St Ann's Home

Summary: MDH found the licensee failed to ensure training and competency evaluations included all the required training for two of three employees (unlicensed personnel (ULP)-E and ULP-Q).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure training and competency evaluations included all the required training for two of three employees (unlicensed personnel (ULP)-E and ULP-Q). [...]”

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 included all the required training for one of three employees (unlicensed personnel (ULP)-Q).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure training and competency evaluations included all the required training for one of three employees (unlicensed personnel (ULP)-Q). [...]”

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 two of four direct-care employees (director of nurses (DON)-B, registered nurse (RN)-C, ) completed at least eight hours of initial dementia training with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure two of four direct-care employees (director of nurses (DON)-B, registered nurse (RN)-C, ) completed at least eight hours of initial dementia training with records reviewed. [...]”

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 ensure the service plans included the required content for one of four residents (R1).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the service plans included the required content for one of four residents (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 an isolated scope (when one or a limited number of residents are affected or one or a [...]”

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 date time-sensitive medications with an opened or expiration dates for R10, R16, and R17.

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 R10, R16, and R17. 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: “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 treatments for one of two residents (R14).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to document treatments for one of two residents (R14). 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 number of staff are involved or [...]”

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

MDH’s finding, as written: “Based on observation, interview, and record review the licensee failed to ensure annual perform reviews were completed for four of four employees (director of nursing (DON-B), registered nurse (RN)-C, unlicensed personal (ULP)-E, 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). [...]”

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 develop a written emergency preparedness plan (EPP) with all the required content.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to develop a written emergency preparedness plan (EPP) with all the required content. This had the potential to affect all residents, staff, and visitors of the facility. [...]”

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 ensure the resident record contained documentation of the services being provided for one of four residents (R6) and failed to ensure a discharge summary was completed for one of one resident (R11).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the resident record contained documentation of the services being provided for one of four residents (R6) and failed to ensure a discharge summary was completed for one of one resident (R11). [...]”

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 complied with fire protection requirements.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to provide smoke alarms that complied with fire protection requirements. This had the potential to directly affect all residents and staff. [...]”

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 portable fire extinguishers.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to maintain the portable fire extinguishers. This had the potential to directly affect all residents and staff. 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: “(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 provide the physical environment in a continuous state of good repair and operation with regard to the health, safety, and well-being of the residents.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to provide the physical environment in a continuous state of good repair and operation with regard to the health, safety, and well-being of the residents. This had the potential to directly affect all 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 plans, training, and drills for fire safety and evacuation.

MDH’s finding, as written: “Based on observation, document review, and interview, the licensee failed to provide the required plans, training, and drills for fire safety and evacuation. This had the potential to directly affect all residents and staff. [...]”

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 two of two residents (R3, R5).

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 two of two residents (R3, R5). This had the potential to affect all 95 residents. [...]”

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 assisted living contract with the required content for three of three residents (R3, R5).

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 (R3, R5). This had the potential to affect all 95 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 execute a written assisted living contract with the required content for three of three residents (R3, R5).

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 (R3, R5). This had the potential to affect all 95 residents. [...]”

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 the assisted living contract did not include language waiving the facility's liability for health, safety, or personal property of a resident.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the assisted living contract did not include language waiving the facility's liability for health, safety, or personal property of a resident. This had the potential to affect all 95 residents. [...]”

Rule cited: “The contract must not include a waiver of facility liability for the health and safety or personal property of a resident. [...]”

MDH’s finding, as written: “Based on interview and record review, licensee failed to provide written notice with required content for an emergency relocation and failed to notify the Office of Ombudsman for Long-Term Care (OOLTC) of the emergency relocation for one of one residents (R2) with records reviewed. [...]”

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 contracted staff met all requirements required for personnel employed by the licensee for one of one contracted unlicensed personnel (ULP-H).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure contracted staff met all requirements required for personnel employed by the licensee for one of one contracted unlicensed personnel (ULP-H). [...]”

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.”

Summary: MDH found the licensee failed to ensure training and competency evaluations included all the required training for two of three employees (unlicensed personnel (ULP)-E and ULP-G).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure training and competency evaluations included all the required training for two of three employees (unlicensed personnel (ULP)-E and ULP-G). [...]”

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

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure training and competency evaluations included all the required training for two of three employees (unlicensed personnel (ULP)-E, ULP-G) with records reviewed. [...]”

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 orientation to assisted living statutes included all the required content for five of five employees (director of nurses (DON)-B), registered nurse (RN)-C, unlicensed personnel (ULP)-E, ULP-F, ULP-G).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure orientation to assisted living statutes included all the required content for five of five employees (director of nurses (DON)-B), registered nurse (RN)-C, unlicensed personnel (ULP)-E, ULP-F, ULP-G). [...]”

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 employees received at least eight hours of annual training for each 12 months of employment for four of four employees (director of nurses (DON)-B, registered nurse (RN)-C, unlicensed personnel (ULP)-E, and ULP-F).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure employees received at least eight hours of annual training for each 12 months of employment for four of four employees (director of nurses (DON)-B, registered nurse (RN)-C, unlicensed personnel (ULP)-E, and ULP-F). [...]”

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 three of

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure three of three direct-care employees (director of nurses (DON)-B, registered nurse (RN)-C, unlicensed personnel (ULP)-E) completed at least eight hours of initial dementia training with records reviewed. [...]”

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 ensure the registered nurse (RN) completed a comprehensive reassessment after a change of condition for two of two residents (R2, R13), and failed to ensure the ongoing resident reassessment did not exceed 90 days for one of four residents (R3).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the registered nurse (RN) completed a comprehensive reassessment after a change of condition for two of two residents (R2, R13), and failed to ensure the ongoing resident reassessment did not exceed 90 days for one of four residents (R3). In addition, the RN failed to complete a comprehensive assessment by day 14 from admission for one of one resident (R5) as required. [...]”

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 the service plans included the required content for four of four residents (R3, R5, R6, R7).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure the service plans included the required content for four of four residents (R3, R5, R6, R7). [...]”

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: “Based on interview and record review the licensee failed to ensure medication administration assessments were conducted face-to-face with the resident for four of four residents (R3, R5, R6, R7). [...]”

Rule cited: “(a) For each resident who requests medication management services, the facility shall, prior to providing medication management services, have a registered nurse, licensed health professional, or authorized prescriber under section 151.37 conduct an [...]”

Summary: MDH found the licensee failed to ensure prior to delegating the nursing task of medication administration, one of two unlicensed personnel (ULP-E) demonstrated competency for administering medications.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure prior to delegating the nursing task of medication administration, one of two unlicensed personnel (ULP-E) demonstrated competency for administering medications. [...]”

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 for one of three residents (R5).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure medications were administered as prescribed for one of three residents (R5). 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 [...]”

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 two of two employees (unlicensed personnel (ULP)-E, ULP-F) were trained and had demonstrated competency to prepare and give medications for residents having unplanned time away.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure two of two employees (unlicensed personnel (ULP)-E, ULP-F) were trained and had demonstrated competency to prepare and give medications for residents having unplanned time away. This had the potential to affect all seventy (70) residents. [...]”

Rule cited: “(2) for unplanned time away, when the pharmacy is not able to provide the medications, a licensed nurse or unlicensed personnel shall provide medications in amounts and dosages needed for the length of the anticipated absence, not to exceed seven calendar [...]”

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 date time-sensitive medications with an opened or expiration dates for R10, R14, R15, R16, and R17.

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 R10, R14, R15, R16, and R17. In addition, the licensee failed to ensure medications were maintained bearing the original prescription label for R18, R19, and further, the licensee failed to monitor for expired medications for R19. [...]”

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 (R11) upon discharge, with records reviewed.

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 (R11) upon discharge, with records reviewed. [...]”

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 unlicensed personnel (ULP) were trained in the proper methods to perform the task or procedure for each resident and were able to demonstrate the ability to competently follow the procedure to perform the tasks for one of one employees (ULP-E).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure prior to delegating nursing tasks, the unlicensed personnel (ULP) were trained in the proper methods to perform the task or procedure for each resident and were able to demonstrate the ability to competently follow the procedure to perform the tasks for one of one employees (ULP-E). [...]”

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 document treatments for one of two residents (R7).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to document treatments for one of two residents (R7). 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 number of staff [...]”

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 provide care and services according to acceptable health care, medical or nursing standards for one of one resident (R6).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to provide care and services according to acceptable health care, medical or nursing standards for one of one resident (R6). [...]”

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 the care and services were provided according to an up-to-date service plan, and acceptable health care and medical, or nursing standards for one of one resident, R3 with medication set-up.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the care and services were provided according to an up-to-date service plan, and acceptable health care and medical, or nursing standards for one of one resident, R3 with medication set-up. [...]”

Rule cited: “(b) Residents have the right to receive health care and other assisted living services with continuity from people who are properly trained and competent to perform their duties and in sufficient numbers to adequately provide the services agreed to in the [...]”