Morning Glory Homes

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 history and symptom screen for two of two employees (unlicensed personnel (ULP)-A, ULP-E).

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 history and symptom screen for two of two employees (unlicensed personnel (ULP)-A, ULP-E). [...]”

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 develop and publicly post a written emergency disaster plan (EDP) with all the required content.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to develop and publicly post a written emergency disaster plan (EDP) with all the required content. This had the potential to affect all residents, employees, and visitors to the facility. [...]”

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 develop a fire safety and evacuation plan with the required elements and failed to conduct required evacuation drills as required.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop a fire safety and evacuation plan with the required elements and failed to conduct required evacuation drills as required. 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 ensure physical facility elements did not constitute a distinct hazard to life.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to ensure physical facility elements did not constitute a distinct hazard to life. The licensee failed to provide a resident bedroom with the minimum window opening meeting the minimum state standard for egress. This affected the occupied resident in bedroom #1 on the lower level. [...]”

Rule cited: “(g) Existing construction or elements, including assisted living facilities that were registered as housing with services establishments under chapter 144D prior to August 1, 2021, shall be permitted to continue in use provided such use does not constitute a [...]”

Summary: MDH found the licensee failed to provide a written notice with the required content for an emergency relocation to the resident, legal representative, or designated representative and failed to provide the notification to the Office of Ombudsman for Long-Term Care (OOLTC) when the resident did not return from the emergency relocation within four days for one of one resident (R1).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide a written notice with the required content for an emergency relocation to the resident, legal representative, or designated representative and failed to provide the notification to the Office of Ombudsman for Long-Term Care (OOLTC) when the resident did not return from the emergency relocation within four days for one of one resident (R1). [...]”

Rule cited: “(a) A facility may remove a resident from the facility in an emergency if necessary due to a resident's urgent medical needs or an imminent risk the resident poses to the health or safety of another facility resident or facility staff member. [...]”

Summary: MDH found the licensee failed to ensure a background study was conducted prior to staff providing services for three of three employees (unlicensed personnel (ULP)-A, ULP-E, ULP-F) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure a background study was conducted prior to staff providing services for three of three employees (unlicensed personnel (ULP)-A, ULP-E, ULP-F) with records reviewed. [...]”

Rule cited: “(a) Employees, contractors, and regularly scheduled volunteers of the facility are subject to the background study required by section 144.057 and may be disqualified under chapter 245C. [...]”

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure employees received the required initial eight (8) hours of dementia care training for two of two unlicensed personnel ((ULP)-A, ULP-E). [...]”

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 a registered nurse (RN) conducted a reassessment, not to exceed 14 calendar days from the initiation of services; and failed to ensure the registered nurse (RN) conducted ongoing resident monitoring and reassessment not to exceed 90 calendar days from the last date of assessment for two of two residents (R1, R2).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure a registered nurse (RN) conducted a reassessment, not to exceed 14 calendar days from the initiation of services; and failed to ensure the registered nurse (RN) conducted ongoing resident monitoring and reassessment not to exceed 90 calendar days from the last date of assessment for two of two residents (R1, R2). [...]”

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 medication administration was documented accurately in the medication administration record (MAR) for six of six residents (R1, R2, R3, R4, R5, R6).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medication administration was documented accurately in the medication administration record (MAR) for six of six residents (R1, R2, R3, R4, R5, R6). [...]”

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 ensure medications were stored securely for six of six residents (R1, R2, R3, R4, R5, R6) with medication management services.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medications were stored securely for six of six residents (R1, R2, R3, R4, R5, R6) with medication management services. [...]”

Rule cited: “An assisted living facility must store all prescription medications in securely locked and substantially constructed compartments according to the manufacturer's directions and permit only authorized personnel to have access.”

Summary: MDH found the licensee failed to provide care and services according to acceptable health care, medical, or nursing standards for one resident (R1) who had bed rails.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to provide care and services according to acceptable health care, medical, or nursing standards for one resident (R1) who had bed rails. This resulted in an immediate order on July 1, 2024. [...]”

Rule cited: “(a) Residents have the right to care and assisted living services that are appropriate based on the resident's needs and according to an up-to-date service plan subject to accepted health care standards.”