Paradise Assisted Living

MDH’s finding, as written: “No further action required.”

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 assisted living contract with all required content for two of two residents (R2, R3) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to execute a written assisted living contract with all required content for two of two residents (R2, R3) with records reviewed. [...]”

Rule cited: “(5) a description of the facility's policies related to medical assistance waivers under chapter 256S and section 256B.49 and the housing support program under chapter 256I, including: (i) whether the facility is enrolled with the commissioner of human [...]”

Summary: MDH found the licensee failed to ensure all staff received eight hours of initial dementia care training within the first 120 working hours of employment for supervisors of direct care staff as required for one of four employees (registered nurse (RN)-A) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure all staff received eight hours of initial dementia care training within the first 120 working hours of employment for supervisors of direct care staff as required for one of four employees (registered nurse (RN)-A) with records reviewed. [...]”

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 have a written emergency disaster preparedness plan with all required content.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to have a written emergency disaster preparedness plan with all required content. This had the potential to affect the licensee's resident, staff, and visitors. [...]”

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 [...]”

MDH’s finding, as written: “No further action required.”

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) [...]”

MDH’s finding, as written: “No further action required.”

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 [...]”

MDH’s finding, as written: “No further action required.”

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 [...]”

MDH’s finding, as written: “No further action required.”

Rule cited: “physical environment (b) Each assisted living facility shall develop and maintain fire safety and evacuation plans. [...]”

Summary: MDH found the licensee failed to execute a written assisted living contract with all required content for one of one resident (R2) with record reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to execute a written assisted living contract with all required content for one of one resident (R2) with record reviewed. [...]”

Rule cited: “(5) a description of the facility's policies related to medical assistance waivers under chapter 256S and section 256B.49 and the housing support program under chapter 256I, including: (i) whether the facility is enrolled with the commissioner of human [...]”

Summary: MDH found the licensee failed to ensure the assisted living contract included designation of representatives in writing with the required statutory language for one of one resident (R2) with record reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the assisted living contract included designation of representatives in writing with the required statutory language for one of one resident (R2) with record reviewed. [...]”

Rule cited: “(a) Before or at the time of execution of an assisted living contract, an assisted living facility must offer the resident the opportunity to identify a designated representative in writing in the contract and must provide the following verbatim notice on a [...]”

Summary: MDH found the licensee failed to ensure all required content of orientation was provided to three of three employees (registered nurse (RN)-A, unlicensed personnel (ULP)-C, ULP-E) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure all required content of orientation was provided to three of three employees (registered nurse (RN)-A, unlicensed personnel (ULP)-C, ULP-E) with records reviewed. [...]”

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 all staff received eight hours of initial dementia care training within the first 120 working hours of employment for supervisors of direct care staff and within the first 160 working hours of employment for direct care employees as required for three of three employees (registered nurse (RN)-A, unlicensed personnel (ULP)-C, ULP-E) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure all staff received eight hours of initial dementia care training within the first 120 working hours of employment for supervisors of direct care staff and within the first 160 working hours of employment for direct care employees as required for three of three employees (registered nurse (RN)-A, unlicensed personnel (ULP)-C, ULP-E) with records reviewed. [...]”

Rule cited: “REQUIRED (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 [...]”

Summary: MDH found the licensee failed to ensure the registered nurse completed a comprehensive reassessment using the uniform assessment tool for one of one resident (R2) as required with record reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the registered nurse completed a comprehensive reassessment using the uniform assessment tool for one of one resident (R2) as required with record reviewed. [...]”

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 service plan included the required content for one of one resident (R2) with record reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the service plan included the required content for one of one resident (R2) with record reviewed. 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 a widespread scope (when problems are pervasive or represent a systemic failure that has affected or has the potential to affect a large [...]”

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 to offer at least three nutritious meals daily, according to the recommended dietary allowances in the United Stated Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables, with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure to offer at least three nutritious meals daily, according to the recommended dietary allowances in the United Stated Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables, with records reviewed. The licensee also failed to post a menu a week in advance that was made available to all residents. This had the potential to affect all residents. [...]”

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 [...]”

Summary: MDH found the licensee failed to have a daily program of social and recreational activities based on individual and group interests, physical, mental, and psychosocial needs.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to have a daily program of social and recreational activities based on individual and group interests, physical, mental, and psychosocial needs. This had the potential to affect all residents residing at the facility. [...]”

Rule cited: “(ii) weekly housekeeping; (iii) weekly laundry service; (iv) upon the request of the resident, provide direct or reasonable assistance with arranging for transportation to medical and social services appointments, shopping, and other recreation, and provide [...]”

Summary: MDH found the licensee failed to establish and maintain an effective infection control program that complied with accepted health care, medical and nursing standards for infection control related to COVID-19, when they did not comply with MDH guidance for COVID-19 related to wearing appropriate PPE (personal protective equipment) and having a testing plan.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to establish and maintain an effective infection control program that complied with accepted health care, medical and nursing standards for infection control related to COVID-19, when they did not comply with MDH guidance for COVID-19 related to wearing appropriate PPE (personal protective equipment) and having a testing plan. This had the potential to affect all current 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. [...]”

Summary: MDH found the licensee failed to post the required information related to the grievance procedure and contact information for the Office of Ombudsman for Long-Term Care and Mental Health and Developmental Disabilities, as well as information for reporting suspected maltreatment to the Minnesota Adult Abuse Reporting Center (MAARC).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to post the required information related to the grievance procedure and contact information for the Office of Ombudsman for Long-Term Care and Mental Health and Developmental Disabilities, as well as information for reporting suspected maltreatment to the Minnesota Adult Abuse Reporting Center (MAARC). This had the potential to affect all the licensee's current residents, staff, and visitors. [...]”

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

Summary: MDH found the licensee failed to display the original current license at the main entrance of the assisted living facility as required.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to display the original current license at the main entrance of the assisted living facility as required. This had the potential to affect all of the licensee's current residents, staff and visitors. [...]”

Rule cited: “The original current license must be displayed at the main entrance of each assisted living facility. The facility must provide a copy of the license to any person who requests it.”

Summary: MDH found the licensee failed to implement and maintain a quality management program (QMP) appropriate to the size of the facility and relevant to the type of services provided.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to implement and maintain a quality management program (QMP) appropriate to the size of the facility and relevant to the type of services provided. This had the potential to affect all current residents, staff, and visitors. [...]”

Rule cited: “The facility shall engage in quality management appropriate to the size of the facility and relevant to the type of services provided. [...]”

Summary: MDH found the licensee failed to immediately report to the Minnesota Adult Abuse Reporting Center (MAARC) suspected maltreatment/self-neglect or complete a thorough investigation for two of two residents (R1, R2) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to immediately report to the Minnesota Adult Abuse Reporting Center (MAARC) suspected maltreatment/self-neglect or complete a thorough investigation for two of two residents (R1, R2) with records reviewed. [...]”

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. [...]”

Summary: MDH found the licensee failed to ensure an individual abuse prevention plan was developed to include the

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure an individual abuse prevention plan was developed to include the required content for two of two residents (R1, R2) with records reviewed. [...]”

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

Summary: MDH found the licensee failed to support protection and safety by not posting information and phone numbers for reporting to the Minnesota Adult Abuse Reporting Center (MAARC) and failed to post the 911 emergency number in common areas and near telephones provided by the assisted living facility.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to support protection and safety by not posting information and phone numbers for reporting to the Minnesota Adult Abuse Reporting Center (MAARC) and failed to post the 911 emergency number in common areas and near telephones provided by the assisted living facility. This had the potential to affect all residents, staff, and visitors. [...]”

Rule cited: “The facility shall support protection and safety through access to the state's systems for reporting suspected criminal activity and suspected vulnerable adult maltreatment by: (1) posting the 911 emergency number in common areas and near telephones provided [...]”

Summary: MDH found the licensee failed to ensure current employee records were maintained to include all required content for two of two employees (registered nurse (RN)-A and unlicensed personnel (ULP)-C) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure current employee records were maintained to include all required content for two of two employees (registered nurse (RN)-A and unlicensed personnel (ULP)-C) with records reviewed. [...]”

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 ensure the provider established and maintained a tuberculosis (TB) prevention program, based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC) current screening for active or latent TB for one of two employees (registered nurse (RN)-A).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the provider established and maintained a tuberculosis (TB) prevention program, based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC) current screening for active or latent TB for one of two employees (registered nurse (RN)-A). In addition, the licensee failed to ensure TB training was completed for one of two employees (unlicensed personnel (ULP)-C) with records reviewed. [...]”

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 [...]”

MDH’s finding, as written: “Based on observation, interview and record review the licensee failed to have a written emergency preparedness plan with all the required content as defined in Appendix Z, with record review. [...]”

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 provide interconnection of smoke alarms

MDH’s finding, as written: “Based on observation and interview, the licensee failed to provide interconnection of smoke alarms for resident bedrooms #1 and #2 as required by Minnesota Statutes, 144G.45, Subd. 2. This has 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 maintain portable fire extinguishers in accordance with the State Fire Code as required by MN Statute 144G.45 Subd(a)(2).

MDH’s finding, as written: “Based on observation and interview, the licensee failed to maintain portable fire extinguishers in accordance with the State Fire Code as required by MN Statute 144G.45 Subd(a)(2). This had the potential to directly affect all residents and staff. [...]”

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 [...]”

Summary: MDH found the licensee failed to maintain the physical environment of the facility in a continuous state of good repair and operation.

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

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 provide the required documentation on fire safety and evacuation plans, training, and evacuation drills.

MDH’s finding, as written: “Based on observation, record review, and interview, the licensee failed to provide the required documentation on fire safety and evacuation plans, training, and evacuation drills. This has the potential to directly affect the safety of all residents receiving assisted living care, 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 develop and execute a written contract with the required content to provided assisted living services for two of two residents (R1, R2) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to develop and execute a written contract with the required content to provided assisted living services for two of two residents (R1, R2) with records reviewed. The licensee also failed to provide to the Office of Ombudsman for Long-Term Care a complete unsigned copy of its contract. This has the potential to affect all residents. [...]”

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 offer two of two residents (R1, R2) the opportunity to identify a designated representative with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to offer two of two residents (R1, R2) the opportunity to identify a designated representative with records reviewed. [...]”

Rule cited: “(a) Before or at the time of execution of an assisted living contract, an assisted living facility must offer the resident the opportunity to identify a designated representative in writing in the contract and must provide the following verbatim notice on a [...]”

Summary: MDH found the licensee failed to ensure a background study was completed as required for one of two employees (registered nurse (RN)-A) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure a background study was completed as required for one of two employees (registered nurse (RN)-A) 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. [...]”

Summary: MDH found the licensee failed to ensure training and competency was completed for one of one employee, unlicensed personnel ((ULP)-C) to include all required content with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure training and competency was completed for one of one employee, unlicensed personnel ((ULP)-C) to include all required content with records reviewed. [...]”

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 was completed for one of one employee, unlicensed personnel ((ULP)-C) to include all required content with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure training and competency was completed for one of one employee, unlicensed personnel ((ULP)-C) to include all required content with records reviewed. [...]”

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 direct supervision of staff performing delegated tasks was provided within 30 calendar days after the date on which the individual began working for the licensee for one of one unlicensed personnel ((ULP)-C) with records reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure direct supervision of staff performing delegated tasks was provided within 30 calendar days after the date on which the individual began working for the licensee for one of one unlicensed personnel ((ULP)-C) with records reviewed. [...]”

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 all required content of orientation was provided to two of two employees (registered nurse (RN)-A and unlicensed personnel (ULP)-C).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure all required content of orientation was provided to two of two employees (registered nurse (RN)-A and unlicensed personnel (ULP)-C). [...]”

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 all staff received dementia care as required for two of two employees (registered nurse (RN)-A and unlicensed personnel (ULP)-C).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure all staff received dementia care as required for two of two employees (registered nurse (RN)-A and unlicensed personnel (ULP)-C). [...]”

Rule cited: “All direct care staff and supervisors providing direct services must demonstrate an understanding of the training specified in section 144G.64.”

Summary: MDH found the licensee failed to ensure all employees had at least eight hours of annual training for each 12 months of employment that included the required content for two of two employees (registered nurse (RN)-A, unlicensed personnel (ULP)-C) with employee records reviewed.

MDH’s finding, as written: “Based on interview and document review, the licensee failed to ensure all employees had at least eight hours of annual training for each 12 months of employment that included the required content for two of two employees (registered nurse (RN)-A, unlicensed personnel (ULP)-C) with employee records reviewed. This had the potential to affect all of the licensee's residents. [...]”

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 timely comprehensive reassessment using the uniform assessment tool for two of two residents (R1, R2) as required with records reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) completed a timely comprehensive reassessment using the uniform assessment tool for two of two residents (R1, R2) as required with records reviewed. [...]”

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 service plan included the required content for two of two residents (R1, R2) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the service plan included the required content for two of two residents (R1, R2) with records reviewed. [...]”

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 immediately report to the Minnesota Adult Abuse Reporting Center (MAARC) suspected maltreatment/self-neglect or complete a thorough investigation for two of two residents (R1, R2) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to immediately report to the Minnesota Adult Abuse Reporting Center (MAARC) suspected maltreatment/self-neglect or complete a thorough investigation for two of two residents (R1, R2) with records reviewed. [...]”

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 [...]”