Shelter Arm

Summary: MDH found the licensee failed to ensure that personnel records were readily available for access to the commissioner upon request.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure that personnel records were readily available for access to the commissioner upon request. 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 [...]”

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. [...]”

Rule cited: “(2) install and maintain portable fire extinguishers in accordance with the State Fire Code; (3) install portable fire extinguishers having a minimum 2-A:10-B:C rating within Group R-3 occupancies, as defined by the State Fire Code, located so that the travel [...]”

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 [...]”

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

Rule cited: “(a) Unlicensed personnel providing assisted living services must have: (1) successfully completed a training and competency evaluation appropriate to the services provided by the facility and the topics listed in section 144G.61, subdivision 2, paragraph (a); [...]”

Rule cited: “(b) Unlicensed personnel performing delegated nursing tasks in an assisted living facility must: (1) have successfully completed training and demonstrated competency by successfully completing a written or oral test of the topics in section 144G.61, [...]”

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 [...]”

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 [...]”

Rule cited: “(a) All assisted living facilities must meet the following dementia care, mental illness, and de-escalation training requirements: (1) supervisors of direct-care staff must have at least eight hours of initial training on dementia topics specified under [...]”

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 provide care and services according to acceptable health care standards, medical or nursing standards for one of one resident (R3) who utilized a side rail.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide care and services according to acceptable health care standards, medical or nursing standards for one of one resident (R3) who utilized a side rail. [...]”

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 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 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 a Department of Human Services (DHS) background study (BGS) was submitted, cleared, and affiliated with the licensee's current assisted living facility's health facility identification (HFID) number for three of three unlicensed personnel ((ULP)-B, ULP-D,

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure a Department of Human Services (DHS) background study (BGS) was submitted, cleared, and affiliated with the licensee's current assisted living facility's health facility identification (HFID) number for three of three unlicensed personnel ((ULP)-B, ULP-D, ULP-E). Additionally, the licensee failed to provide continuous direct supervision of employees who did not have a cleared BGS and provided services to residents. [...]”

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 one of two unlicensed personnel ((ULP)-B) had completed training and competency evaluations in all required topics.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure one of two unlicensed personnel ((ULP)-B) had completed training and competency evaluations in all required topics. This had the potential to affect all residents living in the facility. [...]”

Rule cited: “(a) Unlicensed personnel providing assisted living services must have: (1) successfully completed a training and competency evaluation appropriate to the services provided by the facility and the topics listed in section 144G.61, subdivision 2, paragraph (a); [...]”

Summary: MDH found the licensee failed to ensure one of two unlicensed personnel ((ULP)-B) had completed training and competency evaluations in all required topics.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure one of two unlicensed personnel ((ULP)-B) had completed training and competency evaluations in all required topics. This had the potential to affect all residents living in the facility. [...]”

Rule cited: “(b) Unlicensed personnel performing delegated nursing tasks in an assisted living facility must: (1) have successfully completed training and demonstrated competency by successfully completing a written or oral test of the topics in section 144G.61, [...]”

Summary: MDH found the licensee failed to ensure one of two unlicensed personnel ((ULP)-B) were supervised within 30 days of being trained for a delegated a nursing tasks by the clinical nurse supervisor (CNS)-C.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure one of two unlicensed personnel ((ULP)-B) were supervised within 30 days of being trained for a delegated a nursing tasks by the clinical nurse supervisor (CNS)-C. [...]”

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 one of two unlicensed personnel ((ULP)-B) had completed an orientation in all required topics.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure one of two unlicensed personnel ((ULP)-B) had completed an orientation in all required topics. This had the potential to affect all residents living in the facility. [...]”

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 [...]”

MDH’s finding, as written: “Based on interview and record review the licensee failed to provide evidence of dementia care training on required topics for one of two unlicensed personnel ((ULP)-B). [...]”

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 medications were stored securely for one of one discharged resident (R1).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medications were stored securely for one of one discharged resident (R1). 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: “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 provide care and services according to acceptable health care standards, medical or nursing standards for one of one resident (R3) with transfers and who utilized a side rail.

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 for one of one resident (R3) with transfers and who utilized a side rail. [...]”

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.”