Senior Living, 7949 Brunswick Avenue North

MDH’s finding, as written: “Based on interview and record review, the licensee failed to implement and maintain a quality management program appropriate to the size of the facility and relevant to the type of services provided. This had the potential to affect all current clients, staff and visitors. [...]”

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

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to immediately report an incident to the Minnesota Adult Abuse Reporting Center (MAARC) for one of one resident (R3) who did not return to the facility when expected. [...]”

Rule cited: “(a) The assisted living facility must comply with the requirements for the reporting of maltreatment of vulnerable adults in section 626.557. [...]”

Summary: MDH found the licensee failed to ensure the employee record contained the required content, including a job description for one of two employees (unlicensed personnel (ULP)-C).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the employee record contained the required content, including a job description for one of two employees (unlicensed personnel (ULP)-C). [...]”

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 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), which included a two-step tuberculin skin test (TST) or other evidence of TB screening such as a blood test, history and symptom screen, and TB training for two of three employees (unlicensed personnel (ULP)-C, ULP-E).

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), which included a two-step tuberculin skin test (TST) or other evidence of TB screening such as a blood test, history and symptom screen, and TB training for two of three employees (unlicensed personnel (ULP)-C, ULP-E). [...]”

Rule cited: “(a) The facility must establish and maintain a comprehensive tuberculosis infection control program according to the most current tuberculosis infection control guidelines issued by the United States Centers for Disease Control and Prevention (CDC), Division [...]”

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 and failed to evaluate/revise the missing resident policy at least quarterly. This had the potential to affect all four residents receiving services under the assisted living 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 maintain records in resident records with current, legible, permanently recorded, dated, and authenticated with the name and title of the person making the entry for two of four residents (R1, R6).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to maintain records in resident records with current, legible, permanently recorded, dated, and authenticated with the name and title of the person making the entry for two of four residents (R1, R6). [...]”

Rule cited: “(a) Assisted living facilities must maintain records for each resident for whom it is providing services. [...]”

Summary: MDH found the licensee failed to ensure health and medical information were kept private.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure health and medical information were kept private. This had the potential to affect all residents and visitors. [...]”

Rule cited: “(b) Resident records, whether written or electronic, must be protected against loss, tampering, or unauthorized disclosure in compliance with chapter 13 and other applicable relevant federal and state laws. [...]”

Summary: MDH found the licensee failed to ensure resident records included a discharge summary with the required content for one of one discharged resident (R3), and failed to maintain documentation of medication management for three of three residents (R1, R4, R5).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure resident records included a discharge summary with the required content for one of one discharged resident (R3), and failed to maintain documentation of medication management for three of three residents (R1, R4, R5). [...]”

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, 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.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to maintain 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. 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 and provide the required training and drills.

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

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

Summary: MDH found the licensee failed to ensure physical facility elements did not constitute a distinct hazard to life.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to ensure physical facility elements did not constitute a distinct hazard to life. The licensee failed to provide resident bedrooms with the minimum window opening meeting the minimum state standard for egress. This had the potential to affect some residents, staff, and visitors. [...]”

Rule cited: “(g) Existing construction or elements, including assisted living facilities that were registered as housing with services establishments under chapter 144D prior to August 1, 2021, shall be permitted to continue in use provided such use does not constitute a [...]”

Summary: MDH found the licensee failed to execute a written contract prior to providing assisted living services for four of four residents (R1, R4, R5, R6).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to execute a written contract prior to providing assisted living services for four of four residents (R1, R4, R5, R6). [...]”

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 four of four residents (R1, R4, R5, R6).

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 (R1, R4, R5, R6). 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 or all [...]”

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 four of four residents (R1, R4, R5, R6).

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 (R1, R4, R5, R6). 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 or all [...]”

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 four of four resident's (R1, R4, R5, R6) assisted living contract included a notice with the required verbiage for the residents to identify a designated representative.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure four of four resident's (R1, R4, R5, R6) assisted living contract included a notice with the required verbiage for the residents to identify a designated representative. [...]”

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 facility's liability for health, safety, or personal property of a resident.

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. This had the potential to affect all current 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 required content for an emergency relocation 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 required content for an emergency relocation for one of one resident (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 a widespread scope (when problems are pervasive or represent a systemic [...]”

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 background studies were conducted prior to staff providing services, for one of six employees (unlicensed personnel (ULP)-C).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure background studies were conducted prior to staff providing services, for one of six employees (unlicensed personnel (ULP)-C). [...]”

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 the registered nurse (RN) completed supervision of a ULP within 30 calendar days of beginning to provide delegated tasks and thereafter as needed based on performance for two of two employees (unlicensed personnel (ULP)-B, ULP-E).

MDH’s finding, as written: “Based on observation, 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 and thereafter as needed based on performance for two of two employees (unlicensed personnel (ULP)-B, ULP-E). [...]”

Rule cited: “(a) Staff who perform delegated nursing or therapy tasks must be supervised by an appropriate licensed health professional or a registered nurse according to the assisted living facility's policy where the services are being provided to verify that the work [...]”

Summary: MDH found the licensee failed to ensure orientation to assisted living facility licensing requirements and regulations included all required content for two of three employees (unlicensed personnel (ULP)-C, and ULP-E).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure orientation to assisted living facility licensing requirements and regulations included all required content for two of three employees (unlicensed personnel (ULP)-C, and ULP-E). [...]”

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 on required annual training topics for one of one employee (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 on required annual training topics for one of one employee (unlicensed personnel (ULP)-B). [...]”

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 received at least eight hours of initial training on topics specified under paragraph (b) within 160 working hours of the employment start date for one of two direct care employees (unlicensed personnel (ULP)-E).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure direct-care staff received at least eight hours of initial training on topics specified under paragraph (b) within 160 working hours of the employment start date for one of two direct care employees (unlicensed personnel (ULP)-E). [...]”

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 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.

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

Rule cited: “(5) new employees may satisfy the initial training requirements by producing written proof of previously completed required training within the past 18 months. [...]”

Summary: MDH found the licensee failed to ensure a registered nurse (RN) conducted a nursing assessment of the physical and cognitive needs of the resident for four of four residents (R1, R4, R5, R6).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure a registered nurse (RN) conducted a nursing assessment of the physical and cognitive needs of the resident for four of four residents (R1, R4, R5, R6). [...]”

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 ongoing nursing assessment, not to exceed 14 calendar days from the date of start of services, and ongoing assessment not to exceed 90 days for one of three residents (R4).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the registered nurse (RN) conducted ongoing nursing assessment, not to exceed 14 calendar days from the date of start of services, and ongoing assessment not to exceed 90 days for one of three residents (R4). [...]”

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 included a signature or other authentication by the resident and the facility to document agreement on the services to be provided for two of three residents (R1, R5).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the service plan included a signature or other authentication by the resident and the facility to document agreement on the services to be provided for two of three residents (R1, R5). [...]”

Rule cited: “(a) No later than 14 calendar days after the date that services are first provided, an assisted living facility shall finalize a current written service plan. [...]”

Summary: MDH found the licensee failed to ensure the service plan included

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

Summary: MDH found the licensee failed to ensure the registered nurse (RN) completed annual medication reassessments for one of two residents (R4).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the registered nurse (RN) completed annual medication reassessments for one of two 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 [...]”

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 prior to delegating the nursing task of medication administration, the unlicensed personnel (ULP) demonstrated competency to a registered nurse (RN) for administering medications for two of two ULPs (ULP-E, ULP-C).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure prior to delegating the nursing task of medication administration, the unlicensed personnel (ULP) demonstrated competency to a registered nurse (RN) for administering medications for two of two ULPs (ULP-E, ULP-C). [...]”

Rule cited: “When administration of medications is delegated to unlicensed personnel, the assisted living facility must ensure that the registered nurse has: (1) instructed the unlicensed personnel in the proper methods to administer the medications, and the unlicensed [...]”

Summary: MDH found the licensee failed to ensure medications were documented after administration for two of two residents (R1, R4).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medications were documented after administration for two of two residents (R1, R4). In addition, the licensee failed to transcribe provider orders for one of one resident (R1) receiving medication management services. [...]”

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 documentation of medication setup was completed accurately at the time of set up for four of four residents (R1, R4, R5, R6).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure documentation of medication setup was completed accurately at the time of set up for four of four residents (R1, R4, R5, R6). [...]”

Rule cited: “Documentation of dates of medication setup, name of medication, quantity of dose, times to be administered, route of administration, and name of person completing medication setup must be done at the time of setup.”

Summary: MDH found the licensee failed to ensure the registered nurse (RN) developed comprehensive written procedures for the unlicensed personnel (ULP) providing medications for residents having unplanned time away when the licensed nurse was not available.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the registered nurse (RN) developed comprehensive written procedures for the unlicensed personnel (ULP) providing medications for residents having unplanned time away when the licensed nurse was not available. [...]”

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 ensure current written or electronically recorded prescriptions were obtained for four of four residents (R1, R4, R5, R6) receiving medication management services.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure current written or electronically recorded prescriptions were obtained for four of four residents (R1, R4, R5, R6) receiving medication management services. [...]”

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 store prescription medication securely to permit only authorized personnel to have access.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to store prescription medication securely to permit only authorized personnel to have access. 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 document in the resident's record the disposition of the medications as required for one of one resident (R3) upon discharge.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to document in the resident's record the disposition of the medications as required for one of one resident (R3) upon discharge. [...]”

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. [...]”