Peterson Colonial Homes 2

Summary: MDH found the licensee failed to ensure the physical environment of the facility was maintained in compliance with the requirements of Minnesota Statute 144G.

MDH’s finding, as written: “Based on observation, record review, and interview, the licensee failed to ensure the physical environment of the facility was maintained in compliance with the requirements of Minnesota Statute 144G. [...]”

Rule cited: “Each assisted living facility must comply with the State Fire Code in Minnesota Rules, chapter 7511, and:”

Summary: MDH found the licensee failed to ensure the physical environment of the facility was maintained in compliance with the requirements of Minnesota Statute 144G.

MDH’s finding, as written: “Based on observation, record review, and interview, the licensee failed to ensure the physical environment of the facility was maintained in compliance with the requirements of Minnesota Statute 144G. [...]”

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 ensure the physical environment of the facility was maintained in compliance with the requirements of Minnesota Statute 144G.

MDH’s finding, as written: “Based on observation, record review, and interview, the licensee failed to ensure the physical environment of the facility was maintained in compliance with the requirements of Minnesota Statute 144G. [...]”

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 ensure the physical environment of the facility was maintained in compliance with the requirements of Minnesota Statute 144G.

MDH’s finding, as written: “Based on observation, record review, and interview, the licensee failed to ensure the physical environment of the facility was maintained in compliance with the requirements of Minnesota Statute 144G. [...]”

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

Summary: MDH found the licensee failed to ensure current employee records contained all the required content to include a background study clearance letter for four of ten employees (unlicensed personnel (ULP)-D, ULP-E, ULP-F, ULP-G).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure current employee records contained all the required content to include a background study clearance letter for four of ten employees (unlicensed personnel (ULP)-D, ULP-E, ULP-F, ULP-G). In addition, the licensee failed to ensure background studies were affiliated with the correct health facility identification (HFID) for three of ten employees ULP-H, ULP-I, ULP-J. [...]”

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 evaluations were completed as required prior to providing direct care services for one of one unlicensed personnel (ULP-K).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure training and competency evaluations were completed as required prior to providing direct care services for one of one unlicensed personnel (ULP-K). [...]”

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 were completed as required prior to providing direct care services for one of one unlicensed personnel (ULP-K).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure training and competency evaluations were completed as required prior to providing direct care services for one of one unlicensed personnel (ULP-K). [...]”

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 had begun working for the licensee for one of one unlicensed personnel (ULP)-K.

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 had begun working for the licensee for one of one unlicensed personnel (ULP)-K. [...]”

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 employees received orientation to assisted living requirements and regulations prior to providing services for one of two employees (clinical nurse supervisor (CNS) -B).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure employees received orientation to assisted living requirements and regulations prior to providing services for one of two employees (clinical nurse supervisor (CNS) -B). [...]”

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 direct care staff received the required two hours of initial training on mental illness and de-escalation topics for two of three employees (clinical nurse supervisor (CNS) -B, (unlicensed personnel (ULP)-D).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure direct care staff received the required two hours of initial training on mental illness and de-escalation topics for two of three employees (clinical nurse supervisor (CNS) -B, (unlicensed personnel (ULP)-D). In addition, the licensee failed to ensure one of three employees (CNS-B) received the required amount of dementia care training in the required time frame. [...]”

Rule cited: “(a) All assisted living facilities must meet the following dementia care, mental illness, and de-escalation training requirements: (1) supervisors of direct-care staff must have at least eight hours of initial training on dementia topics specified under [...]”

Summary: MDH found the licensee failed to ensure one of one

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure one of one employee (housekeeping (HSKP) -G) received the required amount of dementia, mental illness, and de-escalation in the required time frame. [...]”

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), clauses (1) to (5), and two hours of initial training on mental [...]”

Summary: MDH found the licensee failed to ensure the registered nurse (RN) conducted ongoing comprehensive nursing assessments not to exceed every 90 days for three of three residents (R2, R3, R4).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) conducted ongoing comprehensive nursing assessments not to exceed every 90 days for three of three residents (R2, R3, R4). [...]”

Rule cited: “(a) Residents who are not receiving any assisted living services shall not be required to undergo an initial nursing assessment. [...]”

Summary: MDH found the licensee failed to ensure the service plan was revised to reflect current services provided for one of two residents (R2).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the service plan was revised to reflect current services provided for one of two residents (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 accountability of controlled substances was maintained by failure to implement the policy and procedure for five of five residents (R4, R5, R8, R9, R10) who received controlled medication storage.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure accountability of controlled substances was maintained by failure to implement the policy and procedure for five of five residents (R4, R5, R8, R9, R10) who received controlled medication storage. [...]”

Rule cited: “(a) This section applies only to assisted living facilities that provide medication management services. [...]”

Summary: MDH found the licensee failed to ensure the registered nurse (RN) prepared in writing specific instructions for one of one resident (R2) who received medication management services.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) prepared in writing specific instructions for one of one resident (R2) who received medication management services. [...]”

Rule cited: “When administration of medications is delegated to unlicensed personnel, the assisted living facility must ensure that the registered nurse has: (1) instructed the unlicensed personnel in the proper methods to administer the medications, and the unlicensed [...]”

Summary: MDH found the licensee failed to ensure refrigerated medications were maintained at manufacturer recommended temperatures by failing to monitor and document medication refrigerator temperatures for one of one medication refrigerator.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure refrigerated medications were maintained at manufacturer recommended temperatures by failing to monitor and document medication refrigerator temperatures for one of one medication refrigerator. [...]”

Rule cited: “An assisted living facility must store all prescription medications in securely locked and substantially constructed compartments according to the manufacturer's directions and permit only authorized personnel to have access.”

Summary: MDH found the licensee failed to ensure medications were maintained bearing the original prescription label with information regarding the direction for

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medications were maintained bearing the original prescription label with information regarding the direction for use, medication name, medication dosage, resident's name, and the pharmacy in which it had been issued. [...]”

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 failed to document in the resident record all of the required content in the disposition of medications for one of one resident (R1) upon discharge.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to document in the resident record all of the required content in the disposition of medications for one of one resident (R1) upon discharge. [...]”

Rule cited: “(a) Any current medications being managed by the assisted living facility must be provided to the resident when the resident's service plan ends or medication management services are no longer part of the service plan. [...]”

Summary: MDH found the licensee failed to ensure the registered nurse (RN) specified, in writing, specific instructions for each resident and documented those instructions in the resident's record for one of two residents (R2) who received treatment and therapy services.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) specified, in writing, specific instructions for each resident and documented those instructions in the resident's record for one of two residents (R2) who received treatment and therapy services. [...]”

Rule cited: “Ordered or prescribed treatments or therapies must be administered by a nurse, physician, or other licensed health professional authorized to perform the treatment or therapy, or may be delegated or assigned to unlicensed personnel by the licensed health [...]”

Summary: MDH found the licensee failed to ensure the required signage was posted at the main entry way of the establishment to display statutory language to disclose electronic monitoring activity, potentially affecting all current residents in the assisted living facility, staff, and any visitors to the facility.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the required signage was posted at the main entry way of the establishment to display statutory language to disclose electronic monitoring activity, potentially affecting all current residents in the assisted living facility, staff, and any visitors to the facility. [...]”

Rule cited: “(a) A facility must post a sign at each facility entrance accessible to visitors that states: "Electronic monitoring devices, including security cameras and audio devices, may be present to record persons and activities. [...]”