Spring Valley Estates

Summary: MDH found the licensee failed to ensure employee records included evidence of training/competency content for insulin pen injection and lacked a job description for one of two unlicensed personnel (ULP)-G).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure employee records included evidence of training/competency content for insulin pen injection and lacked a job description for one of two unlicensed personnel (ULP)-G). [...]”

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 the physical environment of the facility in a continuous state of good repair and operation.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to maintain the physical environment of the facility in a continuous state of good repair and operation. This has the potential to directly affect the residents and staff. [...]”

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 employee training on the fire safety and evacuation plan.

MDH’s finding, as written: “Based on observation, record review, and interview, the licensee failed to provide the required employee training on the fire safety and evacuation plan. This has the potential to directly affect the safety of all residents receiving care, 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 background study was submitted and received in affiliation with the assisted living license for two of two employees (unlicensed personnel (ULP)-G, ULP-J).

MDH’s finding, as written: “Based on observation, 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)-G, ULP-J). [...]”

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 direct supervision of two of two unlicensed personnel (ULP-G and ULP-J) performing delegated tasks was provided within 30 calendar days after the date on which the individuals began working for the licensee.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure direct supervision of two of two unlicensed personnel (ULP-G and ULP-J) performing delegated tasks was provided within 30 calendar days after the date on which the individuals began working for the licensee. [...]”

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 two of two unlicensed personnel (ULP-G, ULP-J) received orientation to assisted living facility licensing requirements and regulations before providing services.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure two of two unlicensed personnel (ULP-G, ULP-J) received orientation to assisted living facility licensing requirements and regulations before providing services. [...]”

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 annual training included all required topics for each 12 months of employment for one of two employees (unlicensed personnel (ULP)-G).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure annual training included all required topics for each 12 months of employment for one of two employees (unlicensed personnel (ULP)-G). [...]”

Rule cited: “(a) All staff that perform direct services must complete at least eight hours of annual training for each 12 months of employment. [...]”

Summary: MDH found the licensee failed to ensure one of two employees (unlicensed personnel (ULP)-G) completed the required number or hours of dementia care training within the required time frame.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure one of two employees (unlicensed personnel (ULP)-G) completed the required number or hours of dementia care training within 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 observation, interview, and record review, the licensee failed to ensure two of two unlicensed personnel (ULP-E, ULP-G) completed insulin administration via a prefilled insulin pen according to manufacturer instructions. [...]”

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 one of two

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure one of two unlicensed personnel (ULP)-G) provided the proper dose of a topical medication. [...]”

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 prescription medications were kept in the original container bearing the original prescription label for one of two residents (R1).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure prescription medications were kept in the original container bearing the original prescription label for one of two residents (R1). [...]”

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 medication including the required content for one of one discharged resident (R4).

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 medication including the required content for one of one discharged resident (R4). [...]”

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 develop a memory care site-specific safety risk assessment plan to identify hazard vulnerabilities and mitigations on and around the property to protect memory care residents from harm.

MDH’s finding, as written: “Based on the observation, document review, and interview, the licensee failed to develop a memory care site-specific safety risk assessment plan to identify hazard vulnerabilities and mitigations on and around the property to protect memory care residents from harm. This has the potential to directly affect staff and all memory care residents receiving assisted living services. [...]”

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 policies and procedures required in assisted living facilities with dementia care were provided to each resident and/or the resident's legal and designated representative at the time of move-in for three of three residents (R1, R2, R3).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure policies and procedures required in assisted living facilities with dementia care were provided to each resident and/or the resident's legal and designated representative at the time of move-in for three of three residents (R1, R2, R3). [...]”

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 immediately report to the Minnesota Adult Abuse Reporting Center (MAARC) for a significant set of medication errors for one of one resident (R5).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to immediately report to the Minnesota Adult Abuse Reporting Center (MAARC) for a significant set of medication errors for one of one resident (R5). [...]”

Rule cited: “(a) A mandated reporter who has reason to believe that a vulnerable adult is being or has been maltreated, or who has knowledge that a vulnerable adult has sustained a physical injury which is not reasonably explained shall immediately report the information [...]”