S&O's Assisted Living

Summary: MDH found the licensee failed to provide smoke alarms inside and out-side resident rooms.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to provide smoke alarms inside and out-side resident rooms. This had the potential to directly affect all residents, staff, 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) [...]”

MDH’s finding, as written: “Not reviewed during this survey.”

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

MDH’s finding, as written: “Not reviewed during this survey.”

Rule cited: “(c) The contract must include: (1) a disclosure of the category of assisted living facility license held by the facility and, if the facility is not an assisted living facility with dementia care, a disclosure that it does not hold an assisted living facility [...]”

MDH’s finding, as written: “Not reviewed during this survey.”

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 [...]”

MDH’s finding, as written: “Not reviewed during this survey.”

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. [...]”

MDH’s finding, as written: “Not reviewed during this survey.”

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 [...]”

MDH’s finding, as written: “Not reviewed during this survey.”

Rule cited: “(3) for assisted living facilities with dementia care, direct-care staff must have completed at least eight hours of initial training on topics specified under paragraph (b) within 80 working hours of the employment start date. [...]”

MDH’s finding, as written: “Not reviewed during this survey.”

Rule cited: “(a) Residents who are not receiving any assisted living services shall not be required to undergo an initial nursing assessment. [...]”

MDH’s finding, as written: “Not reviewed during this survey.”

Rule cited: “(a) For each resident receiving medication management services, a registered nurse, advanced practice registered nurse, or qualified staff delegated the task by a registered nurse must prepare and include in the service plan a written statement of the [...]”

MDH’s finding, as written: “Not reviewed during this survey.”

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: “Not reviewed during this survey.”

Rule cited: “(a) The licensee must follow the assisted living license requirements and the criteria in this section. [...]”

MDH’s finding, as written: “Not reviewed during this survey.”

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 provide smoke alarms inside and outside resident rooms.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to provide smoke alarms inside and outside resident rooms. This had the potential to directly affect all residents, staff, 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 fire extinguishers as required throughout the facility.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to maintain fire extinguishers as required throughout the facility. This deficient condition had the ability to affect all staff, visitors, and residents. [...]”

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 [...]”

MDH’s finding, as written: “Not reviewed during this survey.”

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

MDH’s finding, as written: “Not reviewed during this survey.”

Rule cited: “(c) The contract must include: (1) a disclosure of the category of assisted living facility license held by the facility and, if the facility is not an assisted living facility with dementia care, a disclosure that it does not hold an assisted living facility [...]”

MDH’s finding, as written: “Not reviewed during this survey.”

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 [...]”

MDH’s finding, as written: “Not reviewed during this survey.”

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. [...]”

MDH’s finding, as written: “Not reviewed during this survey.”

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 [...]”

MDH’s finding, as written: “Not reviewed during this survey.”

Rule cited: “(3) for assisted living facilities with dementia care, direct-care staff must have completed at least eight hours of initial training on topics specified under paragraph (b) within 80 working hours of the employment start date. [...]”

MDH’s finding, as written: “Not reviewed during this survey.”

Rule cited: “(a) Residents who are not receiving any assisted living services shall not be required to undergo an initial nursing assessment. [...]”

MDH’s finding, as written: “Not reviewed during this survey.”

Rule cited: “(a) For each resident receiving medication management services, a registered nurse, advanced practice registered nurse, or qualified staff delegated the task by a registered nurse must prepare and include in the service plan a written statement of the [...]”

MDH’s finding, as written: “Not reviewed during this survey.”

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: “Not reviewed during this survey.”

Rule cited: “(a) The licensee must follow the assisted living license requirements and the criteria in this section. [...]”

MDH’s finding, as written: “Not reviewed during this survey.”

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 provide smoke alarms inside and outside resident rooms.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to provide smoke alarms inside and outside resident rooms. This had the potential to directly affect all residents, staff, 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 fire extinguishers as required throughout the facility.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to maintain fire extinguishers as required throughout the facility. This deficient condition had the ability to affect all staff, visitors, and residents. [...]”

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 [...]”

MDH’s finding, as written: “Not reviewed during this survey.”

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

MDH’s finding, as written: “Not reviewed during this survey.”

Rule cited: “(c) The contract must include: (1) a disclosure of the category of assisted living facility license held by the facility and, if the facility is not an assisted living facility with dementia care, a disclosure that it does not hold an assisted living facility [...]”

MDH’s finding, as written: “Not reviewed during this survey.”

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 [...]”

MDH’s finding, as written: “Not reviewed during this survey.”

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. [...]”

MDH’s finding, as written: “Not reviewed during this survey.”

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 [...]”

MDH’s finding, as written: “Not reviewed during this survey.”

Rule cited: “(3) for assisted living facilities with dementia care, direct-care staff must have completed at least eight hours of initial training on topics specified under paragraph (b) within 80 working hours of the employment start date. [...]”

MDH’s finding, as written: “Not reviewed during this survey.”

Rule cited: “(a) Residents who are not receiving any assisted living services shall not be required to undergo an initial nursing assessment. [...]”

MDH’s finding, as written: “Not reviewed during this survey.”

Rule cited: “(a) For each resident receiving medication management services, a registered nurse, advanced practice registered nurse, or qualified staff delegated the task by a registered nurse must prepare and include in the service plan a written statement of the [...]”

MDH’s finding, as written: “Not reviewed during this survey.”

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: “Not reviewed during this survey.”

Rule cited: “(a) The licensee must follow the assisted living license requirements and the criteria in this section. [...]”

MDH’s finding, as written: “Not reviewed during this survey.”

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 maintain fire extinguishers as required throughout the facility.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to maintain fire extinguishers as required throughout the facility. This deficient condition had the ability to affect all staff, visitors, and residents. [...]”

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 [...]”

MDH’s finding, as written: “Not reviewed during this survey.”

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

MDH’s finding, as written: “Not reviewed during this survey.”

Rule cited: “(c) The contract must include: (1) a disclosure of the category of assisted living facility license held by the facility and, if the facility is not an assisted living facility with dementia care, a disclosure that it does not hold an assisted living facility [...]”

MDH’s finding, as written: “Not reviewed during this survey.”

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 [...]”

MDH’s finding, as written: “Not reviewed during this survey.”

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. [...]”

MDH’s finding, as written: “Not reviewed during this survey.”

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 [...]”

MDH’s finding, as written: “Not reviewed during this survey.”

Rule cited: “(3) for assisted living facilities with dementia care, direct-care staff must have completed at least eight hours of initial training on topics specified under paragraph (b) within 80 working hours of the employment start date. [...]”

MDH’s finding, as written: “Not reviewed during this survey.”

Rule cited: “(a) Residents who are not receiving any assisted living services shall not be required to undergo an initial nursing assessment. [...]”

MDH’s finding, as written: “Not reviewed during this survey.”

Rule cited: “(a) For each resident receiving medication management services, a registered nurse, advanced practice registered nurse, or qualified staff delegated the task by a registered nurse must prepare and include in the service plan a written statement of the [...]”

MDH’s finding, as written: “Not reviewed during this survey.”

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: “Not reviewed during this survey.”

Rule cited: “(a) The licensee must follow the assisted living license requirements and the criteria in this section. [...]”

MDH’s finding, as written: “Not reviewed during this survey.”

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 maintain fire extinguishers as required throughout the facility.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to maintain fire extinguishers as required throughout the facility. This deficient condition had the ability to affect all staff, visitors, and residents. [...]”

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 [...]”

MDH’s finding, as written: “Not reviewed during this survey.”

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

MDH’s finding, as written: “Not reviewed during this survey.”

Rule cited: “(c) The contract must include: (1) a disclosure of the category of assisted living facility license held by the facility and, if the facility is not an assisted living facility with dementia care, a disclosure that it does not hold an assisted living facility [...]”

MDH’s finding, as written: “Not reviewed during this survey.”

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 [...]”

MDH’s finding, as written: “Not reviewed during this survey.”

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. [...]”

MDH’s finding, as written: “Not reviewed during this survey.”

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 [...]”

MDH’s finding, as written: “Not reviewed during this survey.”

Rule cited: “(3) for assisted living facilities with dementia care, direct-care employees must have completed at least eight hours of initial training on topics specified under paragraph (b) within 80 working hours of the employment start date. [...]”

MDH’s finding, as written: “Not reviewed during this survey.”

Rule cited: “(c) Resident reassessment and monitoring must be conducted no more than 14 calendar days after initiation of services. [...]”

MDH’s finding, as written: “Not reviewed during this survey.”

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: “Not reviewed during this survey.”

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: “Not reviewed during this survey.”

Rule cited: “(a) The licensee must follow the assisted living license requirements and the criteria in this section. [...]”

MDH’s finding, as written: “Not reviewed during this survey.”

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 maintain fire extinguishers as required throughout the facility.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to maintain fire extinguishers as required throughout the facility. This deficient condition had the ability to affect all staff, visitors, and residents. [...]”

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 [...]”

Summary: MDH found the licensee failed to develop the fire safety and evacuation plan with the required content, the licensee failed to document required fire safety evacuation training for employees and residents and complete the required annual fire 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, the licensee failed to document required fire safety evacuation training for employees and residents and complete the required annual fire 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 execute a written assisted living contract with the required content for one resident (R2).

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 one resident (R2). 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 of the [...]”

Rule cited: “(c) The contract must include: (1) a disclosure of the category of assisted living facility license held by the facility and, if the facility is not an assisted living facility with dementia care, a disclosure that it does not hold an assisted living facility [...]”

Summary: MDH found the licensee failed to execute a written contract with the required content for one of one resident (R2).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to execute a written contract with the required content for one of one resident (R2). 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 of the [...]”

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 a background study was affiliated to the current health facility identification (HFID) number for two of two employees (unlicensed personnel (ULP)-D and clincal nurse supervisor(CNS)-B, on the facility provided employee roster.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure a background study was affiliated to the current health facility identification (HFID) number for two of two employees (unlicensed personnel (ULP)-D and clincal nurse supervisor(CNS)-B, on the facility provided employee roster. [...]”

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 a registered nurse (RN) conducted direct supervision of staff performing a delegated task within 30 days of providing services for one of one employee (unlicensed personnel (ULP)-D).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure a registered nurse (RN) conducted direct supervision of staff performing a delegated task within 30 days of providing services for one of one employee (unlicensed personnel (ULP)-D). [...]”

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 one unlicensed personnel (ULP)-D received the required eight hours of dementia care training in the required time frame.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure one of one unlicensed personnel (ULP)-D received the required eight hours of dementia care training in the required time frame. [...]”

Rule cited: “(3) for assisted living facilities with dementia care, direct-care employees must have completed at least eight hours of initial training on topics specified under paragraph (b) within 80 working hours of the employment start date. [...]”

MDH’s finding, as written: “Based on interview and record review the licensee failed to ensure the registered nurse used the uniform assessment tool for ongoing assessments and monitoring for one of one resident (R2). [...]”

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 develop and maintain a current individualized medication management record for each resident to include all required content for one of one resident (R2).

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 for each resident to include all required content for one of one resident (R2). [...]”

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 document in the resident's record all required content for disposition of medications for one of one resident (R1) upon discharge.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to document in the resident's record all required content for disposition of medications for one of one resident (R1) 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 the licensed assisted living director (LALD)-A completed and documented 10 hours of continuing education related to the care of individuals with dementia.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the licensed assisted living director (LALD)-A completed and documented 10 hours of continuing education related to the care of individuals with dementia. [...]”

Rule cited: “(a) The licensee must follow the assisted living license requirements and the criteria in this section. [...]”

Summary: MDH found the licensee failed to ensure policies and procedures required in the licensing of assisted living facilities with dementia care were developed or implemented, and provided to each resident and/or the resident's legal and designated representative at the time of move-in.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure policies and procedures required in the licensing of assisted living facilities with dementia care were developed or implemented, and provided to each resident and/or the resident's legal and designated representative at the time of move-in. This had the potential to affect all dementia care residents, staff and visitors. [...]”

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 [...]”