Procare Health

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

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: “No further action required.”

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: “(b) Resident records, whether written or electronic, must be protected against loss, tampering, or unauthorized disclosure in compliance with chapter 13 and other applicable relevant federal and state laws. [...]”

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

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, [...]”

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 [...]”

Summary: MDH found the licensee failed to provide facilities that were not a distinct hazard to life.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to provide facilities that were not a distinct hazard to life. This had the potential to directly affect all of the residents and staff. [...]”

Rule cited: “(g) Existing construction or elements, including assisted living facilities that were registered as housing with services establishments under chapter 144D prior to August 1, 2021, shall be permitted to continue in use provided such use does not constitute a [...]”

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

Rule cited: “The contract must not include a waiver of facility liability for the health and safety or personal property of a resident. [...]”

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

Rule cited: “(a) A facility may initiate an expedited termination of housing or services if: (1) the resident has engaged in conduct that substantially interferes with the rights, health, or safety of other residents; (2) the resident has engaged in conduct that [...]”

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

Rule cited: “(a) A facility terminating a contract must issue a written notice of termination according to this section. [...]”

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

Rule cited: “(a) A facility may remove a resident from the facility in an emergency if necessary due to a resident's urgent medical needs or an imminent risk the resident poses to the health or safety of another facility resident or facility staff member. [...]”

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

Rule cited: “All staff providing and supervising direct services must complete an orientation to assisted living facility licensing requirements and regulations before providing assisted living services to residents. [...]”

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

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 [...]”

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

Rule cited: “(c) Resident reassessment and monitoring must be conducted no more than 14 calendar days after initiation of services. [...]”

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

Rule cited: “Each medication administered by the assisted living facility staff must be documented in the resident's record. The documentation must include the signature and title of the person who administered the medication. [...]”

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

Rule cited: “(2) for unplanned time away, when the pharmacy is not able to provide the medications, a licensed nurse or unlicensed personnel shall provide medications in amounts and dosages needed for the length of the anticipated absence, not to exceed seven calendar [...]”

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

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.”

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

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. [...]”

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

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." (b) The facility is responsible for [...]”

Summary: MDH found the licensee 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 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 maintain a tuberculosis (TB) prevention and control program, based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC), which included a two-step tuberculin skin test (TST) or other evidence of TB screening such as a blood

MDH’s finding, as written: “Based on interview and record review, the licensee failed to maintain a tuberculosis (TB) prevention and control program, based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC), which included a two-step tuberculin skin test (TST) or other evidence of TB screening such as a blood test, and a completed health history and symptom screening for one of three employees (clinical nurse supervisor (CNS)-C). [...]”

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 [...]”

Summary: MDH found the licensee failed to maintain an emergency preparedness plan (EPP) with all the required content as defined in Appendix Z. This had the potential to affect all residents, staff, and visitors.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to maintain an emergency preparedness plan (EPP) with all the required content as defined in Appendix Z. This had the potential to affect all residents, 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 [...]”

Summary: MDH found the licensee failed to ensure resident records were protected against unauthorized disclosure of written records for four of four residents (R1, R2, R3, R4).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure resident records were protected against unauthorized disclosure of written records for four of four residents (R1, R2, R3, R4). [...]”

Rule cited: “(b) Resident records, whether written or electronic, must be protected against loss, tampering, or unauthorized disclosure in compliance with chapter 13 and other applicable relevant federal and state laws. [...]”

Summary: MDH found the licensee failed to provide a discharge summary with required content for one of one resident (R5) discharged from the licensee.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide a discharge summary with required content for one of one resident (R5) discharged from the licensee. In addition, the licensee failed to document provided services for three of three residents (R1, R2, R3) in resident records as required. [...]”

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 maintain the portable fire extinguishers.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to maintain the portable fire extinguishers. This deficient condition had the potential to affect all staff, residents, and visitors. [...]”

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 provide facilities that were not a distinct hazard to life.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to provide facilities that were not a distinct hazard to life. This had the potential to directly affect all of the residents and staff. [...]”

Rule cited: “(g) Existing construction or elements, including assisted living facilities that were registered as housing with services establishments under chapter 144D prior to August 1, 2021, shall be permitted to continue in use provided such use does not constitute a [...]”

Summary: MDH found the licensee failed to ensure the assisted living contract did not include language waiving the facility's liability for health, safety, or personal property of a resident for two of two residents (R1 and R3).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the assisted living contract did not include language waiving the facility's liability for health, safety, or personal property of a resident for two of two residents (R1 and R3). [...]”

Rule cited: “The contract must not include a waiver of facility liability for the health and safety or personal property of a resident. [...]”

MDH’s finding, as written: “Based on interview and record review, the licensee initiated an expedited termination without having sufficient evidence or reason for one of one resident (R5). 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 [...]”

Rule cited: “(a) A facility may initiate an expedited termination of housing or services if: (1) the resident has engaged in conduct that substantially interferes with the rights, health, or safety of other residents; (2) the resident has engaged in conduct that [...]”

Summary: MDH found the licensee failed to give adequate notice of 15 days ahead of the termination (for situations that have documentation supporting the need for expedited termination) for one of one resident (R5).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to give adequate notice of 15 days ahead of the termination (for situations that have documentation supporting the need for expedited termination) for one of one resident (R5). [...]”

Rule cited: “(a) A facility terminating a contract must issue a written notice of termination according to this section. [...]”

Summary: MDH found the licensee failed to provide a written notice with required content and for an emergency relocation and failed to notify the Office of Ombudsman for Long-Term Care (OOLTC) for one of one resident (R4) who had been relocated and has not returned to the facility within four days.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide a written notice with required content and for an emergency relocation and failed to notify the Office of Ombudsman for Long-Term Care (OOLTC) for one of one resident (R4) who had been relocated and has not returned to the facility within four days. [...]”

Rule cited: “(a) A facility may remove a resident from the facility in an emergency if necessary due to a resident's urgent medical needs or an imminent risk the resident poses to the health or safety of another facility resident or facility staff member. [...]”

Summary: MDH found the licensee failed to ensure one of three employees (clinical nurse supervisor (CNS)-C) completed an orientation to assisted living facility licensing requirements and regulations before providing services to residents.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure one of three employees (clinical nurse supervisor (CNS)-C) completed an orientation to assisted living facility licensing requirements and regulations before providing services to residents. [...]”

Rule cited: “All staff providing and supervising direct services must complete an orientation to assisted living facility licensing requirements and regulations before providing assisted living services to residents. [...]”

Summary: MDH found the licensee failed to ensure two of two employees (unlicensed personnel (ULP)-A and (ULP)-B) received at least eight hours of initial dementia care training within 160 working hours of their employment start date.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure two of two employees (unlicensed personnel (ULP)-A and (ULP)-B) received at least eight hours of initial dementia care training within 160 working hours of their employment start date. [...]”

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 ensure the registered nurse (RN) conducted ongoing resident assessment and reassessment, not to exceed 90 calendar days from the last date of the assessment for one of three residents (R1).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the registered nurse (RN) conducted ongoing resident assessment and reassessment, not to exceed 90 calendar days from the last date of the assessment for one of three residents (R1). [...]”

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 accurately transcribe medication orders, and document medication administration for two of two residents (R2 and R3).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to accurately transcribe medication orders, and document medication administration for two of two residents (R2 and R3). [...]”

Rule cited: “Each medication administered by the assisted living facility staff must be documented in the resident's record. The documentation must include the signature and title of the person who administered the medication. [...]”

Summary: MDH found the licensee failed to ensure the registered nurse (RN) documented training and/or competencies for three of three unlicensed personnel ((ULP)-A, ULP-B, ULP-E) who would provide medications

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the registered nurse (RN) documented training and/or competencies for three of three unlicensed personnel ((ULP)-A, ULP-B, ULP-E) who would provide medications for residents with unplanned time away from home when a licensed nurse was not available. [...]”

Rule cited: “(2) for unplanned time away, when the pharmacy is not able to provide the medications, a licensed nurse or unlicensed personnel shall provide medications in amounts and dosages needed for the length of the anticipated absence, not to exceed seven calendar [...]”

Summary: MDH found the licensee failed to maintain current medication orders for two of two residents (R2, R3).

MDH’s finding, as written: “Based on interview, and record review, the licensee failed to maintain current medication orders for two of two residents (R2, 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 a widespread scope (when problems are pervasive or represent a systemic failure that has affected or has [...]”

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 provide documentation of disposition of medications for one of one discharged resident (R5).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide documentation of disposition of medications for one of one discharged resident (R5). 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 [...]”

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 required notice was posted at the main entryway of the facility to display statutory language to disclose electronic monitoring activity.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to ensure the required notice was posted at the main entryway of the facility to display statutory language to disclose electronic monitoring activity. This had the potential to affect all of the licensee's residents, staff, and visitors. [...]”

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." (b) The facility is responsible for [...]”