personnel (ULP)-H, licensed practical nurse (LPN)-J). [...]”

  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 790: 144G.45 Subd. 2 (a) (2)-(3) 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 ensure maintenance of portable fire

  MDH’s finding, as written: “Based on observation and interview, the licensee failed to ensure maintenance of portable fire extinguishers at the facility. 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 [...]”

Allegation, as written: “The facility neglected the resident when staff did not administer the residents Pulmicort nebulizer treatment for 12 days. The resident experienced increasing shortness of breath and coughing. requiring hospitalization. The resident's oxygen saturation (O2 sat) in the hospital was 82% on room air and she was diagnosed with asthma exacerbation.”

“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's medication administration record (MAR) indicated she went 12 days without using her Pulmicort nebulizer. However, the resident stated she self-administered the nebulizer during that timeframe, although the facility had no documentation. The resident's medication management plan changed frequently between self-administration of medications and treatments, and at other times staff would be assigned to do so. Staff were unclear as to whether the resident was evaluated to self-administer her Pulmicort nebulizer during this timeframe, or if staff were to administer the nebulizer. The resident said two days before she went to the hospital, her nebulizer solution got low, so she started using it once a day instead of twice a day as ordered. [...]”

Action taken by facility: “Services were added for nursing to check the resident's apartment weekly to ensure medications were not low on supply. The process to clarify which medications were self-administer and staff-administer were clarified for staff members.”

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

Survey completed April 29, 2025: 1 correction order

• Tag 1750: 144G.71 Subd. 7 Delegation of medication administration Level 3, isolated scope, scope/level letter G · correction period: Seven (7) days
  Details

  Summary: MDH found the facility failed to provide oversight and specific written instructions for medication administration when delegated to unlicensed personnel (ULP) for one of one resident (R1).

  MDH’s finding, as written: “Based on interview, and record review, the facility failed to provide oversight and specific written instructions for medication administration when delegated to unlicensed personnel (ULP) for one of one resident (R1). [...]”

  Rule cited: “When administration of medications is delegated to unlicensed personnel, the assisted living facility must ensure that the registered nurse has: (1) instructed the unlicensed personnel in the proper methods to administer the medications, and the unlicensed [...]”

Allegation, as written: “The facility neglected the resident when they failed to administer scheduled medications as ordered.”

“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 facility followed the care plan and nursing staff assessed and adjusted the care plan as needed. There was not a preponderance of evidence to support that the actions of the facility staff met the definition of neglect.”

Action taken by facility: “The nursing staff continued to monitor the resident's ability to self-administer medication, as well as offering continued training to staff on proper data entry into the electronic health record.”

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

Survey completed February 3, 2025: no correction orders issued.