Rose Arbor Wildflower Lodge

Summary: MDH found the licensee failed to develop and implement current policies and procedures as required.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop and implement current policies and procedures as required. 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 is issued at a widespread scope (when problems are pervasive or represent a systemic failure that has affected or has the [...]”

Rule cited: “Each assisted living facility must have policies and procedures in place to address the following and keep them current: (1) requirements in section 626.557, reporting of maltreatment of vulnerable adults; (2) conducting and handling background studies on [...]”

Summary: MDH found the licensee failed to maintain an effective infection control program to comply with acceptable health care, medical, and nursing standards for infection control by three of six employees (unlicensed personnel (ULP)-M, ULP-R and ULP-W).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to maintain an effective infection control program to comply with acceptable health care, medical, and nursing standards for infection control by three of six employees (unlicensed personnel (ULP)-M, ULP-R and ULP-W). [...]”

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, interview, and record review, the licensee failed to post the required information related to the grievance procedure. This had the potential to affect all the licensee's 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 post the required content in common areas, including posting the 911 emergency number and contact information for Minnesota Adult Abuse Reporting Center (MAARC) in common areas on the main floor of the facility.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to post the required content in common areas, including posting the 911 emergency number and contact information for Minnesota Adult Abuse Reporting Center (MAARC) in common areas on the main floor of the facility. This had the potential to affect 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 observation, interview, and record review, the licensee failed to ensure employee records included all required content for five of five employees (unlicensed personnel (ULP)-B, ULP-Q, ULP-R, ULP-T, ULP-U). [...]”

Rule cited: “(a) The facility must maintain current records of each paid staff member, each regularly scheduled volunteer providing services, and each individual contractor providing services. [...]”

Summary: MDH found the licensee failed to maintain a tuberculosis (TB) prevention and control program based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC).

MDH’s finding, as written: “Based on interview, and record review, the licensee failed to maintain a tuberculosis (TB) prevention and control program based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC). [...]”

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 (EP) plan 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 the resident records were readily available to contract (pool) staff

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the resident records were readily available to contract (pool) staff when services completed by pool staff required access to the records. This could affect all resident records pool staff document in. [...]”

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 with the required content for one of one discharged resident (R1).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the resident record included a discharge summary with the required content for one of one discharged resident (R1). [...]”

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 comply with the Minnesota State Fire Code in Minnesota Rules, chapter 7511.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to comply with the Minnesota State Fire Code in Minnesota Rules, chapter 7511. This had the potential to directly affect all residents, staff, and visitors. [...]”

Rule cited: “Each assisted living facility must comply with the State Fire Code in Minnesota Rules, chapter 7511, and:”

Summary: MDH found the licensee failed to maintain the physical environment, 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, in a continuous state of good repair and operation. 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 develop the fire safety and evacuation plan with the required content, to provide the required training.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to develop the fire safety and evacuation plan with the required content, to provide the required training. 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 execute a written contract with the required content for four of four residents (R2, R6, R13, R15).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to execute a written contract with the required content for four of four residents (R2, R6, R13, R15). 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 the potential to affect a large portion or [...]”

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

Summary: MDH found the licensee failed to execute a written contract with the required content for three of three residents (R2, R6, R13) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to execute a written contract with the required content for three of three residents (R2, R6, R13) 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 execute a written assisted living contract with all required content.

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. This had the potential to affect all residents. [...]”

Rule cited: “(5) a description of the facility's policies related to medical assistance waivers under chapter 256S and section 256B.49 and the housing support program under chapter 256I, including: (i) whether the facility is enrolled with the commissioner of human [...]”

Summary: MDH found the licensee failed to ensure the assisted living contract did not include language waiving the licensee's liability for health, safety, or personal

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 and failed to provide the notification to the Office of Ombudsman for Long-Term Care (OOLTC) of the emergency relocation greater than four days for one of one resident (R6).

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 and failed to provide the notification to the Office of Ombudsman for Long-Term Care (OOLTC) of the emergency relocation greater than four days for one of one resident (R6). [...]”

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 current and eligible on NETStudy 2.0 (web-based system for submitting background study requests to the Department of Human Services (DHS)) prior to staff providing services for four of 80 staff, (unlicensed personnel (ULP)-F, clinical coordinator (CC)-G, and dining service chef (DSC)-H and DSC-I).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure a background study was current and eligible on NETStudy 2.0 (web-based system for submitting background study requests to the Department of Human Services (DHS)) prior to staff providing services for four of 80 staff, (unlicensed personnel (ULP)-F, clinical coordinator (CC)-G, and dining service chef (DSC)-H and DSC-I). [...]”

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 contracted staff met all requirements for training and competency evaluation, as identified in 144G.60, Subd. 4 and 144G.61 Subd 1. and 2, for two of two unlicensed personnel (ULP-K and ULP-M).

MDH’s finding, as written: “Based on observation and interview, the licensee failed to ensure contracted staff met all requirements for training and competency evaluation, as identified in 144G.60, Subd. 4 and 144G.61 Subd 1. and 2, for two of two unlicensed personnel (ULP-K and ULP-M). This had the potential to affect all residents receiving medication and treatment services. [...]”

Rule cited: “When a facility contracts with a temporary staffing agency, those individuals must meet the same requirements required by this section for personnel employed by the facility and shall be treated as if they are staff of the facility.”

Summary: MDH found the licensee failed to ensure training and competency evaluations were completed for all required skill areas, prior to providing services, for

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure training and competency evaluations were completed for all required skill areas, prior to providing services, for four of four unlicensed personnel ((ULP)-Q, ULP-R, ULP-T and ULP-U). [...]”

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 four of four unlicensed personnel ((ULP)-Q, ULP-R, ULP-T and ULP-U).

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 four of four unlicensed personnel ((ULP)-Q, ULP-R, ULP-T and ULP-U). [...]”

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 the registered nurse (RN) conducted training and competency evaluations for seven of seven unlicensed personnel (ULP)-B, ULP-M, ULP-Q, ULP-R, ULP-S, ULP-T, ULP-U) who utilized full body mechanical lift (Hoyer) transfers and provided catheter cares.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure the registered nurse (RN) conducted training and competency evaluations for seven of seven unlicensed personnel (ULP)-B, ULP-M, ULP-Q, ULP-R, ULP-S, ULP-T, ULP-U) who utilized full body mechanical lift (Hoyer) transfers and provided catheter cares. [...]”

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 a registered nurse (RN) conducted direct supervision of staff performing a delegated task within 30 days of providing services for five of five employees (unlicensed personnel (ULP)-B, ULP-Q, ULP-R, ULP-T and ULP-U).

MDH’s finding, as written: “Based on observation, 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 five of five employees (unlicensed personnel (ULP)-B, ULP-Q, ULP-R, ULP-T and ULP-U). [...]”

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 employees received orientation to 144G licensing requirements for two of five employees (unlicensed personnel (ULP)-Q and ULP-T) with employee records reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure employees received orientation to 144G licensing requirements for two of five employees (unlicensed personnel (ULP)-Q and ULP-T) with employee records reviewed. [...]”

Rule cited: “(a) 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 employees received orientation to assisted living facility licensing requirements and regulations prior to providing services for two of five employees (unlicensed personnel (ULP)- B, and ULP-U).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure employees received orientation to assisted living facility licensing requirements and regulations prior to providing services for two of five employees (unlicensed personnel (ULP)- B, and ULP-U). [...]”

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 staff received dementia training in the required areas for five of five employees (unlicensed personnel (ULP)-B, ULP-Q, ULP-R, ULP-T and ULP-U).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure staff received dementia training in the required areas for five of five employees (unlicensed personnel (ULP)-B, ULP-Q, ULP-R, ULP-T and ULP-U). [...]”

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 all employees that performed direct services completed all required training components for each twelve months of employment for two of two employees (unlicensed personnel (ULP)-B and ULP-U).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure all employees that performed direct services completed all required training components for each twelve months of employment for two of two employees (unlicensed personnel (ULP)-B and ULP-U). [...]”

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 direct-care staff completed the required amount of dementia care training in the required time frame for five of five employees unlicensed personnel (ULP)-B, ULP-Q, ULP-R, ULP-T and ULP-U), with employee records reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure direct-care staff completed the required amount of dementia care training in the required time frame for five of five employees unlicensed personnel (ULP)-B, ULP-Q, ULP-R, ULP-T and ULP-U), with employee records reviewed. [...]”

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 a conduct a nursing assessment by a registered nurse (RN) of the physical and cognitive needs for one of five residents (R8) on or before the admission date.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to a conduct a nursing assessment by a registered nurse (RN) of the physical and cognitive needs for one of five residents (R8) on or before the admission date. [...]”

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 the registered nurse (RN) conducted a comprehensive re-assessment following a change of condition for one of one resident (R8).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the registered nurse (RN) conducted a comprehensive re-assessment following a change of condition for one of one resident (R8). In addition, the licensee failed to ensure the RN conducted ongoing nursing assessments not to exceed every 90-days for four of five residents (R5, R6, R8, and R10). [...]”

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 current service plan included a signature or other authentication by the resident or resident's designated representative and the licensee to document agreement on the services to be provided for four of five residents (R5, R7, R8, and R13).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the current service plan included a signature or other authentication by the resident or resident's designated representative and the licensee to document agreement on the services to be provided for four of five residents (R5, R7, R8, and R13). [...]”

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 develop and maintain a current individualized medication management record for each resident to include all required content for two of five residents (R8 and R10).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop and maintain a current individualized medication management record for each resident to include all required content for two of five residents (R8 and R10). [...]”

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 administer medications according to provider orders for one of one resident (R9).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to administer medications according to provider orders for one of one resident (R9). 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 [...]”

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

Summary: MDH found the licensee failed to ensure the registered nurse (RN) developed training and competencies for unlicensed personnel (ULP) providing medications to residents for unplanned time away from home when the licensed nurse

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) developed training and competencies for unlicensed personnel (ULP) providing medications to residents for unplanned time away from home when the licensed nurse was not available for three of three employees (ULP-B, ULP-Q, and ULP-U). [...]”

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 observation, interview, and record review the licensee failed to ensure over the counter (OTC) drugs were stored as appropriate for one of one resident (R5). This practice resulted in a level two violation (a violation that did not harm a resident's health or safety but had the potential to have harmed a resident's health or safety, but was not likely to cause serious injury, impairment, or death), and was issued at an isolated scope (when one or a limited number of residents are [...]”

Rule cited: “An assisted living facility providing medication management services for over-the-counter drugs or dietary supplements must retain those items in the original labeled container with directions for use prior to setting up for immediate or later administration. [...]”

Summary: MDH found the licensee failed to ensure written or electronically recorded prescriptions were obtained for one of two residents (R5).

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 two residents (R5). This practice resulted in a level two violation (a violation that did not harm a resident's health or safety but had the potential to have harmed a resident's health or safety, but was not likely to cause serious injury, impairment, or death), and was issued at an isolated scope (when one or a limited number of residents are affected [...]”

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 (R5).

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 (R5). This practice resulted in a level two violation (a violation that did not harm a resident's health or safety but had the potential to have harmed a resident's health or safety, but was not likely to cause serious injury, impairment, or death), and was issued at an isolated scope (when one or a limited number of residents are affected or one or 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.”

Summary: MDH found the licensee failed to store all medications according to manufacturer's instructions when they failed to monitor the temperature of the secured unit medication refrigerator.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to store all medications according to manufacturer's instructions when they failed to monitor the temperature of the secured unit medication refrigerator. This had the potential to affect all residents with refrigerated medications. [...]”

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 time sensitive medications were dated when opened

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure time sensitive medications were dated when opened for four of four residents (R24, R25, R26, and R28) with time sensitive medications. In addition, the licensee failed to ensure to discard expired medication were removed from five out of five medication carts observed. [...]”

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 provide documentation in the resident's record regarding the disposition of medication to include the medication strength, prescription number, quantity, date of disposition,

MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide documentation in the resident's record regarding the disposition of medication to include the medication strength, prescription number, quantity, date of disposition, and names of staff and other individuals involved in the disposition for one of one discharged resident (R1). [...]”

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 and implement a treatment or therapy management plan to include all required content and failed to include all treatments or therapies ordered for one of one resident (R10).

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 and failed to include all treatments or therapies ordered for one of one resident (R10). [...]”

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) instructed and ensured competency of the unlicensed personnel (ULP) on proper treatment procedures, specified, in writing, specific treatment instructions for each resident, and documented those instructions in the resident record for one of one resident (R10) with record reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure the registered nurse (RN) instructed and ensured competency of the unlicensed personnel (ULP) on proper treatment procedures, specified, in writing, specific treatment instructions for each resident, and documented those instructions in the resident record for one of one resident (R10) with record 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 ensure up-to-date written or electronically recorded treatment orders were maintained for one of one resident (R8).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure up-to-date written or electronically recorded treatment orders were maintained for one of one resident (R8). [...]”

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 provide a hazard vulnerability assessment or safety risk assessment of the physical environment with mitigation factors on and around the property for the facility.

MDH’s finding, as written: “Based on record review and interview, the licensee failed to provide a hazard vulnerability assessment or safety risk assessment of the physical environment with mitigation factors on and around the property for the facility. This deficient practice had the ability to affect all staff, residents, and visitors. [...]”

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 policies and procedures for assisted living with dementia care (ALFDC) were provided to residents or the resident's legal and/or designated representative at the time of move-in for one of one residents (R13).

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 or the resident's legal and/or designated representative at the time of move-in for one of one residents (R13). [...]”

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 ensure staff working in the dementia care unit were trained in person-centered care approach for two of three unlicensed personnel (ULP)-Q and ULP-T with records reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure staff working in the dementia care unit were trained in person-centered care approach for two of three unlicensed personnel (ULP)-Q and ULP-T with records reviewed. [...]”

Rule cited: “(a) The licensee must ensure that staff who provide support to residents with dementia can demonstrate a basic understanding and ability to apply dementia training to the residents' emotional and unique health care needs using person-centered planning [...]”

Summary: MDH found the licensee failed to have a written individualized activity evaluation that addressed all provisions for two of two residents (R10 and R13).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to have a written individualized activity evaluation that addressed all provisions for two of two residents (R10 and R13). [...]”

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 in written or electronic form to residents, families, or other persons who request it, an accurate description of the dementia care training program with the required content.

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, an accurate description of the dementia care training program with the required content. [...]”

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 provide care and services according to acceptable health care, medical or nursing standards for two of five residents (R5 and 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 (R5 and 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 ensure unlicensed personnel (ULP)-N followed appropriate medication administration procedures.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure unlicensed personnel (ULP)-N followed appropriate medication administration procedures. 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 portion or [...]”

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 one of one resident (R7) was treated with courtesy, respect, dignity, and privacy when assisted with activities of daily living.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure one of one resident (R7) was treated with courtesy, respect, dignity, and privacy when assisted with activities of daily living. [...]”

Rule cited: “Residents have the right to be treated with courtesy and respect, and to have the resident's property treated with respect”

Summary: MDH found the licensee failed to ensure privacy was maintained for two of two residents (R10 and R13) observed during medication and treatment administration.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure privacy was maintained for two of two residents (R10 and R13) observed during medication and treatment administration. [...]”

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 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 to the facility.

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 to the facility. [...]”

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 [...]”