Ostrander Assisted Living

Summary: MDH found the licensee failed to practice and document testing of it's emergency preparedness (EP) plan at least twice annually as required, post an emergency disaster plan prominently, have a written EP plan with all the required content, and evaluate its missing person policy at least quarterly.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to practice and document testing of it's emergency preparedness (EP) plan at least twice annually as required, post an emergency disaster plan prominently, have a written EP plan with all the required content, and evaluate its missing person policy at least quarterly. This had the potential to affect all residents, staff, and visitors of 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 ensure the resident record included a discharge summary with the required content for one of one discharged resident (R2).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the resident record included a discharge summary with the required content for one of one discharged resident (R2). [...]”

Rule cited: “Contents of a resident record include the following for each resident: (1) identifying information, including the resident's name, date of birth, address, and telephone number; (2) the name, address, and telephone number of the resident's emergency contact, [...]”

Summary: MDH found the licensee failed to provide smoke alarms that complied with fire protection requirements.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to provide smoke alarms that complied with fire protection requirements. This had the potential to directly affect all residents, staff, and visitors. [...]”

Rule cited: “(a) Each assisted living facility must comply with the State Fire Code in Minnesota Rules, chapter 7511, and: (1) for dwellings or sleeping units, as defined in the State Fire Code: (i) provide smoke alarms in each room used for sleeping purposes; (ii) [...]”

Summary: MDH found the licensee failed to complete fire safety and evacuation training with residents and

MDH’s finding, as written: “Based on record review and interview, the licensee failed to complete fire safety and evacuation training with residents and employees. This had the potential to 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 execute a written contract with the required content for the individual(s) who resided in apartment 105 of the licensee's assisted living facility.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to execute a written contract with the required content for the individual(s) who resided in apartment 105 of the licensee's assisted living facility. [...]”

Rule cited: “(a) An assisted living facility may not offer or provide housing or assisted living services to any individual unless it has executed a written contract with the resident. [...]”

Summary: MDH found the licensee failed to provide a written notice with

MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide a written notice with required content for an emergency relocation and failed to notify the Office of Ombudsman for Long-Term Care of the emergency relocation for one of one resident (R3). [...]”

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 submitted and received in affiliation with the assisted living license for one of one employee (licensed practical nurse (LPN)-D).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure a background study was submitted and received in affiliation with the assisted living license for one of one employee (licensed practical nurse (LPN)-D). [...]”

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. [...]”

Summary: MDH found the licensee failed to ensure one of one employee (licensed practical nurse (LPN-D) received orientation to assisted living facility licensing requirements and regulations before providing services.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure one of one employee (licensed practical nurse (LPN-D) received orientation to assisted living facility licensing requirements and regulations before providing services. [...]”

Rule cited: “(a) The orientation must contain the following topics: (1) an overview of this chapter; (2) an introduction and review of the facility's policies and procedures related to the provision of assisted living services by the individual staff person; (3) handling [...]”

Summary: MDH found the licensee failed to ensure annual training included all required topics for each 12 months of employment for one of one employee (licensed practical nurse (LPN)-D).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure annual training included all required topics for each 12 months of employment for one of one employee (licensed practical nurse (LPN)-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 the registered nurse (RN) completed a reassessment not to exceed 90 days for one of one resident (R1).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the registered nurse (RN) completed a reassessment not to exceed 90 days for one of one resident (R1). [...]”

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 a service plan included the required content for one of one resident (R1).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure a service plan included the required content for one of one resident (R1). 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 is issued at a widespread scope (when problems are pervasive or represent a systemic failure that has [...]”

Rule cited: “(f) The service plan must include: (1) a description of the services to be provided, the fees for services, and the frequency of each service, according to the resident's current assessment and resident preferences; (2) the identification of staff or [...]”

Summary: MDH found the licensee failed to ensure the registered nurse (RN) conducted a face-to-face medication management assessment to include all required content for one of one resident (R1) prior to providing medication management services.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) conducted a face-to-face medication management assessment to include all required content for one of one resident (R1) prior to providing medication management services. [...]”

Rule cited: “(a) For each resident who requests medication management services, the facility shall, prior to providing medication management services, have a registered nurse, licensed health professional, or authorized prescriber under section 151.37 conduct an [...]”