Obed-Edom Assisted Living

Summary: MDH found the licensee failed to ensure employee records included all required content for two of two employees (unlicensed personnel (ULP)-C and ULP-D).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure employee records included all required content for two of two employees (unlicensed personnel (ULP)-C and ULP-D). [...]”

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. [...]”

Summary: MDH found the licensee failed to establish and

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to establish and maintain a tuberculosis (TB) prevention and control program, based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC), to include an updated facility TB risk assessment. [...]”

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 a written emergency preparedness (EP) plan with all the required content.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop a written emergency preparedness (EP) plan 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 maintain the facility physical environment

MDH’s finding, as written: “Based on observation and interview, the licensee failed to maintain the facility physical environment in a continuous state of good repair and operation regarding the health, safety, and well-being of the residents. This had the potential to directly affect some of the residents, staff, 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 [...]”

Summary: MDH found the licensee failed to develop a fire safety and evacuation plan with required elements.

MDH’s finding, as written: “Based on a record review and interview, the licensee failed to develop a fire safety and evacuation plan with required elements. This had the potential to affect all staff, residents, 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 training and competency evaluations were completed for all required skill areas, prior to providing services, for two of two employees (unlicensed personnel (ULP)-C and ULP-D).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure training and competency evaluations were completed for all required skill areas, prior to providing services, for two of two employees (unlicensed personnel (ULP)-C and ULP-D). [...]”

Rule cited: “(a) Training and competency evaluations for all unlicensed personnel must include the following: (1) documentation requirements for all services provided; (2) reports of changes in the resident's condition to the supervisor designated by the facility; (3) [...]”

Summary: MDH found the licensee failed to ensure training and competency evaluations for the required topics were completed for two of two employees (unlicensed personnel (ULP)-C and ULP-D).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure training and competency evaluations for the required topics were completed for two of two employees (unlicensed personnel (ULP)-C and ULP-D). [...]”

Rule cited: “(b) In addition to paragraph (a), training and competency evaluation for unlicensed personnel providing assisted living services must include: (1) observing, reporting, and documenting resident status; (2) basic knowledge of body functioning and changes in [...]”

Summary: MDH found the licensee failed to ensure a registered nurse completed delegated task supervision within 30 calendar days for two of two employees (unlicensed personnel (ULP)-C and ULP-D) who performed delegated tasks.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure a registered nurse completed delegated task supervision within 30 calendar days for two of two employees (unlicensed personnel (ULP)-C and ULP-D) who performed delegated tasks. [...]”

Rule cited: “(a) Staff who perform delegated nursing or therapy tasks must be supervised by an appropriate licensed health professional or a registered nurse according to the assisted living facility's policy where the services are being provided to verify that the work [...]”

Summary: MDH found the licensee failed to ensure annual training included all required topics for each 12 months of employment for two of two employees (unlicensed personnel (ULP)-C and ULP-D).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure annual training included all required topics for each 12 months of employment for two of two employees (unlicensed personnel (ULP)-C and ULP-D). [...]”

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 a registered nurse (RN) conducted ongoing 14-day resident reassessment for one of two residents (R1) and failed to conduct ongoing nursing assessments not to exceed 90 calendar days and failed to use the uniform assessment tool for two of two residents (R1, and R2).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure a registered nurse (RN) conducted ongoing 14-day resident reassessment for one of two residents (R1) and failed to conduct ongoing nursing assessments not to exceed 90 calendar days and failed to use the uniform assessment tool for two of two residents (R1, and 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 the current service plan included a signature or other authentication by the resident to document agreement on the services to be provided for two of two residents (R1 and R2).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the current service plan included a signature or other authentication by the resident to document agreement on the services to be provided for two of two residents (R1 and R2). [...]”

Rule cited: “(a) No later than 14 calendar days after the date that services are first provided, an assisted living facility shall finalize a current written service plan. [...]”

Summary: MDH found the licensee failed to ensure the registered nurse (RN) completed annual medication re-assessments for two of two residents (R1 and R2).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the registered nurse (RN) completed annual medication re-assessments for two of two residents (R1 and R2). [...]”

Rule cited: “The assisted living facility must monitor and reassess the resident's medication management services as needed under subdivision 2 when the resident presents with symptoms or other issues that may be medication-related and, at a minimum, annually.”

Summary: MDH found the licensee failed to discuss with the resident the possible consequences of the resident's medication refusal and document the discussion in the resident's record for two of four residents (R1 and R2) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to discuss with the resident the possible consequences of the resident's medication refusal and document the discussion in the resident's record for two of four residents (R1 and R2) with records reviewed. [...]”

Rule cited: “The assisted living facility must document in the resident's record any refusal for an assessment for medication management by the resident. [...]”

Summary: MDH found the licensee failed to ensure documentation of medication setup included all the required content for one of one resident (R2).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure documentation of medication setup included all the required content for one of one resident (R2). [...]”

Rule cited: “Documentation of dates of medication setup, name of medication, quantity of dose, times to be administered, route of administration, and name of person completing medication setup must be done at the time of setup.”

Summary: MDH found the licensee failed to develop and implement policies and procedures for giving accurate and current medications for those residents who received medication management services during planned times away from home.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop and implement policies and procedures for giving accurate and current medications for those residents who received medication management services during planned times away from home. This had the potential to affect five residents receiving medication management services. [...]”

Rule cited: “(a) An assisted living facility that is providing medication management services to the resident must develop and implement policies and procedures for giving accurate and current medications to residents for planned or unplanned times away from home [...]”

Summary: MDH found the licensee failed to ensure written or electronically recorded prescriptions were obtained for two of two residents (R1 and R4).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure written or electronically recorded prescriptions were obtained for two of two residents (R1 and R4). [...]”

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.”

Summary: MDH found the licensee failed to ensure prescriptions were renewed at least every 12 months for two of two residents (R1 and R2).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure prescriptions were renewed at least every 12 months for two of two residents (R1 and 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, 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: “Prescriptions must be renewed at least every 12 months or more frequently as indicated by the assessment in subdivision 2. Prescriptions for controlled substances must comply with chapter 152.”

Summary: MDH found the licensee failed to ensure written or electronically recorded prescriptions were communicated to the registered nurse (RN) for one of one resident (R1).

MDH’s finding, as written: “Based on interview, and record review, the licensee failed to ensure written or electronically recorded prescriptions were communicated to the registered nurse (RN) for one of one resident (R1). [...]”

Rule cited: “When a written or electronic prescription is received, it must be communicated to the registered nurse in charge and recorded or placed in the resident's record.”

Summary: MDH found the licensee failed to discard expired medication for one of four residents (R4).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to discard expired medication for one of four residents (R4). 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: “A prescription drug, prior to being set up for immediate or later administration, must be kept in the original container in which it was dispensed by the pharmacy bearing the original prescription label with legible information including the expiration or [...]”

Summary: MDH found the licensee limited the rights of residents when the licensee required all residents who resided in the facility to follow certain house rules.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee limited the rights of residents when the licensee required all residents who resided in the facility to follow certain house rules. [...]”

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 unlicensed personnel (ULP) followed appropriate medication administration procedures for one of one employee (ULP-C), observed during medication administration.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure unlicensed personnel (ULP) followed appropriate medication administration procedures for one of one employee (ULP-C), observed during medication administration. [...]”

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 [...]”

Summary: MDH found the licensee failed to respect the resident's right to receive visits at any time.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to respect the resident's right to receive visits at any time. This had the potential to affect all residents at the facility. [...]”

Rule cited: “(a) Residents have the right to meet with or receive visits at any time by the resident's family, guardian, conservator, health care agent, attorney, advocate, or religious or social work counselor, or any person of the resident's choosing. [...]”