Restful Home

Summary: MDH found the licensee failed to provide a daily program of social and recreational activities that are based upon individual and group interests, physical, mental, and psychosocial needs, and that creates opportunities for active participation in the community at large This had the potential to affect all eight residents of the facility.

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

Rule cited: “(iv) upon the request of the resident, provide direct or reasonable assistance with arranging for transportation to medical and social services appointments, shopping, and other recreation, and provide the name of or other identifying information about the [...]”

Summary: MDH found the licensee failed to ensure staff had access to the registered nurse (RN), 24 hours per day, seven days per week.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure staff had access to the registered nurse (RN), 24 hours per day, seven days per week. RN-B the licensee employed also worked full-time on the night shift at a local hospital. This affected all residents and unlicensed staff. This resulted in an immediate correction order issued on April 3, 2023, at approximately 7:30 p.m. [...]”

Rule cited: “(14) 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 an infection control program to comply with accepted health care, medical, and nursing standards for infection control, as directed by the Centers for Disease Control and Prevention (CDC), including:

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to establish an infection control program to comply with accepted health care, medical, and nursing standards for infection control, as directed by the Centers for Disease Control and Prevention (CDC), including: registered nurse (RN) oversight, monitoring and training to prevent the potential spread of infections, the licensee failed to ensure direct care staff appropriately gloved and performed adequate hand hygiene (HH) [...]”

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 post the required information related to the grievance procedure and contact information for the Office of Ombudsman for Long-Term Care (OOLTC) and Mental Health and Developmental Disabilities.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to post the required information related to the grievance procedure and contact information for the Office of Ombudsman for Long-Term Care (OOLTC) and Mental Health and Developmental Disabilities. This had the potential to affect all eight residents receiving assisted living services. [...]”

Rule cited: “All facilities must post in a conspicuous place information about the facilities' grievance procedure, and the name, telephone number, and email contact information for the individuals who are responsible for handling resident grievances. [...]”

Summary: MDH found the licensee failed to ensure an individual abuse prevention plan (IAPP) contained statements of the specific measures to be taken by staff to minimize the risk of abuse for two of two residents (R1, R3).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure an individual abuse prevention plan (IAPP) contained statements of the specific measures to be taken by staff to minimize the risk of abuse for two of two residents (R1, R3). [...]”

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 maintain employee records with all required content for three of three personnel, registered nurse (RN)-B, and unlicensed personnel (ULP)-D, ULP-E.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to maintain employee records with all required content for three of three personnel, registered nurse (RN)-B, and unlicensed personnel (ULP)-D, ULP-E. [...]”

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 establish and maintain a

MDH’s finding, as written: “Based on interview and record review, the licensee failed to establish and maintain a tuberculosis (TB) prevention program based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC) which included completion of a TB facility risk assessment, baseline testing and history and symptom screening and TB training for three of three employees, registered nurse (RN)-B, and unlicensed personnel (ULP)-D, ULP-E. [...]”

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 develop a written emergency preparedness (EP) plan with all the required content.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to develop a written emergency preparedness (EP) plan with all the required content. 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 maintain the physical environment, including walls, floors, ceiling, all furnishings, grounds, systems, and equipment in a continuous state of good repair and operation regarding the health, safety, comfort, and well-being of the residents.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to maintain the physical environment, including walls, floors, ceiling, all furnishings, grounds, systems, and equipment in a continuous state of good repair and operation regarding the health, safety, comfort, and well-being of the residents. This deficient condition had the potential to affect all staff, residents, and visitors. [...]”

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 have fire safety and evacuation plans with the required elements, failed to conduct required drills, and did not complete required training for residents and employees.

MDH’s finding, as written: “Based on record review and interview, the licensee failed to have fire safety and evacuation plans with the required elements, failed to conduct required drills, and did not complete required training for residents and employees. These deficient practices had the potential to affect all staff, residents, and visitors. [...]”

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

Summary: MDH found the licensee failed to develop and execute a written assisted living contract with the required content for two of two residents (R1, R3).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop and execute a written assisted living contract with the required content for two of two residents (R1, R3). [...]”

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 designated representative, on a separate form including statutory language, for two of two residents (R1, R3).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to offer the opportunity to identify a designated representative, on a separate form including statutory language, for two of two residents (R1, R3). [...]”

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 a background study was conducted prior to staff providing services for one of one employee (unlicensed personnel (ULP)-D).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure a background study was conducted prior to staff providing services for one of one employee (unlicensed personnel (ULP)-D). This resulted in an immediate correction order on April 3, 2023, at approximately 7:30 p.m. Further, the licensee failed to maintain documentation of the background study for each paid employee, as required under section 144.057, for one of one employee (ULP-E). [...]”

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 to include all required content was completed for two of two unlicensed employees, unlicensed personnel (ULP)-D and ULP-E.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure training and competency to include all required content was completed for two of two unlicensed employees, unlicensed personnel (ULP)-D and ULP-E. [...]”

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 facility failed to ensure training and competency evaluations were completed as required prior to providing direct care to residents for two of two unlicensed personnel (ULP)-D, ULP-E. This resulted in an immediate order identified on April 4, 2023, at approximately 2:45 p.m.

MDH’s finding, as written: “Based on observation, interview and record review, the facility failed to ensure training and competency evaluations were completed as required prior to providing direct care to residents for two of two unlicensed personnel (ULP)-D, ULP-E. This resulted in an immediate order identified on April 4, 2023, at approximately 2:45 p.m. [...]”

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 a registered nurse (RN) conducted direct supervision of staff performing a delegated task within 30 days of providing services for two of two employees, unlicensed personnel (ULP)-D and ULP-E.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure a registered nurse (RN) conducted direct supervision of staff performing a delegated task within 30 days of providing services for two of two employees, unlicensed personnel (ULP)-D and ULP-E. [...]”

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 staff providing services completed orientation to assisted living facility licensing requirements and regulations, before providing services, for three of three employees, registered nurse (RN)-B, unlicensed personnel (ULP)-D, and ULP-E.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure staff providing services completed orientation to assisted living facility licensing requirements and regulations, before providing services, for three of three employees, registered nurse (RN)-B, unlicensed personnel (ULP)-D, and ULP-E. [...]”

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 the required amount of dementia care training was completed in the required time frame in accordance with 144G.64 for three of three employees, (registered nurse (RN)-B, unlicensed personnel (ULP)-D, and ULP-E).

MDH’s finding, as written: “Based on interview, and record review, the licensee failed to ensure the required amount of dementia care training was completed in the required time frame in accordance with 144G.64 for three of three employees, (registered nurse (RN)-B, unlicensed personnel (ULP)-D, and ULP-E). [...]”

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 a registered nurse (RN) completed an initial comprehensive nursing assessment prior to signing the assisted living contract/providing services for three of three

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure a registered nurse (RN) completed an initial comprehensive nursing assessment prior to signing the assisted living contract/providing services for three of three residents (R1, R2, R4). This resulted in an immediate correction order issued on April 3, 2023, at approximately 7:30 p.m. [...]”

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 a registered nurse (RN) conducted ongoing resident monitoring and reassessment 14 calendar days from the initial assessment, and not to exceed 90 calendar days from the previous assessment for two of two residents (R1, R3) with records reviewed.

MDH’s finding, as written: “Based on interview, and record review, the licensee failed to ensure a registered nurse (RN) conducted ongoing resident monitoring and reassessment 14 calendar days from the initial assessment, and not to exceed 90 calendar days from the previous assessment for two of two residents (R1, R3) with records reviewed. [...]”

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 initiate a temporary service plan as required, for one of one resident (R2).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to initiate a temporary service plan as required, for one of one resident (R2). This resulted in an immediate correction order issued on April 4, 2023, at approximately 2:45 p.m. [...]”

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 current written service plan within 14 calendar days for two of two residents (R1, R3).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to finalize a current written service plan within 14 calendar days for two of two residents (R1, R3). [...]”

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 implement current medication management policies and procedures, which were developed under the supervision and direction of a registered nurse (RN)-B, consistent with current practice standards and guidelines related to medication management, delegation and pain management.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to implement current medication management policies and procedures, which were developed under the supervision and direction of a registered nurse (RN)-B, consistent with current practice standards and guidelines related to medication management, delegation and pain management. The deficient practice affected two of two residents (R1, R2). [...]”

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) monitored and reassessed the resident receiving medication management services as needed when the resident presents with symptoms other issues that may be medication-related and, at a minimum, annually, for two of two residents (R1, R3).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure the registered nurse (RN) monitored and reassessed the resident receiving medication management services as needed when the resident presents with symptoms other issues that may be medication-related and, at a minimum, annually, for two of two residents (R1, R3). [...]”

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 develop and maintain a current individualized medication management plan to include all required content for two of two residents (R1, R3) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to develop and maintain a current individualized medication management plan to include all required content for two of two residents (R1, R3) 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 administered per physician's orders for three of three residents (R1, R2, R3).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medications were administered per physician's orders for three of three residents (R1, R2, 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 documentation of medication setup included all the required content for two of two residents (R2, R3).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure documentation of medication setup included all the required content for two of two residents (R2, R3). This had the potential to affect all eight licensee residents. This resulted in an immediate order identified on April 4, 2023, at approximately 2:45 p.m. [...]”

Rule cited: “Documentation of dates of medication setup, name of medication, quantity of dose, times to be administered, route of administration, and name of person completing medication setup must be done at the time of setup.”

Summary: MDH found the licensee failed to ensure written or electronically recorded prescriptions were obtained for two of three residents (R2, R3).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure written or electronically recorded prescriptions were obtained for two of three 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) and was issued at a pattern scope (when more than a limited number of residents are affected, more than a limited number of staff are involved, or the [...]”

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 medications were stored under proper temperature controls according to manufacturer instructions.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to ensure medications were stored under proper temperature controls according to manufacturer instructions. This had the potential to affect three of three) residents (R1, R3, R6) with refrigerated medications. Further, the licensee failed to ensure all medications were securely locked in substantially constructed compartments and only authorized personnel had access. This had the potential to affect all eight residents in the facility. [...]”

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 develop, implement, and maintain an up-to-date written treatment or therapy management policies and procedures that were developed under the supervision and direction of a registered nurse (RN) consistent with current practice standards and guidelines.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop, implement, and maintain an up-to-date written treatment or therapy management policies and procedures that were developed under the supervision and direction of a registered nurse (RN) consistent with current practice standards and guidelines. [...]”

Rule cited: “(a) An assisted living facility that provides treatment and therapy management services must develop, implement, and maintain up-to-date written treatment or therapy management policies and procedures. [...]”

Summary: MDH found the licensee failed to develop and implement a treatment or therapy management plan to include all required content for one of two residents (R1).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop and implement a treatment or therapy management plan to include all required content for one of two residents (R1). This resulted in an immediate correction order issued on April 3, 2023, at approximately 7:30 p.m. [...]”

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 document treatment administration for one of one resident (R1).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to document treatment administration for one of one resident (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 an isolated scope (when one or a limited number of residents are affected or one or a limited [...]”

Rule cited: “Each treatment or therapy administered by an assisted living facility must be in the resident record. [...]”

Summary: MDH found the licensee failed to obtain prescriber orders for all treatments and therapies, including the frequency, duration and other information needed to administer the treatment or therapy for one of three residents (R1).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to obtain prescriber orders for all treatments and therapies, including the frequency, duration and other information needed to administer the treatment or therapy for one of three residents (R1). [...]”

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 current "Minnesota Bill of Rights for Assisted Living Residents" was provided to the resident and a written acknowledgement received for two of two residents (R1, R3).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the current "Minnesota Bill of Rights for Assisted Living Residents" was provided to the resident and a written acknowledgement received for two of two residents (R1, R3). [...]”

Rule cited: “(a) An assisted living facility must provide the resident a written notice of the rights under section 144G.91 before the initiation of services to that resident. [...]”