Oak Terrace Senior Housing of

Survey completed June 23, 2023: 10 correction orders

• Tag 480: 144G.41 Subd 1 (13) (i) (B) Minimum requirements Level 1, widespread scope, scope/level letter C · correction period: Twenty-one (21) days
  Details

  Summary: MDH found the licensee failed to ensure food was prepared and served 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 and served according to the Minnesota Food Code. 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 the potential to affect a large portion or all the [...]”

  Rule cited: “(13) offer to provide or make available at least the following services to residents: (B) food must be prepared and served according to the Minnesota Food Code, Minnesota Rules, chapter 4626; and”

• Tag 550: 144G.41 Subd. 7 Resident grievances; reporting maltreatment Level 2, widespread scope, scope/level letter F · correction period: Seven (7) days
  Details

  Summary: MDH found the licensee failed to develop and implement an individual abuse prevention plan (IAPP) with required content for all identified housing only residents.

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop and implement an individual abuse prevention plan (IAPP) with required content for all identified housing only residents. [...]”

  Rule cited: “All facilities must post in a conspicuous place information about the facilities' grievance procedure, and the name, telephone number, and email contact information for the individuals who are responsible for handling resident grievances. [...]”

• Tag 630: 144G.42 Subd. 6 (b) Compliance with requirements for reporting ma Level 2, widespread scope, scope/level letter F · correction period: Seven (7) days
  Details

  Summary: MDH found the licensee failed to develop and implement an individual abuse prevention plan (IAPP) with required content for all identified independent living residents.

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop and implement an individual abuse prevention plan (IAPP) with required content for all identified independent living residents. [...]”

  Rule cited: “(b) The facility must develop and implement an individual abuse prevention plan for each vulnerable adult. [...]”

• Tag 660: 144G.42 Subd. 9 Tuberculosis prevention and control Level 2, widespread scope, scope/level letter F · correction period: Twenty-one (21) days
  Details

  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 an updated facility TB risk assessment. This had the potential to affect all current residents, staff and visitors. [...]”

  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 800: 144G.45 Subd. 2 (a) (4) Fire protection and physical environment Level 2, widespread scope, scope/level letter F · correction period: Seven (7) days
  Details

  Summary: MDH found the licensee failed to maintain 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.

  MDH’s finding, as written: “Based on observation and interview, the licensee failed to maintain 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. This deficient condition had the potential to affect all staff, residents, and visitors. [...]”

  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 [...]”

From MDH’s letter: no immediate fines.

Allegation, as written: “The facility neglected a resident when they did not administer the correct dose monoclonal antibodies (also called REGEN-COV, a medication to treat positive COVID patients) and not following the resident's care plan which contributed to the resident's death due to COVID-19.”

“The Minnesota Department of Health determined neglect was inconclusive.”

Summary: MDH looked into an allegation and found: neglect inconclusive.

MDH’s conclusion, as written: “An equal opportunity employer. The Minnesota Department of Health determined neglect was inconclusive. A facility nurse administered a partial dose of monoclonal antibodies without a physician's order to a resident that had COVID-19 infection. It is not known if administering the full dose of the medication to the resident would have resulted in a different outcome.”

Action taken by facility: “The facility conducted an internal investigation of the medication incident. The nurse was placed on suspension and a notification of the incident was forwarded to the MN Board of Nursing. Nurses were educated on proper administration and documentation of the Regen medication.”

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

Survey completed April 5, 2022: 2 correction orders

• Tag 1760: 144G.71 Subd. 8 Documentation of administration of medication Level 2, isolated scope, scope/level letter D · correction period: Seven (7) Days
  Details

  Summary: MDH found the licensee failed to ensure medications were documented after administration for two of two residents (R1, R2).

  MDH’s finding, as written: “Based on interview, and record review, the licensee failed to ensure medications were documented after administration for two of two residents (R1, R2). 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 an isolated scope (when one or a limited number of residents are affected or one or a limited number of staff are involved, or the situation has [...]”

  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 1820: 144G.71 Subd. 13 Prescriptions Level 2, isolated scope, scope/level letter D · correction period: Seven (7) Days
  Details

  Summary: MDH found the licensee failed to ensure medications were administered as ordered for one of one resident (R2), and failed to ensure there was a doctor's order prior to medication administration for one of one residents (R1).

  MDH’s finding, as written: “Based on interview, and record review, the licensee failed to ensure medications were administered as ordered for one of one resident (R2), and failed to ensure there was a doctor's order prior to medication administration for one of one residents (R1). [...]”

  Rule cited: “There must be a current written or electronically recorded prescription as defined in section 151.01, subdivision 16a, for all prescribed medications that the assisted living facility is managing for the resident.”

Allegation, as written: “The alleged perpetrators (AP#1, AP#2) financially exploited the resident when the resident had 8.5 milliliters (mL) of morphine unaccounted for. The former director of nursing (AP#2) documented the missing morphine as spillage and waste without investigating the missing morphine. An unlicensed personnel, (AP#1), documented frequent administrations of morphine during the overnight shifts with discrepancies of documentation in the narcotic ledger compared to the electronic medication administration record (eMAR).”

“The Minnesota Department of Health determined financial exploitation for drug diversion, was inconclusive.”

Summary: MDH looked into an allegation and found: financial exploitation for drug diversion, inconclusive.

MDH’s conclusion, as written: “The Minnesota Department of Health determined financial exploitation for drug diversion, was inconclusive. AP#1 had vast experience passing medications although she incorrectly transcribed the morphine dosage instructions in the narcotic logbook. AP#1 frequently signed out morphine than other direct care staff and signed out more doses of morphine than what the resident's electronic medication administration (eMAR) indicated the resident received. AP#2 signed off the 8.5 mL of missing morphine as spillage/waste yet never investigated the An equal opportunity employer. incident. There was no documentation AP#2 talked to AP#1 to find out how the morphine went missing.”

Action taken by facility: “The facility changed their process on how narcotics were signed out from the narcotic box. Two direct care staff persons need to verify and witness the removal of a narcotic from the locked narcotic box. AP#1 and AP#2 are no longer employed at the facility.”

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

Survey completed August 31, 2022: 7 correction orders

• Tag 620: 144G.42 Subd. 6 (a) Compliance with requirements for reporting ma Level 2, isolated scope, scope/level letter D
  Details

  Summary: MDH found the facility failed to comply with the requirements for reporting suspected maltreatment within 24 hours for one of one residents (R1) with records reviewed.

  MDH’s finding, as written: “Based on interview and record review, the facility failed to comply with the requirements for reporting suspected maltreatment within 24 hours for one of one residents (R1) with records reviewed. R1's liquid oral morphine went unaccounted for during unlicensed personnel (ULP)-I's overnight shift. The former director of nursing (DON)-G signed off R1's 8.5 mL missing morphine as spillage and waste yet never investigated the missing morphine and never alerted other administrative staff. [...]”

  Rule cited: “144G.42 Subd. 6. Compliance with requirements for reporting maltreatment of vulnerable adults; abuse prevention plan. (a) The assisted living facility must comply with the requirements for the reporting of maltreatment of vulnerable adults in section 626.557. [...]”

• Tag 1430: 144G.62 Subd. 3 Supervision of staff Level 2, isolated scope, scope/level letter D
  Details

  Summary: MDH found the licensee failed to ensure periodic, direct supervision and documentation were performed for one of two unlicensed personnel (ULP-I) with records reviewed.

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure periodic, direct supervision and documentation were performed for one of two unlicensed personnel (ULP-I) with records reviewed. [...]”

  Rule cited: “(a) Staff who only provide assisted living services specified in section 144G.08, subdivision 9, clauses (1) to (5), must be supervised periodically where the services are being provided to verify that the work is being performed competently and to identify [...]”

• Tag 1500: 144G.63 Subd. 5 Required annual training Level 2, pattern scope, scope/level letter E
  Details

  Summary: MDH found the licensee failed to ensure employees received at least eight hours of annul training for each 12 months of employment for two of three employees, unlicensed personnel (ULP)-E and ULP-I, with training records reviewed.

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure employees received at least eight hours of annul training for each 12 months of employment for two of three employees, unlicensed personnel (ULP)-E and ULP-I, with training records reviewed. [...]”

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

• Tag 1540: 144G.64 (a) TRAINING IN DEMENTIA CARE REQUIRED Level 2, isolated scope, scope/level letter D
  Details

  Summary: MDH found the licensee failed to ensure staff received the required amount of dementia care training in the required time frame for one of three unlicensed personnel ((ULP)-E) personnel records reviewed.

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure staff received the required amount of dementia care training in the required time frame for one of three unlicensed personnel ((ULP)-E) personnel records reviewed. [...]”

  Rule cited: “(3) for assisted living facilities with dementia care, direct-care employees must have completed at least eight hours of initial training on topics specified under paragraph (b) within 80 working hours of the employment start date. [...]”

• Tag 1760: 144G.71 Subd. 8 Documentation of administration of medication Level 3, isolated scope, scope/level letter G
  Details

  Summary: MDH found the licensee failed to ensure an unlicensed personnel (ULP)-I correctly transcribed a narcotic in the narcotic ledger for one of one resident (R1) with records reviewed.

  MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure an unlicensed personnel (ULP)-I correctly transcribed a narcotic in the narcotic ledger for one of one resident (R1) with records reviewed. ULP-I removed two doses of morphine from R1's narcotic box yet never documented the morphine was administered in R1's electronic medication administration record (eMAR). [...]”

  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 1920: 144G.71 Subd. 23 Loss or spillage Level 3, isolated scope, scope/level letter G
  Details

  Summary: MDH found the licensee failed to follow procedure for loss and spillage of a controlled substance for one of one resident (R1) with records reviewed.

  MDH’s finding, as written: “Based on observation and record review, the licensee failed to follow procedure for loss and spillage of a controlled substance for one of one resident (R1) with records reviewed. R1 was prescribed a controlled substance that was managed by the licensee's facility. [...]”

  Rule cited: “(a) Assisted living facilities providing medication management must develop and implement procedures for loss or spillage of all controlled substances defined in Minnesota Rules, part 6800.4220. [...]”

• Tag 3000: 626.557 Subd. 3 Timing of report Level 2, isolated scope, scope/level letter D
  Details

  Summary: MDH found the facility failed to comply with the requirements for reporting suspected maltreatment within 24 hours for one of one residents (R1) with records reviewed.

  MDH’s finding, as written: “Based on interview and record review, the facility failed to comply with the requirements for reporting suspected maltreatment within 24 hours for one of one residents (R1) with records reviewed. R1's liquid oral morphine went unaccounted for during unlicensed personnel (ULP)-I's overnight shift. The former director of nursing (DON)-G signed off R1's 8.5 mL missing morphine as spillage and waste yet never investigated the missing morphine and never alerted other administrative staff. [...]”

  Rule cited: “(a) A mandated reporter who has reason to believe that a vulnerable adult is being or has been maltreated, or who has knowledge that a vulnerable adult has sustained a physical injury which is not reasonably explained shall immediately report the information [...]”

Allegation, as written: “The facility neglected the resident when a staff member combined Metolazone and Mirtazapine in the same bottle. As a result, the resident was hospitalized due to fluid overload.”

“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. Due to the resident's complex health history, there was insufficient evidence to prove that the incident caused the resident's death. Although a staff member combined Metolazone and Mirtazapine in the same bottle, the error was an isolated incident. The resident's weight was elevated, and he was sent to the hospital due to fluid overload. He received treatment and returned to the facility two days later.”

Action taken by facility: “A Medication Pass meeting was held where it was discussed that medications should never be mixed, or pill bottles combined. In addition, all staff members who pass medications were given an acknowledgment form to sign and return, confirming that they understand they cannot combine pill bottles and must use each bottle until it is gone.”

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

Survey completed June 18, 2024: no correction orders issued.

Allegation, as written: “The facility neglected the resident when the resident was found on the floor surrounded by blood. She was admitted to the hospital.”

“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. Although the resident did fall and require hospitalization, the resident had not had recent falls and the facility put additional falls prevention interventions in placed after this fall. The resident returned the same day from the hospital after evaluation and treatment.”

Action taken by facility: “The facility reported the case to the Minnesota Adult Abuse Reporting Center and initiated an internal investigation. The service plan was updated, and re-education was provided to all staff.”

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

Survey completed June 18, 2024: no correction orders issued.