Sister Support, Rockford Road

Summary: MDH found the licensee failed to ensure the appropriate records for residents and staff were readily available for timely access to the commissioner authorized to access the records.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the appropriate records for residents and staff were readily available for timely access to the commissioner authorized to access the records. [...]”

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. [...]”

MDH’s finding, as written: “Based on interview and record review the licensee failed to complete a discharge summary 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 a widespread scope (when problems are pervasive or represent a systemic failure that has affected or has [...]”

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 provide smoke alarms that functioned and are interconnected so that the actuation of one alarm causes all alarms in the dwelling unit to actuate.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to provide smoke alarms that functioned and are interconnected so that the actuation of one alarm causes all alarms in the dwelling unit to actuate. This deficient condition had the ability to affect all staff and residents. [...]”

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 facility's 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's 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 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 provide facilities that were not a distinct hazard to life.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to provide facilities that were not a distinct hazard to life. This had the potential to directly affect all residents and staff. [...]”

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 with the required content on, or before, the date of admission for one of one resident (R1).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to execute a written contract with the required content on, or before, the date of admission for one of one resident (R1). [...]”

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 include verbatim language, separate from the resident contract, giving residents the right to identify a designated representative for one of one resident (R1).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to include verbatim language, separate from the resident contract, giving residents the right to identify a designated representative for one of one resident (R1). [...]”

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 [...]”

MDH’s finding, as written: “Based on observation, interview, and record review, licensee failed to prepare a relocation plan that included documentation of considerations for the care needs, psychosocial impacts of moving, and accounting of resident's property prior to initiating a transfer of a resident (R1) receiving assisted living services. [...]”

Rule cited: “The facility must prepare a relocation plan to prepare for the move to a new safe location or appropriate service provider, as required by this section.”

Summary: MDH found the facility failed to provide a 30-day advance written notice to the resident and/or the resident's legal/designated representative, prior to initiating a transfer for one of one resident (R1).

MDH’s finding, as written: “Based on interview and record review, the facility failed to provide a 30-day advance written notice to the resident and/or the resident's legal/designated representative, prior to initiating a transfer for one of one resident (R1). [...]”

Rule cited: “(a) A facility must provide at least 30 calendar days' advance written notice to the resident and the resident's legal and designated representative of a facility-initiated transfer. [...]”

MDH’s finding, as written: “Based on interview and record review, licensee failed to provide advance notice to residents, legal representatives, designated representatives or provide notice to the Office of Ombudsman for Long Term Care prior to initiating the transfer of a resident receiving assisted living services. [...]”

Rule cited: “(a) In situations where there is a curtailment, reduction, or capital improvement within a facility necessitating transfers, the facility must: (1) minimize the number of transfers it initiates to complete the project or change in operations; (2) consider [...]”

Summary: MDH found the licensee failed to ensure a background study was submitted and received in affiliation with the assisted living license for two of two employees (unlicensed personnel (ULP)-B, ULP-C).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure a background study was submitted and received in affiliation with the assisted living license for two of two employees (unlicensed personnel (ULP)-B, 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 training and competency evaluations were completed for all required skill areas, prior to providing services, 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 training and competency evaluations were completed for all required skill areas, prior to providing services, for one of one employee (unlicensed personnel (ULP)-B). [...]”

Rule cited: “(a) Training and competency evaluations for all unlicensed personnel must include the following: (1) documentation requirements for all services provided; (2) reports of changes in the resident's condition to the supervisor designated by the facility; (3) [...]”

Summary: MDH found the licensee failed to ensure training and competency evaluations were completed for all required skill areas, prior to providing services, 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 training and competency evaluations were completed for all required skill areas, prior to providing services, for one of one employee (unlicensed personnel (ULP)-B). [...]”

Rule cited: “(b) In addition to paragraph (a), training and competency evaluation for unlicensed personnel providing assisted living services must include: (1) observing, reporting, and documenting resident status; (2) basic knowledge of body functioning and changes in [...]”

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 one employee (unlicensed personnel (ULP)-B)

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 one employee (unlicensed personnel (ULP)-B) 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 [...]”

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 conduct a nursing assessment by a registered nurse (RN) of the physical and cognitive needs to include all parts of a uniform assessment tool (Minn. Rule 4659.0150) for one of one resident (R1) on or before the admission date.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to conduct a nursing assessment by a registered nurse (RN) of the physical and cognitive needs to include all parts of a uniform assessment tool (Minn. Rule 4659.0150) for one of one resident (R1) on or before the admission date. [...]”

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 a comprehensive assessment within fourteen days of the initiation of services and every 90 days thereafter for one of one resident (R1).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the registered nurse (RN) conducted a comprehensive assessment within fourteen days of the initiation of services and every 90 days thereafter for one of one resident (R1). In addition, the licensee failed to ensure all areas of the uniform assessment tool as required per Minnesota Administrative Rule 4659.0150 were addressed. [...]”

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 for one of one resident (R1).

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

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 was finalized and included a signature or other authentication by the resident and the facility within 14 calendar days after the date services were first provided for one of one resident (R1).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the service plan was finalized and included a signature or other authentication by the resident and the facility within 14 calendar days after the date services were first provided for one of one resident (R1). [...]”

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. [...]”