River Oaks at Lake Pepin

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

Rule cited: “All direct care staff and supervisors providing direct services must demonstrate an understanding of the training specified in section 144G.64.”

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

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. [...]”

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: “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: “No further action required.”

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 [...]”

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

Rule cited: “An assisted living facility with dementia care shall make available in written or electronic form, to residents and families or other persons who request it, a description of the training program and related training it provides, including the categories of [...]”

Summary: MDH found the licensee failed to ensure training for dementia care was completed as required for two of two unlicensed personnel (ULP-G, ULP-M) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure training for dementia care was completed as required for two of two unlicensed personnel (ULP-G, ULP-M) with records reviewed. [...]”

Rule cited: “All direct care staff and supervisors providing direct services must demonstrate an understanding of the training specified in section 144G.64.”

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure an individualized medication management plan included all the required content for one of four residents (R10) 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 three of three unlicensed personnel (ULP-F, ULP-G and ULP-M) were trained and had demonstrated competency to prepare and give medications for residents having unplanned time away with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure three of three unlicensed personnel (ULP-F, ULP-G and ULP-M) were trained and had demonstrated competency to prepare and give medications for residents having unplanned time away with records reviewed. [...]”

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 develop a treatment management plan to include all required content and/or was revised as needed for three of four

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop a treatment management plan to include all required content and/or was revised as needed for three of four residents (R2, R8, R10) receiving treatments with records reviewed 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 [...]”

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 ensure an the registered nurse (RN) had instructed the unlicensed personnel (ULP) in the proper methods with respect to each resident (R2, R8, R10) and the ULP has demonstrated the ability to competently follow the procedures for three of three employees (ULP-F, ULP-G, ULP-M) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure an the registered nurse (RN) had instructed the unlicensed personnel (ULP) in the proper methods with respect to each resident (R2, R8, R10) and the ULP has demonstrated the ability to competently follow the procedures for three of three employees (ULP-F, ULP-G, ULP-M) with records reviewed. [...]”

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 provide in written or electronic form to residents, families, or other persons who request it, a description of the dementia care training program and the basic topics covered with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide in written or electronic form to residents, families, or other persons who request it, a description of the dementia care training program and the basic topics covered with records reviewed. [...]”

Rule cited: “An assisted living facility with dementia care shall make available in written or electronic form, to residents and families or other persons who request it, a description of the training program and related training it provides, including the categories of [...]”

Summary: MDH found the licensee failed to post required content in common areas to include posting 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 required content in common areas to include posting the 911 emergency number in common areas and near telephones provided by the assisted living facility. This had the potential to impact all 36 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 [...]”

MDH’s finding, as written: “Based on interview and record review the licensee failed to establish and maintain a TB (tuberculosis) prevention and control program based on the most current guidelines issued by the centers for Disease Control and Prevention (CDC) guidelines. This had the potential to affect all residents, staff and visitors. [...]”

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 post an emergency exit diagram on each floor.

MDH’s finding, as written: “Based on observation, interview and document review, the licensee failed to post an emergency exit diagram on each floor. In addition, the licensee failed to develop an all-hazards emergency preparedness (EP) program and plan to include Appendix Z required elements. This had the potential to affect all 36 residents in the facility, staff and any 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 facility failed to provide and maintain the building's physical environment including walls, floors, ceiling, in a continuous state of good repair and operation for health, comfort, and well-being of residents in accordance with a maintenance and repair program.

MDH’s finding, as written: “Based on observation and interview, the facility failed to provide and maintain the building's physical environment including walls, floors, ceiling, in a continuous state of good repair and operation for health, comfort, and well-being of residents in accordance with a maintenance and repair program. This has the potential to affect all residents of the facility and staff. [...]”

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 and maintain fire safety and evacuation plans, failed to provide required training to residents and employees for fire safety and evacuation, and failed to conduct required employee evacuation drills.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop and maintain fire safety and evacuation plans, failed to provide required training to residents and employees for fire safety and evacuation, and failed to conduct required employee evacuation drills. This had the potential to affect all current residents, staff, and visitors to the facility. [...]”

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

Summary: MDH found the licensee failed to execute a written contract prior to providing assisted living services for three of three residents (R1, R2, R3) and failed to offer the resident the opportunity to identify a designated representative for one of three residents (R3) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to execute a written contract prior to providing assisted living services for three of three residents (R1, R2, R3) and failed to offer the resident the opportunity to identify a designated representative for one of three residents (R3) with records reviewed. [...]”

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 execute a written contract with the required content for one of three residents (R3) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to execute a written contract with the required content for one of three residents (R3) with records reviewed. [...]”

Rule cited: “(a) The contract must include in a conspicuous place and manner on the contract the legal name and the license number of the facility. [...]”

Summary: MDH found the licensee failed to execute a written contract with the required content for one of three residents (R3) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to execute a written contract with the required content for one of three residents (R3) with records reviewed. [...]”

Rule cited: “(c) The contract must include: (1) a disclosure of the category of assisted living facility license held by the facility and, if the facility is not an assisted living facility with dementia care, a disclosure that it does not hold an assisted living facility [...]”

Summary: MDH found the licensee failed to ensure training and competency evaluations contained all the required training for two of two unlicensed personnel (ULP-F, ULP-G) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure training and competency evaluations contained all the required training for two of two unlicensed personnel (ULP-F, ULP-G) with records reviewed. [...]”

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 licensee failed to ensure staff providing assisted

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure staff providing assisted living services were oriented specifically to each individual resident and the services to be provided for two of two unlicensed personnel (ULP-F, ULP-G) with records reviewed. [...]”

Rule cited: “Staff providing assisted living services must be oriented specifically to each individual resident and the services to be provided. This orientation may be provided in person, orally, in writing, or electronically.”

Summary: MDH found the licensee failed to ensure training for dementia care was completed as required for one of two unlicensed personnel (ULP-G) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure training for dementia care was completed as required for one of two unlicensed personnel (ULP-G) with records reviewed. [...]”

Rule cited: “All direct care staff and supervisors providing direct services must demonstrate an understanding of the training specified in section 144G.64.”

Summary: MDH found the licensee failed to ensure the registered nurse had completed and/or documented a comprehensive assessment for change in condition for two of three residents (R1, R2) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure the registered nurse had completed and/or documented a comprehensive assessment for change in condition for two of three residents (R1, R2) 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 ensure the service plan contained all required content for three of three residents (R1, R2, R3) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure the service plan contained all required content for three of three residents (R1, R2, R3) with records reviewed. [...]”

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 [...]”

MDH’s finding, as written: “Based on interview and record review the licensee failed to ensure medicatinon errors were investigated and corrective actions were documented for two of three residents (R6, R9) 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) conducted an individualized assessment to determine what medication management services would be provided, and how the services would be provided for three of three residents (R1, R2, R3) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure the registered nurse (RN) conducted an individualized assessment to determine what medication management services would be provided, and how the services would be provided for three of three residents (R1, R2, R3) with records reviewed. [...]”

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 ensure the registered nurse (RN) completed a reassessment when there was a change in the resident's medications for one of three residents (R2) with records reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) completed a reassessment when there was a change in the resident's medications for one of three residents (R2) with records 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 an individualized medication management plan to include all required content for three of three residents (R1, R2, R3) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure an individualized medication management plan to include all required content for three of three residents (R1, R2, 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. [...]”

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure two of two unlicensed personnel (ULP-F and ULP-G) were trained and had demonstrated competency to prepare and give medications for residents having unplanned time away with records reviewed. [...]”

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: “Based on interview and record review the licensee failed to ensure two of three residents (R1, R3) had signed prescriber's orders for medications with records reviewed. [...]”

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 document in the resident's record the disposition of the medication including the medication's name, strength, prescription number as applicable, quantity, to whom the medications were given, date of disposition, and names of staff and other individuals involved in the disposition for one of one discharged resident (R4) with record reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to document in the resident's record the disposition of the medication including the medication's name, strength, prescription number as applicable, quantity, to whom the medications were given, date of disposition, and names of staff and other individuals involved in the disposition for one of one discharged resident (R4) with record reviewed. [...]”

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: “Based on interview and document review the licensee failed to ensure the policy and procedures for treatments and therapy management services included all the required content with records reviewed. [...]”

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 a treatment management plan to include all required content and/or was revised as needed for two of two residents (R1, R2) receiving treatments with records reviewed

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to develop a treatment management plan to include all required content and/or was revised as needed for two of two residents (R1, R2) receiving treatments with records reviewed 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 [...]”

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 ensure an the registered nurse (RN) specified, in writing, specific instructions for each resident and

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure an the registered nurse (RN) specified, in writing, specific instructions for each resident and documented those instructions in the resident's records for two of two residents (R1, R2) receiving treatments and had instructed the unlicensed personnel (ULP) in the proper methods with respect to each resident and the unlicensed personnel has demonstrated the ability to competently follow the procedures for two of two [...]”

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 [...]”

MDH’s finding, as written: “Based on observation, interview and record review the licensee failed to ensure documentation and administration of treatment as prescribed for one of two residents (R2) receiving treatments with records reviewed. [...]”

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 ensure prescriber's order for change in wound care treatment for one of two residents (R2) receiving wound care with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure prescriber's order for change in wound care treatment for one of two residents (R2) receiving wound care with records reviewed. [...]”

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 a written acknowledgment of receipt of the current home care bill of rights was obtained prior to initiating services for three of three residents (R1, R2, R3) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure a written acknowledgment of receipt of the current home care bill of rights was obtained prior to initiating services for three of three residents (R1, R2, R3) with records reviewed. [...]”

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. [...]”

Summary: MDH found the licensee failed to provide in written or electronic form to residents, families, or other persons who request it, a description of the dementia care training program, the categories of employees trained, the frequency of training, and the basic topics covered with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide in written or electronic form to residents, families, or other persons who request it, a description of the dementia care training program, the categories of employees trained, the frequency of training, and the basic topics covered with records reviewed. [...]”

Rule cited: “An assisted living facility with dementia care shall make available in written or electronic form, to residents and families or other persons who request it, a description of the training program and related training it provides, including the categories of [...]”

Summary: MDH found 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 (R1) observed with bedrails, with records reviewed.

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 (R1) observed with bedrails, with records reviewed. In addition, the licensee failed to document the site of injection for administration of medications for three of four residents (R2, R3, R5) with records reviewed. [...]”

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 the required notice was posted at the main entry way of the establishment to display statutory language to disclose electronic monitoring activity, potentially affecting all current residents in the assisted living facility, staff and

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

Rule cited: “Subd. 8.Notice to visitors. (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 [...]”