Pelican Landing Senior Living

Survey completed March 29, 2023: 7 correction orders

• Tag 130: 144G.12, Subd. 1 Application for Licensure Level 1, widespread scope, scope/level letter C · correction period: Two (2) days
  Details

  Summary: MDH found the licensee failed to hold an assisted living with dementia care license for their current capacity of residents.

  MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to hold an assisted living with dementia care license for their current capacity of residents. The assisted living with dementia care license effective August 1, 2022, indicated a capacity of 85 residents, however 89 residents resided at the facility. [...]”

  Rule cited: “Each application for an assisted living facility license, including provisional and renewal applications, must include information sufficient to show that the applicant meets the requirements of licensure, including: (1) the business name and legal entity [...]”

• Tag 470: 144G.41 Subdivision 1 Minimum requirements Level 3, widespread scope, scope/level letter I · correction period: Immediate
  Details

  Summary: MDH found the licensee failed to ensure the facility had sufficient staffing 24 hours per day to meet the scheduled and reasonably foreseeable unscheduled needs of each resident.

  MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure the facility had sufficient staffing 24 hours per day to meet the scheduled and reasonably foreseeable unscheduled needs of each resident. This had the potential to affect all residents, staff and visitors. [...]”

  Rule cited: “(11) develop and implement a staffing plan for determining its staffing level that: (i) includes an evaluation, to be conducted at least twice a year, of the appropriateness of staffing levels in the facility; (ii) ensures sufficient staffing at all times to [...]”

• Tag 480: 144G.41 Subd 1 (13) (i) (B) Minimum requirements Level 2, widespread scope, scope/level letter F · 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 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 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 1550: 144G.64 (a) TRAINING IN DEMENTIA CARE REQUIRED Level 2, isolated scope, scope/level letter D · correction period: Twenty-One (21) days
  Details

  Summary: MDH found the licensee failed to ensure employees that did not provide direct care, received at least four hours of initial training on dementia care within 160 working hours of the employment start date, for one of three employees (dietary assistant (DA)-G).

  MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure employees that did not provide direct care, received at least four hours of initial training on dementia care within 160 working hours of the employment start date, for one of three employees (dietary assistant (DA)-G). In addition, the licensee failed to ensure DA-G received two hours of annual dementia training. [...]”

  Rule cited: “(4) staff who do not provide direct care, including maintenance, housekeeping, and food service staff, must have at least four hours of initial training on topics specified under paragraph (b) within 160 working hours of the employment start date, and must [...]”

• Tag 2040: 144G.81 Subdivision 1 Fire protection and physical environment 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 conduct a hazard vulnerability or safety risk assessment on or around the facility property. This had the potential to directly affect all residents, staff, and visitors. [...]”

  Rule cited: “An assisted living facility with dementia care that has a secured dementia care unit must meet the requirements of section 144G.45 and the following additional requirements: (1) a hazard vulnerability assessment or safety risk must be performed on and around [...]”

• Tag 2070: 144G.81 Subd. 4 Awake staff requirement Level 3, widespread scope, scope/level letter I · correction period: IMMEDIATE
  Details

  Summary: MDH found the licensee failed to ensure one or more persons were physically present and available 24 hours a day, seven days a week, who were responsible for responding to requests for assistance with health and safety needs of residents in one of one secure memory care unit.

  MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure one or more persons were physically present and available 24 hours a day, seven days a week, who were responsible for responding to requests for assistance with health and safety needs of residents in one of one secure memory care unit. This had the potential to affect all 21 residents residing in the memory unit. [...]”

  Rule cited: “An assisted living facility with dementia care providing services in a secured dementia care unit must have an awake person who is physically present in the secured dementia care unit 24 hours per day, seven days per week, who is responsible for responding to [...]”

• Tag 2140: 144G.83 Subd. 3 Supervising staff training Level 2, widespread scope, scope/level letter F · correction period: Twenty-One (21) days
  Details

  Summary: MDH found the licensee failed to ensure the designated person overseeing staff training in the care of individuals with dementia, had documented evidence of competency or knowledge test required by the commissioner.

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the designated person overseeing staff training in the care of individuals with dementia, had documented evidence of competency or knowledge test required by the commissioner. This had the potential to affect all residents and staff of the facility. [...]”

  Rule cited: “Persons providing or overseeing staff training must have experience and knowledge in the care of individuals with dementia, including: (1) two years of work experience related to Alzheimer's disease or other dementias, or in health care, gerontology, or [...]”

From MDH’s letter: the letter says the facility is in substantial compliance.

Total fines assessed, as printed in the letter: $6,000.00.

Allegation, as written: “The facility neglected the resident when it failed to provide adequate supervision. The resident wandered into another resident's room and drank unsecured dish soap. The resident was hospitalized.”

“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 was hospitalized after drinking dish soap, the error was an isolated incident and the resident returned to his baseline health condition.”

Action taken by facility: “The facility reported the incident to MAARC. The facility directed staff to ensure caps on soap bottles were secured tightly.”

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

Survey completed December 17, 2024: no correction orders issued.