River Oaks Columbia Heights

Summary: MDH found the licensee failed to ensure the registered nurse (RN) completed supervision of a ULP within 30 calendar days of beginning to provide delegated tasks for one of two employees (unlicensed personnel (ULP)-G).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the registered nurse (RN) completed supervision of a ULP within 30 calendar days of beginning to provide delegated tasks for one of two employees (unlicensed personnel (ULP)-G). [...]”

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 document administration or refusal of medications according to provider orders for five of five residents (R3, R11, R13, R23, and R24).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to document administration or refusal of medications according to provider orders for five of five residents (R3, R11, R13, R23, and R24). [...]”

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 store prescription medication securely and permit only authorized personnel to have access to the nurse's medication cart located in the nurse's office that contained all the overflow medications for all residents in the building.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to store prescription medication securely and permit only authorized personnel to have access to the nurse's medication cart located in the nurse's office that contained all the overflow medications for all residents in the building. This had the potential to affect all residents. [...]”

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 ensure all medications were properly labeled and failed to discard expired medications.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure all medications were properly labeled and failed to discard expired medications. This practice resulted in a level two violation (a violation that did not harm a resident's health or safety but had the potential to have harmed a resident's health or safety, but was not likely to cause serious injury, impairment, or death) and was issued at a pattern scope (when more than a limited number of residents are affected, [...]”

Rule cited: “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 develop a treatment management plan to include all required content for one of four residents (R11).

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 for one of four residents (R11). This practice resulted in a level two violation (a violation that did not harm a resident's health or safety but had the potential to have harmed a resident's health or safety, but was not likely to cause serious injury, impairment, or death), and was issued at a widespread scope (when problems are pervasive or represent a systemic [...]”

Rule cited: “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 the registered nurse (RN) specified, in writing, specific instructions for each resident treatment and documented those instructions in the resident's record for one of three residents (R11).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the registered nurse (RN) specified, in writing, specific instructions for each resident treatment and documented those instructions in the resident's record for one of three residents (R11). [...]”

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 that has a secured dementia care unit must meet the requirements of section 144G.45 and the following additional requirements: (1) a hazard vulnerability assessment or safety risk must be performed on and around [...]”

Summary: MDH found the licensee failed to establish and maintain an infection control program to comply with accepted health care, medical and nursing standards for infection control for one of one unlicensed personnel ((ULP)-F) observed to provide personal cares and medication administration for multiple residents.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to establish and maintain an infection control program to comply with accepted health care, medical and nursing standards for infection control for one of one unlicensed personnel ((ULP)-F) observed to provide personal cares and medication administration for multiple residents. [...]”

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.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to post the required information related to the grievance procedure. This had the potential to affect all current residents, staff, and visitors. [...]”

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) was developed to include statements of the specific measures to be taken to minimize the risk of abuse for two of four residents (R1, R3).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure an individual abuse prevention plan (IAPP) was developed to include statements of the specific measures to be taken to minimize the risk of abuse for two of four 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 ensure employee records contained the required content for two of two employees (unlicensed personnel (ULP)-B, and licensed practical nurse (LPN)-A).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure employee records contained the required content for two of two employees (unlicensed personnel (ULP)-B, and licensed practical nurse (LPN)-A). [...]”

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 facility 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 documentation of a completed health history and symptom screening, baseline screening and TB training for two of two employees (unlicensed personnel (ULP)-B) and (licensed practical nurse (LPN)-A).

MDH’s finding, as written: “Based on interview and record review, the facility 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 documentation of a completed health history and symptom screening, baseline screening and TB training for two of two employees (unlicensed personnel (ULP)-B) and (licensed practical nurse (LPN)-A). [...]”

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: “Based on interview and record review the licensee failed to have a written emergency preparedness plan (EPP) with all the required content. This had the potential to affect all residents receiving services under the assisted living with dementia license. [...]”

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 that resident records were readily available for employees authorized to access the records during medication administration.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure that resident records were readily available for employees authorized to access the records during medication administration. This had the potential to affect all residents. [...]”

Rule cited: “The facility must ensure that the appropriate records are readily available to employees and contractors authorized to access the records. Resident records must be maintained in a manner that allows for timely access, printing, or transmission of the records. [...]”

Summary: MDH found the licensee failed to ensure the resident record included a discharge summary for one of two discharged residents (R2).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the resident record included a discharge summary for one of two discharged residents (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 [...]”

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 physical environment of the facility in a continuous state of good repair and operation.

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

MDH’s finding, as written: “Based on observation, record review, and interview, the licensee failed to provide all required content on the fire safety and evacuation plan, evacuation drills, and the minimum required training of staff and residents on fire safety and evacuation. This has the potential to directly affect the safety of visitors, staff, and all residents receiving care. [...]”

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

Summary: MDH found the licensee failed to follow applicable state and local laws, regulations, standards, ordinances, and codes related to smoking for one of one resident (R1).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to follow applicable state and local laws, regulations, standards, ordinances, and codes related to smoking for one of one resident (R1). [...]”

Rule cited: “Assisted living facilities shall comply with all applicable state and local governing laws, regulations, standards, ordinances, and codes for fire safety, building, and zoning requirements.”

Summary: MDH found the licensee failed to execute a written assisted living contract with all required content for two of four residents (R3, R4).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to execute a written assisted living contract with all required content for two of four residents (R3, R4). This practice resulted in a level one violation (a violation that has no potential to cause more than a minimal impact on the resident and does not affect health or safety) and was issued at a widespread scope (when problems are pervasive or represent a systemic failure that has affected or has potential to affect a large portion [...]”

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 the assisted living contract did not include language waiving the

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 licensee's liability for health, safety, or personal property of a resident. This had the potential to affect all residents. [...]”

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

Summary: MDH found the licensee failed to provide a written notice with the required content for an emergency relocation to the resident, legal representative, or designated representative for one of one resident (R1).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide a written notice with the required content for an emergency relocation to the resident, legal representative, or designated representative for one of one resident (R1). [...]”

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 a background study was submitted and received in affiliation with the assisted living license for one of three employees (unlicensed personnel (ULP)-B).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure a background study was submitted and received in affiliation with the assisted living license for one of three employees (unlicensed personnel (ULP)-B). [...]”

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 staff providing services completed an orientation to assisted living facility licensing requirements and regulations before providing services for three of three employees (unlicensed personnel (ULP)-B, ULP-F, and licensed practical nurse (LPN)-A).

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

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 annual training included all required topics for each 12 months of employment for three of three employees (unlicensed personnel (ULP)-B and ULP-F, licensed practical nurse (LPN)-A).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure annual training included all required topics for each 12 months of employment for three of three employees (unlicensed personnel (ULP)-B and ULP-F, licensed practical nurse (LPN)-A). [...]”

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

MDH’s finding, as written: “Based on interview and record review the licensee failed to provide evidence of annual dementia care training on required topics for one of one employee (licensed practical nurse (LPN)-J). [...]”

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 direct-care staff completed at least eight hours of initial dementia care training within 80 working hours of the employment start date for three of three employees (unlicensed personnel (ULP-B), ULP-F, licensed practical nurse (LPN)-A).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure direct-care staff completed at least eight hours of initial dementia care training within 80 working hours of the employment start date for three of three employees (unlicensed personnel (ULP-B), ULP-F, licensed practical nurse (LPN)-A). [...]”

Rule cited: “(3) for assisted living facilities with dementia care, direct-care employees must have completed at least eight hours of initial training on topics specified under paragraph (b) within 80 working hours of the employment start date. [...]”

Summary: MDH found the licensee failed to ensure the registered nurse (RN) conducted assessments within 14-days following a residents admission date and ongoing

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the registered nurse (RN) conducted assessments within 14-days following a residents admission date and ongoing nursing assessments not to exceed every 90-days thereafter for four of five residents (R1, R5, R3 and R4). In addition, licensee failed to complete a change in condition assessment for one of one resident (R1) after a hospitalization. [...]”

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 have a service plan in place documenting agreement on the services to be provided for one of five residents (R5).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to have a service plan in place documenting agreement on the services to be provided for one of five residents (R5). The licensee also failed to ensure service plans included signatures or other authentication by the residents and the licensee to document agreement on the change of services to be provided for one of five residents (R1). [...]”

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 that based on the assessment, the registered nurse (RN) determined what medication management services would be provided, and how the services would be provided for one of four residents (R5).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure that based on the assessment, the registered nurse (RN) determined what medication management services would be provided, and how the services would be provided for one of four residents (R5). [...]”

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 on the resident's medication management services after a change in condition for one of four residents (R1).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) completed a reassessment on the resident's medication management services after a change in condition for one of four residents (R1). [...]”

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 an individualized medication management plan prior to providing medication management services, and with the required content, for one of four residents (R5).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to develop an individualized medication management plan prior to providing medication management services, and with the required content, for one of four residents (R5). [...]”

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 prior to delegating the task of medication administration, the registered nurse (RN) trained the unlicensed personnel (ULP) in the proper methods to perform the task or procedure for each resident and verified the ULPs were able to demonstrate the ability to competently follow the procedure for two of two employees (ULP-B, ULP-F).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure prior to delegating the task of medication administration, the registered nurse (RN) trained the unlicensed personnel (ULP) in the proper methods to perform the task or procedure for each resident and verified the ULPs were able to demonstrate the ability to competently follow the procedure for two of two employees (ULP-B, ULP-F). [...]”

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 [...]”

MDH’s finding, as written: “Based on observation, interview, and record review the licensee failed to ensure medication was administered as prescribed for two of four residents (R3, R4), and failed to ensure that medications were administered per protocol for two of four residents (R3, R4). The licensee also failed to transcribe provider orders correctly for one of four residents (R5). [...]”

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 written or electronically recorded prescriptions were obtained for one of four residents (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 one of four residents (R3). This practice resulted in a level two violation (a violation that did not harm a resident's health or safety but had the potential to have harmed a resident's health or safety, but was not likely to cause serious injury, impairment, or death), and was issued at an isolated scope (when one or a limited number of residents are affected [...]”

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

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

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure prescriptions were renewed at least every 12 months for one of four residents (R3). This practice resulted in a level two violation (a violation that did not harm a resident's health or safety but had the potential to have harmed a resident's health or safety, but was not likely to cause serious injury, impairment, or death), and was issued at an isolated scope (when one or a limited number of residents are affected or one or a [...]”

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

MDH’s finding, as written: “Based on observation, interview, and record review the licensee failed to discard expired medication for nine of 11 residents (R10, R11, R12, R13, R14, R15, R16, R17, and R20). [...]”

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 [...]”

MDH’s finding, as written: “Based on observation, interview, and record review the licensee failed to ensure medications were destroyed when medications were no longer in use. This had the potentional to affect all residents receiving medication management. [...]”

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 develop a treatment management plan to include all required content for one of one resident (R5) with blood glucose monitoring and continuous positive airway pressure (CPAP) machine.

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 for one of one resident (R5) with blood glucose monitoring and continuous positive airway pressure (CPAP) machine. [...]”

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 the registered nurse (RN) specified, in writing, specific instructions for each resident and documented those instructions in the resident's record for one of one resident receiving blood glucose monitoring (R5).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the registered nurse (RN) specified, in writing, specific instructions for each resident and documented those instructions in the resident's record for one of one resident receiving blood glucose monitoring (R5). [...]”

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 develop a memory care site-specific safety risk assessment plan to identify hazard vulnerabilities and mitigations on and around the property to protect memory care residents from harm.

MDH’s finding, as written: “Based on observation, document review, and interview, the licensee failed to develop a memory care site-specific safety risk assessment plan to identify hazard vulnerabilities and mitigations on and around the property to protect memory care residents from harm. This has the potential to directly affect staff and all memory care residents receiving assisted living services. [...]”

Rule cited: “An assisted living facility with dementia care that has a secured dementia care unit must meet the requirements of section 144G.45 and the following additional requirements: (1) a hazard vulnerability assessment or safety risk must be performed on and around [...]”

Summary: MDH found the licensee failed to ensure an awake person was physically present in a secured care unit, 24 hours a day, seven days a week who was responsible for responding to requests of residents for assistance in a secured area.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure an awake person was physically present in a secured care unit, 24 hours a day, seven days a week who was responsible for responding to requests of residents for assistance in a secured area. This had the potential to affect all residents in the secured dementia care unit. [...]”

Rule cited: “An assisted living facility with dementia care providing services in a secured dementia care unit must have an awake person who is physically present in the secured dementia care unit 24 hours per day, seven days per week, who is responsible for responding to [...]”

Summary: MDH found the licensee failed to ensure policies and procedures for assisted living with dementia care (ALFDC) were provided to residents and the residents' legal and designated representatives at the time of move in for four of four residents (R1, R3, R4, and R5).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure policies and procedures for assisted living with dementia care (ALFDC) were provided to residents and the residents' legal and designated representatives at the time of move in for four of four residents (R1, R3, R4, and R5). [...]”

Rule cited: “(a) In addition to the policies and procedures required in the licensing of all facilities, the assisted living facility with dementia care licensee must develop and implement policies and procedures that address the: (1) philosophy of how services are [...]”

Summary: MDH found the licensee failed to conduct an evaluation for activities that addressed all provisions and failed to develop an individualized activity plan based on the evaluation, for two of two residents (R3 and R4) who resided in the secured memory care unit.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to conduct an evaluation for activities that addressed all provisions and failed to develop an individualized activity plan based on the evaluation, for two of two residents (R3 and R4) who resided in the secured memory care unit. [...]”

Rule cited: “(b) Each resident must be evaluated for activities according to the licensing rules of the facility. [...]”

Summary: MDH found the licensee failed to provide care and services according to acceptable health care, medical or nursing standards for two of five residents (R3, R8) with consumer bed rails and assistive devices.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to provide care and services according to acceptable health care, medical or nursing standards for two of five residents (R3, R8) with consumer bed rails and assistive devices. [...]”

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 document the results of reviewed grievances for two of three known residents (R18, R19).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to document the results of reviewed grievances for two of three known residents (R18, R19). 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 an isolated scope (when one or a limited number of residents are affected or one or a limited number of staff are involved or the situation has occurred [...]”

Rule cited: “Residents have the right to make and receive a timely response to a complaint or inquiry, without limitation. [...]”