Shiloh Assisted Living

Summary: MDH found the licensee failed to ensure R4's medications were stored in the locked medication cart.

MDH’s finding, as written: “Based on observation, interview and record reviewed, the licensee failed to ensure R4's medications were stored in the locked medication cart. 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 limited [...]”

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 monitor for expired medications being managed and stored by the licensee.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to monitor for expired medications being managed and stored by the licensee. 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: “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 document in the resident's record the disposition of the medications as required for one of one resident (R6) upon discharge.

MDH’s finding, as written: “Based on 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 (R6) 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. [...]”

MDH’s finding, as written: “No further action required.”

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

Summary: MDH found the licensee failed to post a menu a week in advance that was made available to all residents on the secured unit.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to post a menu a week in advance that was made available to all residents on the secured unit. This had the potential to affect all 18 residents. [...]”

Rule cited: “(13) offer to provide or make available at least the following services to residents: (i) at least three nutritious meals daily with snacks available seven days per week, according to the recommended dietary allowances in the United States Department of [...]”

Summary: MDH found the licensee failed to ensure infection control standards were followed by three of four unlicensed personnel (ULP)-E, ULP-F ULP-M, during personal cares for R2, R1, R11.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to ensure infection control standards were followed by three of four unlicensed personnel (ULP)-E, ULP-F ULP-M, during personal cares for R2, R1, R11. In addition, ULP-F failed to ensure reusable equipment was cleaned in-between resident use. [...]”

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 ensure individual abuse prevention plans (IAPP) were developed to include the required content for four of four residents (R6, R17, R18, R24) who had exhibited inappropriate sexual behaviors toward others.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure individual abuse prevention plans (IAPP) were developed to include the required content for four of four residents (R6, R17, R18, R24) who had exhibited inappropriate sexual behaviors toward others. [...]”

Rule cited: “(b) The facility must develop and implement an individual abuse prevention plan for each vulnerable adult. [...]”

Summary: MDH found the licensee failed to ensure the employee record contained the required content for one of three employees (unlicensed personnel (ULP)-F.

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

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).

MDH’s finding, as written: “Based on observation, 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). The licensee failed to ensure history and symptom screenings and screening for active TB (either a two-step tuberculin skin test (TST) or blood test) were completed and documented for one of three employees (unlicensed personnel (ULP)-H). [...]”

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 [...]”

Summary: MDH found the licensee failed to have a written emergency preparedness plan (EPP) with all the required content and failed to post an exit diagram in one of three buildings (Shiloh 2) prominently.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to have a written emergency preparedness plan (EPP) with all the required content and failed to post an exit diagram in one of three buildings (Shiloh 2) prominently. This had the potential to affect all Shiloh 2 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 maintain the facility physical environment in a continuous state of good repair and operation regarding the health, safety, and well-being of the residents.

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

MDH’s finding, as written: “Based on a record review and interview, the licensee failed to provide the required documentation of employee and resident training on fire safety and evacuation drills. This had the potential to affect all staff, residents, 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 the registered nurse (RN) provided written instructions in the resident's record for the delegated tasks provided by the unlicensed personnel (ULP) for one of three residents (R1) whose delegated tasks included personal cares, brace application, and sit to stand lift transfers.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) provided written instructions in the resident's record for the delegated tasks provided by the unlicensed personnel (ULP) for one of three residents (R1) whose delegated tasks included personal cares, brace application, and sit to stand lift transfers. [...]”

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 one of three employees, unlicensed personnel (ULP)-H's employee record contained orientation to assisted living facility licensing to include all the required topics.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure one of three employees, unlicensed personnel (ULP)-H's employee record contained orientation to assisted living facility licensing to include all the required topics. [...]”

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 the registered nurse (RN) completed a comprehensive reassessment on day 14 for one of three residents (R1) and for a change of condition/hospital return for one of two residents (R4).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) completed a comprehensive reassessment on day 14 for one of three residents (R1) and for a change of condition/hospital return for one of two 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 one of three residents (R1) service plans were revised to include provided services.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure one of three residents (R1) service plans were revised to include provided services. In addition, the licensee failed to ensure one of three residents (R4) service plans provided all services required by the current service plan. [...]”

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 medications were administered as prescribed for three of four residents (R8, R10, R1).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure medications were administered as prescribed for three of four residents (R8, R10, 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 a pattern scope (when more than a limited number of residents are [...]”

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 renew prescriptions at least every 12 months for one of three residents (R8).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to renew prescriptions at least every 12 months for one of three residents (R8). This practice resulted in a level two violation (a violation that did not harm a resident's health or safety but had the potential to have harmed a resident's health or safety, but was not likely to cause serious injury, impairment, or death) and was issued at an isolated scope (when one or a limited number of residents are affected or one or a [...]”

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

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure the medications were stored according to manufacturer's instructions by maintaining acceptable medication refrigerator temperatures. In addition, the licensee failed to ensure medication was secured in a locked area for R4. [...]”

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 date time-sensitive medications with an opened or expiration dates for six of seven residents (R4, R12, R13, R14, R15, R16).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to date time-sensitive medications with an opened or expiration dates for six of seven residents (R4, R12, R13, R14, R15, R16). In addition, the licensee failed to ensure medications were maintained bearing the original prescription label for three of seven residents (R14, R15, R4). Further, the licensee failed to monitor for expired medications for one of seven residents (R13). [...]”

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 document in the resident's record the required content on disposition of the medications for one of one resident (R5) upon discharge.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to document in the resident's record the required content on disposition of the medications for one of one resident (R5) 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. [...]”

Summary: MDH found the licensee failed to ensure prior to delegating nursing tasks, the registered nurse (RN) trained unlicensed personnel (ULP) to demonstrate the ability to follow the procedure to perform the tasks using the FreeStyle blood glucose (sugar) monitoring system (system that

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure prior to delegating nursing tasks, the registered nurse (RN) trained unlicensed personnel (ULP) to demonstrate the ability to follow the procedure to perform the tasks using the FreeStyle blood glucose (sugar) monitoring system (system that measures glucose levels through a small sensor, the size of two stacked quarters, applied to the back of the upper arm), for one of one resident (R10). [...]”

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 treatments or therapies were administered as prescribed for one of two residents (R3) with oxygen administration.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure treatments or therapies were administered as prescribed for one of two residents (R3) with oxygen administration. In addition, the licensee failed to ensure treatment or therapies were administered as directed, or to document the reason they were not and any follow up procedures that were provided to meet the resident's needs for one of three residents (R1) with health monitoring managed by the provider. [...]”

Rule cited: “Each treatment or therapy administered by an assisted living facility must be in the resident record. [...]”

Summary: MDH found the licensee failed to renew treatment orders at least every 12 months for one of one resident (R8).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to renew treatment orders at least every 12 months for one of one resident (R8). 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: “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 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 ensure one or more persons were physically present and available 24 hours a day, seven days a week, who were responsible for responding to requests for assistance with health and safety needs of residents in one of one secured unit (Dakota).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure one or more persons were physically present and available 24 hours a day, seven days a week, who were responsible for responding to requests for assistance with health and safety needs of residents in one of one secured unit (Dakota). This had the potential to affect all 18 residents residing in the secured unit. [...]”

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

Summary: MDH found the licensee failed to develop a comprehensive evaluation for activities and an individual activity plan (IAP) for one of three residents (R6) who received services under an assisted living with dementia care license.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop a comprehensive evaluation for activities and an individual activity plan (IAP) for one of three residents (R6) who received services under an assisted living with dementia care license. [...]”

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 ensure the care and services were provided according to acceptable health care and medical, or nursing standards for one of three residents (R1) with an assistive device of hospital-style bed rails.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure the care and services were provided according to acceptable health care and medical, or nursing standards for one of three residents (R1) with an assistive device of hospital-style bed rails. In addition, based on observation and interview the licensee failed to provide care and services according to acceptable health care, medical, or nursing standards for storage of oxygen for three of seventeen oxygen tanks. [...]”

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 10 of 18 residents (R8, R17, R19, R20, R21, R22, R23,

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure 10 of 18 residents (R8, R17, R19, R20, R21, R22, R23, R24, R25, R26) had the right to enter and leave the facility as they chose. [...]”

Rule cited: “Residents have the right to enter and leave the facility as they choose. This right may be restricted only as allowed by other law and consistent with a resident's service plan.”

MDH’s finding, as written: “Based on observation, and interview the licensee failed to ensure signage was posted at the main entry in one of two buildings (secured) of the establishment to display statutory language to disclose electronic monitoring activity, potentially affecting all 18 residents, staff and visitors of the licensee. [...]”

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. [...]”