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

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 [...]”

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

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

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

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. [...]”

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

Rule cited: “(d) The contract must include a description of the facility's complaint resolution process available to residents, including the name and contact information of the person representing the facility who is designated to handle and resolve complaints. [...]”

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

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. [...]”

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

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 one of one unlicensed personnel (ULP-L).

MDH’s finding, as written: “Based on interview and record review, 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 one of one unlicensed personnel (ULP-L). 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.”

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

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 [...]”

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

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. [...]”

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

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: “No further action required.”

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.”

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 [...]”

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

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 [...]”

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

Rule cited: “Persons providing or overseeing staff training must have experience and knowledge in the care of individuals with dementia, including: (1) two years of work experience related to Alzheimer's disease or other dementias, or in health care, gerontology, or [...]”

Summary: MDH found the licensee failed to provide smoke alarms outside each separate sleeping area in the immediate vicinity of bedrooms.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to provide smoke alarms outside each separate sleeping area in the immediate vicinity of bedrooms. This deficient condition had the potential to affect all staff, residents, and visitors. [...]”

Rule cited: “(a) Each assisted living facility must comply with the State Fire Code in Minnesota Rules, chapter 7511, and: (1) for dwellings or sleeping units, as defined in the State Fire Code: (i) provide smoke alarms in each room used for sleeping purposes; (ii) [...]”

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 provide fire safety and evacuation plans with the required elements; failed to provide the required frequency for employee and resident training on fire safety and evacuation; and failed to document the required employee evacuation drills.

MDH’s finding, as written: “Based on record review and interview, the licensee failed to provide fire safety and evacuation plans with the required elements; failed to provide the required frequency for employee and resident training on fire safety and evacuation; and failed to document the required employee evacuation drills. This deficient condition 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 develop and execute a written assisted living contract/rental agreement with the required content for one of one contracted staff, unlicensed personnel (ULP)-J, who obtained temporarily housing by the licensee.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to develop and execute a written assisted living contract/rental agreement with the required content for one of one contracted staff, unlicensed personnel (ULP)-J, who obtained temporarily housing by the licensee. This had the potential to affect all residents. [...]”

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 assisted living contract with the required content for three of three residents (R2, R3, R4).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to execute a written assisted living contract with the required content for three of three residents (R2, R3, R4). This had the potential to affect all 28 residents. [...]”

Rule cited: “(d) The contract must include a description of the facility's complaint resolution process available to residents, including the name and contact information of the person representing the facility who is designated to handle and resolve complaints. [...]”

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.

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. Further, the licensee failed to notify the Office of Ombudsman for Long-Term Care of resident relocation within four days for one of one resident (R4). [...]”

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 submitted and clearance was received in affiliation with the assisted living with dementia care license for one of two employees (director or nursing/registered nurse (DON/RN-B).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure a background study was submitted and clearance was received in affiliation with the assisted living with dementia care license for one of two employees (director or nursing/registered nurse (DON/RN-B). [...]”

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 service plans included the required content for three of three residents (R2, R3, R4).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure service plans included the required content for three of three residents (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) 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 [...]”

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 three of three residents (R2, R3, 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 three of three residents (R2, R3, 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 prior to delegating the nursing task of medication administration, the unlicensed personnel (ULP) demonstrated competency for administering medications.

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 for administering medications. This had the potential to affect all 28 residents receiving assisted living services. [...]”

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 administered as prescribed and administered according to manufacturer's instructions for one of three residents (R2).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure medications were administered as prescribed and administered according to manufacturer's instructions for one of three residents (R2). [...]”

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 refrigerated medications were maintained at manufacturer recommended temperatures by failing to monitor and document medication refrigerator temperatures.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure refrigerated medications were maintained at manufacturer recommended temperatures by failing to monitor and document medication refrigerator temperatures. [...]”

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 prior to delegating the nursing task of blood glucose monitoring, unlicensed personnel (ULP) demonstrated competency to perform the tasks or procedure to the registered nurse (RN) for one of one employee (ULP-D).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure prior to delegating the nursing task of blood glucose monitoring, unlicensed personnel (ULP) demonstrated competency to perform the tasks or procedure to the registered nurse (RN) for one of one employee (ULP-D). [...]”

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 provide a safety risk assessment or hazard vulnerability assessment of the physical environment 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 safety risk assessment or hazard vulnerability assessment of the physical environment 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 [...]”

MDH’s finding, as written: “2110 - F Based on interview and record review, the licensee failed to ensure the required dementia care policies and procedures were provided to each resident and/or the resident's legal and designated representatives for three of three residents (R2, R3, R4). [...]”

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 the designated person overseeing staff training in the care of individuals with dementia [resident assisted living director (RALD)-A or director of nursing/registered nurse (DON/RN-B)], had documented evidence of competency or knowledge test required by the commissioner.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the designated person overseeing staff training in the care of individuals with dementia [resident assisted living director (RALD)-A or director of nursing/registered nurse (DON/RN-B)], had documented evidence of competency or knowledge test required by the commissioner. This had the potential to affect all residents and staff of the facility. [...]”

Rule cited: “Persons providing or overseeing staff training must have experience and knowledge in the care of individuals with dementia, including: (1) two years of work experience related to Alzheimer's disease or other dementias, or in health care, gerontology, or [...]”