Pleasant Assisted Living, Brunswick Avenue North

Summary: MDH found the licensee failed to have daily programs of social and recreational activities based on individual and group interests, physical, mental, and psychosocial needs, that created opportunities for active participation in the community at large.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to have daily programs of social and recreational activities based on individual and group interests, physical, mental, and psychosocial needs, that created opportunities for active participation in the community at large. This had the potential to affect all residents of the facility. [...]”

Rule cited: “All assisted living facilities must offer to provide or make available the following services to residents: (1) weekly housekeeping; (2) weekly laundry service; (3) upon the request of the resident, provide direct or reasonable assistance with arranging for [...]”

Summary: MDH found the licensee failed to provide staff access to a licensed registered nurse (RN) 24 hours a day, seven days per week, when the licensee hired licensed assisted living director/clinical nurse supervisor (LALD/CNS) -A to perform all nursing tasks and the LALD/CNS-A simultaneously enrolled in a nursing master's degree program that required LALD/CNS-A to complete clinical hours which would not allow them to be available 24 hours per day, 7 days per week, to address the licensee's emergencies or concerns.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to provide staff access to a licensed registered nurse (RN) 24 hours a day, seven days per week, when the licensee hired licensed assisted living director/clinical nurse supervisor (LALD/CNS) -A to perform all nursing tasks and the LALD/CNS-A simultaneously enrolled in a nursing master's degree program that required LALD/CNS-A to complete clinical hours which would not allow them to be available 24 hours per day, 7 days per [...]”

Rule cited: “(13) provide staff access to an on-call registered nurse 24 hours per day, seven days per week.”

Summary: MDH found the licensee failed to establish and maintain an infection control program that complied with accepted health care, medical and nursing standards for infection control.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to establish and maintain an infection control program that complied with accepted health care, medical and nursing standards for infection control. The deficient practice had the potential to affect residents, employees, 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 display the original current license at the main entrances of the assisted living facility that indicated each address on the campus 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 entrances of the assisted living facility that indicated each address on the campus as required. This had the potential to affect all 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 provide a written policy or procedure on reporting maltreatment for two of seven residents (R1, R7).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to provide a written policy or procedure on reporting maltreatment for two of seven residents (R1, R7). [...]”

Rule cited: “(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 develop an individual abuse prevention plan (IAPP) for two of seven residents (R1, R7).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to develop an individual abuse prevention plan (IAPP) for two of seven residents (R1, R7). 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 was issued at a widespread scope (when problems are pervasive or represent a systemic [...]”

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 ensure employee records included all required content for one of two employees (unlicensed personnel (ULP)-B).

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 two employees (unlicensed personnel (ULP)-B). [...]”

Rule cited: “(a) The facility must maintain current records of each paid staff member, each regularly scheduled volunteer providing services, and each individual contractor providing services. [...]”

Summary: MDH found the licensee failed to have a written emergency preparedness plan (EPP) with all the required content.

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

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: “Based on interview and record review, the licensee failed to ensure entries in the resident records were authenticated with the name and title of the person making the entry for one of seven residents (R1). [...]”

Rule cited: “(a) Assisted living facilities must maintain records for each resident for whom it is providing services. [...]”

Summary: MDH found the licensee failed to ensure a resident record was developed, implemented, and maintained for two of seven residents (R1, R7).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure a resident record was developed, implemented, and maintained for two of seven residents (R1, R7). [...]”

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 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, interview, and record review, 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, interview, and record review, 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, interview, and record review, 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, interview, and record review, 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 follow applicable state and local laws, regulations, standards,

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to follow applicable state and local laws, regulations, standards, ordinances, and codes related to smoking for four of seven residents (R2, R3, R4, R5). [...]”

Rule cited: “Assisted living facilities shall comply with all applicable state and local governing laws, regulations, standards, ordinances, and codes for fire safety, building, and zoning requirements, except a facility with a licensed resident capacity of six or fewer [...]”

Summary: MDH found the licensee failed to execute a written assisted living contract prior to providing services for two of seven residents (R1, R7).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to execute a written assisted living contract prior to providing services for two of seven residents (R1, R7). [...]”

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 the opportunity to identify a representative in writing for two of seven residents (R1, R7).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to offer the opportunity to identify a representative in writing for two of seven residents (R1, R7). [...]”

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 employees received two hours of mental illness and de-escalation training within the first 160 working hours of employment for direct care employees as required for two of two employees (unlicensed personnel (ULP)-B, ULP-C).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure all employees received two hours of mental illness and de-escalation training within the first 160 working hours of employment for direct care employees as required for two of two employees (unlicensed personnel (ULP)-B, ULP-C). [...]”

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 a registered nurse (RN) conducted an initial physical and cognitive assessment on or before the move-in date for two of seven residents (R1, R7).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure a registered nurse (RN) conducted an initial physical and cognitive assessment on or before the move-in date for two of seven residents (R1, R7). [...]”

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 develop a temporary service plan when services are initiated for a new resident prior to completion of the individualized resident assessment for one of seven residents (R1).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop a temporary service plan when services are initiated for a new resident prior to completion of the individualized resident assessment for one of seven residents (R1). [...]”

Rule cited: “When a facility initiates services and the individualized assessment required in subdivision 2 has not been completed, the facility must complete a temporary plan and agreement with the resident for services. [...]”

Summary: MDH found the licensee failed to finalize a written service plan (SP) within 14 calendar days after the initiation of services for one of seven residents (R7).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to finalize a written service plan (SP) within 14 calendar days after the initiation of services for one of seven residents (R7). [...]”

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 residents' service plans included all required content for two of five residents (R3, R4).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure residents' service plans included all required content for two of five residents (R3, R4). 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 was issued at a pattern scope (when more than a limited number of residents are affected, [...]”

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) completed initial assessments for medication management services for two of seven residents (R1, R7).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) completed initial assessments for medication management services for two of seven residents (R1, R7). [...]”

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 [...]”

Summary: MDH found the licensee failed to develop an individualized medication management record for two of seven residents (R1, R7).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to develop an individualized medication management record for two of seven residents (R1, R7). 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 was issued at a widespread scope (when problems are pervasive or represent a [...]”

Rule cited: “(a) For each resident receiving medication management services, a registered nurse, advanced practice registered nurse, or qualified staff delegated the task by a registered nurse must prepare and include in the service plan a written statement of the [...]”

Summary: MDH found the licensee failed to ensure written or electronically recorded prescriptions were obtained for one of seven residents (R1).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure written or electronically recorded prescriptions were obtained for one of seven residents (R1). [...]”

Rule cited: “There must be a current written or electronically recorded prescription as defined in section 151.01, subdivision 16a, for all prescribed medications that the assisted living facility is managing for the resident.”

Summary: MDH found the licensee failed to ensure prescriptions were renewed at least every 12 months for one of five residents (R3).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure prescriptions were renewed at least every 12 months for one of five residents (R3). 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 was issued at an isolated scope (when one or a limited number of residents are affected or one or a [...]”

Rule cited: “Prescriptions must be renewed at least every 12 months or more frequently as indicated by the assessment in subdivision 2. Prescriptions for controlled substances must comply with chapter 152.”

Summary: MDH found the licensee failed to develop a treatment or therapy management plan for one of seven residents (R1).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop a treatment or therapy management plan for one of seven residents (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 was issued at a widespread scope (when problems are pervasive or represent a systemic failure that has [...]”

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 [...]”

Summary: MDH found the licensee failed to obtain a treatment or therapy management prescriber's order for one of seven residents (R1).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to obtain a treatment or therapy management prescriber's order for one of seven residents (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 was issued at a widespread scope (when problems are pervasive or represent a systemic failure [...]”

Rule cited: “There must be an up-to-date written or electronically recorded order from an authorized prescriber for all treatments and therapies. [...]”

Summary: MDH found the licensee failed to ensure the required notice was posted at the main entryway of the establishment to display statutory language to disclose electronic monitoring activity, potentially

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the required notice was posted at the main entryway 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. [...]”