Pines III Assisted Living

Summary: MDH found the licensee failed to ensure employee records included all required content for one of three employees (interim clinical director(ICD)-B) with employee records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure employee records included all required content for one of three employees (interim clinical director(ICD)-B) with employee 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 conduct evacuation drills.

MDH’s finding, as written: “Based on record review and interview, the licensee failed to conduct evacuation drills. This had the potential to affect all 53 residents and staff. 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 of [...]”

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

Summary: MDH found the licensee failed to offer the resident the opportunity to identify a designated representative in writing for five of five residents (R3, R4, R1, R2, and R7) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to offer the resident the opportunity to identify a designated representative in writing for five of five residents (R3, R4, R1, R2, and R7) with records reviewed. This had the potential to affect al 53 residents. [...]”

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 employees received orientation to assisted living facility licensing requirements and regulations for two of three employees (unlicensed personnel (ULP)-D, and ULP-G) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure employees received orientation to assisted living facility licensing requirements and regulations for two of three employees (unlicensed personnel (ULP)-D, and ULP-G) 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 one of three direct-care employees (unlicensed personnel (ULP)-D) completed at least eight hours of initial dementia training with records reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure one of three direct-care employees (unlicensed personnel (ULP)-D) completed at least eight hours of initial dementia training with records reviewed. [...]”

Rule cited: “(3) for assisted living facilities with dementia care, direct-care employees must have completed at least eight hours of initial training on topics specified under paragraph (b) within 80 working hours of the employment start date. [...]”

Summary: MDH found the licensee failed to ensure the registered nurse (RN) assessed one of one resident (R3) with falls for causative factors to determine individualized interventions to reduce the resident's risk for injury with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the registered nurse (RN) assessed one of one resident (R3) with falls for causative factors to determine individualized interventions to reduce the resident's risk for injury with records reviewed. This resulted in an immediate correction order on December 16, 2021. [...]”

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 follow their written

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to follow their written policy pertaining to the counting of controlled medications for one of seven residents (R1) with records reviewed. [...]”

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) completed a reassessment of a resident's medication management services after medication changes for one of one resident (R1)with record reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the registered nurse (RN) completed a reassessment of a resident's medication management services after medication changes for one of one resident (R1)with record reviewed. [...]”

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 ensure individual medication management plans were followed and/or failed to ensure individual medication management plans contained all the required content for four of four residents (R6, R1, R2, and R7) with records reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure individual medication management plans were followed and/or failed to ensure individual medication management plans contained all the required content for four of four residents (R6, R1, R2, and R7) with records reviewed. [...]”

Rule cited: “(a) For each resident receiving medication management services, the assisted living facility must prepare and include in the service plan a written statement of the medication management services that will be provided to the resident. [...]”

Summary: MDH found the licensee failed to ensure medications were stored according to manufacturer's recommendations for one of five residents (R1) with records reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medications were stored according to manufacturer's recommendations for one of five residents (R1) with records reviewed. [...]”

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 a treatment management plan was developed for one of one resident (R1) receiving blood glucose monitoring with records reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure a treatment management plan was developed for one of one resident (R1) receiving blood glucose monitoring with records reviewed. [...]”

Rule cited: “For each resident receiving management of ordered or prescribed treatments or therapy services, the assisted living facility must prepare and include in the service plan a written statement of the treatment or therapy services that will be provided to the [...]”

MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide a hazard vulnerability or safety risk assessment that included hazards identified on and around the property. Mitigation of hazards to protect residents from harm was not included in the plan. This had the potential to affect all dementia care residents and staff. [...]”

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 [...]”