Ridgeview Assisted Living

Summary: MDH found the licensee failed to engage in and maintain documentation of quality management activity appropriate to the size and relevant to the type of services provided by the assisted living.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to engage in and maintain documentation of quality management activity appropriate to the size and relevant to the type of services provided by the assisted living. This had the potential to affect all residents receiving assisted living services. [...]”

Rule cited: “The facility shall engage in quality management appropriate to the size of the facility and relevant to the type of services provided. [...]”

Summary: MDH found the licensee failed to ensure the provider established and maintained a tuberculosis (TB) prevention program based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC) which included the completion of baseline TB screenings for one of three employees (unlicensed personnel (ULP)-E).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the provider established and maintained a tuberculosis (TB) prevention program based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC) which included the completion of baseline TB screenings for one of three employees (unlicensed personnel (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 plan (EPP) with all the required content.

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

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 facility failed to protect three of three resident's records (R2, R6, R3) against tampering.

MDH’s finding, as written: “Based on interview and record review, the facility failed to protect three of three resident's records (R2, R6, R3) against tampering. 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 [...]”

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 interconnected smoke alarms throughout the facility.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to provide interconnected smoke alarms throughout the facility. This had the potential to directly affect all residents, staff, and visitors. [...]”

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 provide or maintain fire extinguishers as required throughout the facility.

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

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 maintain the facility's physical environment in a continuous state of good repair and operation regarding the health, safety, and well-being of the residents.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to maintain the facility's physical environment in a continuous state of good repair and operation regarding the health, safety, and well-being of the residents. This had the potential to directly affect all residents, staff, 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 develop the fire safety and evacuation plan with required content, make the plan readily available, provide required training and drills.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to develop the fire safety and evacuation plan with required content, make the plan readily available, provide required training and drills. This had the potential to directly affect all residents, staff, 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 provide a written notice with required content to the resident, legal representative, and designated representative; and failed to provide the notification to the Office of Ombudsman for Long-Term Care (OOLTC) when the resident did not return from the emergency relocation within four days for one of one resident (R7).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide a written notice with required content to the resident, legal representative, and designated representative; and failed to provide the notification to the Office of Ombudsman for Long-Term Care (OOLTC) when the resident did not return from the emergency relocation within four days for one of one resident (R7). [...]”

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 the registered nurse (RN) ensured training and competency demonstration was completed for two of two unlicensed personnel (ULP-D, ULP-E), and additionally, the licensee failed to provide written instructions in the resident records for delegated tasks for two of two residents (R7, R2).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) ensured training and competency demonstration was completed for two of two unlicensed personnel (ULP-D, ULP-E), and additionally, the licensee failed to provide written instructions in the resident records for delegated tasks for two of two residents (R7, R2). [...]”

Rule cited: “(b) When the registered nurse or licensed health professional delegates tasks to unlicensed personnel, that person must ensure that prior to the delegation the unlicensed personnel is trained in the proper methods to perform the tasks or procedures for each [...]”

Summary: MDH found the licensee failed to ensure direct supervision of staff performing delegated tasks was provided within 30 calendar days after the

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 began working for the licensee and first performed delegated tasks for one of one unlicensed personnel (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 one of two employees, (unlicensed personnel (ULP)-E) employee record contained orientation to assisted living facility licensing to include all the required topics.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure one of two employees, (unlicensed personnel (ULP)-E) employee record contained orientation to assisted living facility licensing to include all the required topics. [...]”

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 employees received all required content of annual training for each 12 months of employment for three of three employees, (clinical nurse supervisor (CNS)-C, unlicensed personnel, (ULP)-B, ULP-D).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure employees received all required content of annual training for each 12 months of employment for three of three employees, (clinical nurse supervisor (CNS)-C, unlicensed personnel, (ULP)-B, ULP-D). [...]”

Rule cited: “(a) All staff that perform direct services must complete at least eight hours of annual training for each 12 months of employment. [...]”

Summary: MDH found the licensee failed to ensure one of three employees, (unlicensed personnel (ULP)-E) received the required amount of dementia care training in the required time frame.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure one of three employees, (unlicensed personnel (ULP)-E) received the required amount of dementia care training in the required time frame. [...]”

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: “Based on observation, interview, and record review the licensee failed to ensure the registered nurse (RN) completed a comprehensive reassessment using the uniform assessment tool by day 14-day for three of three residents (R2, R6, R3) and on day 90 for three of three residents (R2, R6, 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 [...]”

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 ensure service plans were revised and authenticated to confirm agreement of the services to be provided for two of two residents (R2, R7).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure service plans were revised and authenticated to confirm agreement of the services to be provided for two of two residents (R2, 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 the service plan included 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 the service plan included the required content 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) 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 [...]”

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) prepared in writing specific instructions for each resident and documented those instructions for one of three residents (R2).

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 each resident and documented those instructions for one of three residents (R2). [...]”

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 the steps of the medication administration process was followed by one of two employees (unlicensed personnel/ULP-E).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the steps of the medication administration process was followed by one of two employees (unlicensed personnel/ULP-E). [...]”

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 renew prescriptions at least every 12 months for one of one resident (R2).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to renew prescriptions at least every 12 months for one of one resident (R2). 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 [...]”

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 ensure medications were secure and permitted access to only authorized personnel into the locked medication room, for one of one medication room.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medications were secure and permitted access to only authorized personnel into the locked medication room, for one of one medication room. [...]”

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 date time sensitive medications for three of three residents (R4, R5, R2) and the licensee failed to ensure medication was maintained bearing the original prescription label with legible information for one of one resident (R5.)

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to date time sensitive medications for three of three residents (R4, R5, R2) and the licensee failed to ensure medication was maintained bearing the original prescription label with legible information 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) and was issued at [...]”

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 ensure the registered nurse (RN) prepared in writing specific instructions for each resident and documented those instructions for one of one resident (R2) receiving blood glucose monitoring.

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 each resident and documented those instructions for one of one resident (R2) receiving blood glucose monitoring. [...]”

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 up-to-date written or electronically recorded orders were maintained for one of one resident (R2) who received treatments managed by the provider.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure up-to-date written or electronically recorded orders were maintained for one of one resident (R2) who received treatments managed by the provider. [...]”

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 care and

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the care and services were provided according to acceptable health care and medical, or nursing standards for one of one resident (R6) with hospital-style bed rails. In addition, the licensee failed to ensure the care and services were provided according to acceptable health care, medical, or nursing standards for one of one residents (R2) with an assistive device (consumer bedrail). [...]”

Rule cited: “(a) Residents have the right to care and assisted living services that are appropriate based on the resident's needs and according to an up-to-date service plan subject to accepted health care standards.”

Summary: MDH found the licensee failed to ensure insulin was administered per the manufacturer's instructions by one of two employees (unlicensed personnel/ULP-E).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure insulin was administered per the manufacturer's instructions by one of two employees (unlicensed personnel/ULP-E). [...]”

Rule cited: “(b) Residents have the right to receive health care and other assisted living services with continuity from people who are properly trained and competent to perform their duties and in sufficient numbers to adequately provide the services agreed to in the [...]”

Summary: MDH found the licensee failed to ensure privacy was maintained for two of four residents (R8, R7) observed during personal cares.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to ensure privacy was maintained for two of four residents (R8, R7) observed during personal cares. 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, more [...]”

Rule cited: “(a) Residents have the right to consideration of their privacy, individuality, and cultural identity as related to their social, religious, and psychological well-being. [...]”

Summary: MDH found the licensee failed to ensure signage was posted at the main entry of the establishment to display statutory language to disclose electronic monitoring activity, potentially affecting all ten residents,

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

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 [...]”