Saint Therese of Oxbow Lake

Summary: MDH found the licensee failed to ensure two of two staff (registered nurse (RN)-A, unlicensed personnel (ULP)-B) received emergency preparedness

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure two of two staff (registered nurse (RN)-A, unlicensed personnel (ULP)-B) received emergency preparedness training and education upon hire and annually thereafter. This had the potential to effect all 45 residents, staff and visitors. [...]”

Rule cited: “(a) The facility must meet the following requirements: (1) have a written emergency disaster plan that contains a plan for evacuation, addresses elements of sheltering in place, identifies temporary relocation sites, and details staff assignments in the event [...]”

Summary: MDH found the licensee failed to ensure the residents were given the opportunity to designate a representative when signing the assisted living contract as required for two of four residents (R2, R12).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the residents were given the opportunity to designate a representative when signing the assisted living contract as required for two of four residents (R2, R12). [...]”

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 facility's liability for health, safety or personal property of a resident for four of four residents (R2, R3, R4, R12). [...]”

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 ensure employees received orientation to all required assisted living regulation content for two of two employees (registered nurse (RN-A), and unlicensed personnel (ULP)-B).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure employees received orientation to all required assisted living regulation content for two of two employees (registered nurse (RN-A), and unlicensed personnel (ULP)-B). [...]”

Rule cited: “(a) The orientation must contain the following topics: (1) an overview of this chapter; (2) an introduction and review of the facility's policies and procedures related to the provision of assisted living services by the individual staff person; (3) handling [...]”

Summary: MDH found the licensee failed to ensure employees received at least eight hours of annual training for each 12 months of employment for one of two employees (unlicensed personnel (ULP)-B).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure employees received at least eight hours of annual training for each 12 months of employment for one of two employees (unlicensed personnel (ULP)-B). In addition, the licensee failed to include all required training topics for the annual training. [...]”

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 the required amount of dementia care training was completed in the required time frame for two of two employees (registered nurse (RN)-A, unlicensed personnel (ULP)-B).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the required amount of dementia care training was completed in the required time frame for two of two employees (registered nurse (RN)-A, unlicensed personnel (ULP)-B). This had the potential to affect all residents of the facility. [...]”

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 complete a pre-admission assessment by a registered nurse (RN) for one of one resident (R11) on or before the admission date.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to complete a pre-admission assessment by a registered nurse (RN) for one of one resident (R11) on or before the admission date. [...]”

Rule cited: “(a) Residents who are not receiving any services shall not be required to undergo an initial nursing assessment. [...]”

Summary: MDH found the licensee failed to ensure the registered nurse

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the registered nurse (RN) conducted ongoing resident monitoring and reassessments, not to exceed 90 calendar days from the last date of assessment for one of four residents (R3). In addition, the licensee failed to accurately reflect the licensee's ability to conduct change of condition assessments and update the service plan over the weekend for one of four residents (R3). [...]”

Rule cited: “(c) Resident reassessment and monitoring must be conducted no more than 14 calendar days after initiation of services. [...]”

Summary: MDH found the licensee failed to initiate a temporary service plan as required, for one of one resident (R11).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to initiate a temporary service plan as required, for one of one resident (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) 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 [...]”

Rule cited: “When a facility initiates services and the individualized assessment required in subdivision 2 has not been completed, the facility must complete a temporary plan and agreement with the resident for services. [...]”

Summary: MDH found the licensee failed to ensure the service plan included the required content for four of four residents (R1, R2, R3, R4).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the service plan included the required content for four of four residents (R1, R2, R3, R4). 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: “(f) The service plan must include: (1) a description of the services to be provided, the fees for services, and the frequency of each service, according to the resident's current assessment and resident preferences; (2) the identification of staff or [...]”

Summary: MDH found the licensee failed to develop and maintain a current individualized medication management record to include all required content for one of four residents (R4).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to develop and maintain a current individualized medication management record to include all required content for one of four residents (R4). [...]”

Rule cited: “(a) For each resident receiving medication management services, the assisted living facility must prepare and include in the service plan a written statement of the medication management services that will be provided to the resident. [...]”

Summary: MDH found the licensee failed to ensure medications were administered per providers orders for one of seven residents (R6).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure medications were administered per providers orders for one of seven residents (R6). 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: “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. [...]”

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 (R4). 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 ensure medications were maintained bearing the original prescription label with legible information for two of 20 residents (R1, R2) and failed to discard expired medication for five of 20 residents (R1, R2, R7,

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure medications were maintained bearing the original prescription label with legible information for two of 20 residents (R1, R2) and failed to discard expired medication for five of 20 residents (R1, R2, R7, R8, R10). In addition, the licensee failed to ensure time sensitive medications were labeled with the date opened for three of three residents (R3, R7, R15). [...]”

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 include in the service plan the treatments the resident received for two of four residents (R2, R4).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to include in the service plan the treatments the resident received for two of four residents (R2, R4). In addition, licensee failed to develop and implement a treatment or therapy management plan to include all required content for four of four residents (R1, R2, R3, R4). [...]”

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 conduct a hazard vulnerability or safety risk assessment on or around the facility property.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to conduct a hazard vulnerability or safety risk assessment on or around the facility property. This had the potential to directly affect all residents, staff, 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 maintain a dignified dining experience for all of the memory care residents during the breakfast meal period.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to maintain a dignified dining experience for all of the memory care residents during the breakfast meal period. [...]”

Rule cited: “The licensee of an assisted living facility with dementia care is responsible for the care and housing of the persons with dementia and the provision of person-centered care that promotes each resident's dignity, independence, and comfort. [...]”

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 two of four residents (R1, R3).

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 two of four residents (R1, R3). [...]”

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 provide care and services according to acceptable health care standards, medical or nursing standards with medication administration for four of four residents (R1, R12, R13, R14).

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 standards, medical or nursing standards with medication administration for four of four residents (R1, R12, R13, R14). [...]”

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.”