Sugar Brook Villa

Allegation, as written: “Alleged perpetrator (AP) #1 and AP #2 neglected the resident when the staff failed to prevent the resident from falling out of her chair causing a large skin tear and other injuries.”

“The Minnesota Department of Health determined neglect was inconclusive.”

Summary: MDH looked into an allegation and found: neglect inconclusive.

MDH’s conclusion, as written: “The Minnesota Department of Health determined neglect was inconclusive. There was conflicting information regarding the use of the resident's wheelchair pedals and cushions.”

Action taken by facility: “The facility reassessed the resident. The facility updated the resident's plan of care for staff to always use foot pedals, and for the staff to not put two cushions under the resident. The staff were educated on the changes and the instructions were added to the care plan for the staff to use as a reference.”

Action taken by MDH: “The facility was found to be in noncompliance.”

Survey completed July 7, 2023: 2 correction orders

• Tag 250: 144G.20 Subdivision 1 Conditions Level 2, isolated scope, scope/level letter D · correction period: Seven (7) days
  Details

  Summary: MDH found the licensee failed to provide requested records during a complaint investigation.

  MDH’s finding, as written: “Based on record review and interview, the licensee failed to provide requested records during a complaint investigation. The licensed failed to provide records for one of one resident (R1) and for one of two employees, unlicensed personnel (ULP)-G reviewed. [...]”

  Rule cited: “(a) The commissioner may refuse to grant a provisional license, refuse to grant a license as a result of a change in ownership, refuse to renew a license, suspend or revoke a license, or impose a conditional license if the owner, controlling individual, or [...]”

• Tag 700: 144G.43 Subdivision 1 Resident record Level 2, isolated scope, scope/level letter D · correction period: Seven (7) days
  Details

  Summary: MDH found the licensee failed to ensure three of three residents (R2, R3, R4's) personal information and amount owed to the facility information was kept private.

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure three of three residents (R2, R3, R4's) personal information and amount owed to the facility information was kept private. [...]”

  Rule cited: “(b) Resident records, whether written or electronic, must be protected against loss, tampering, or unauthorized disclosure in compliance with chapter 13 and other applicable relevant federal and state laws. [...]”

Allegation, as written: “The resident was neglected when the unlicensed personnel (ULP)/alleged perpetrator (AP) utilized tweezers to remove ear wax, rupturing the resident's ear drums.”

“The Minnesota Department of Health determined neglect was inconclusive.”

Summary: MDH looked into an allegation and found: neglect inconclusive.

MDH’s conclusion, as written: “The Minnesota Department of Health determined neglect was inconclusive. The exact cause of the ear rupture(s) could not be identified. The unlicensed personnel (ULP)/alleged perpetrator (AP) admitted s/he used a tweezer to remove the resident's ear wax. When the resident was An equal opportunity employer. later observed to be bleeding from both ears, the resident was taken to the emergency room and diagnosed with bilateral ear infection and ruptured ear drums. It could not be determined if the tweezers or ear infection caused the ruptures.”

Action taken by facility: “The facility filed a vulnerable adult report and re-educated the AP.”

Action taken by MDH: “The facility was found to be in noncompliance.”

Survey completed September 28, 2022: 3 correction orders

• Tag 1760: 144G.71 Subd. 8 Documentation of administration of medication Level 3, isolated scope, scope/level letter G · correction period: Seven (7) days
  Details

  Summary: MDH found the licensee failed to ensure medications were administered as prescribed for one of one resident (R3) with records reviewed.

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure medications were administered as prescribed for one of one resident (R3) with records reviewed. This practice resulted in a level three violation (a violation that harmed a resident's health or safety, not including serious injury, impairment, or death, or a violation that has the potential to lead to serious injury, impairment, or death), and was issued at an isolated scope (when one or a limited number of residents are [...]”

  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. [...]”

• Tag 1840: 144G.71 Subd. 15 Verbal prescription orders Level 2, isolated scope, scope/level letter D · correction period: Two (2) days
  Details

  Summary: MDH found the licensee failed to ensure verbal prescription orders from an authorized prescriber were received by a nurse or pharmacist for one of one resident (R3).

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure verbal prescription orders from an authorized prescriber were received by a nurse or pharmacist for one of one resident (R3). [...]”

  Rule cited: “Verbal prescription orders from an authorized prescriber must be received by a nurse or pharmacist. The order must be handled according to Minnesota Rules, part 6800.6200.”

• Tag 2310: 144G.91 Subd. 4 Appropriate care and services Level 3, pattern scope, scope/level letter H · correction period: Seven (7) days
  Details

  Summary: MDH found the licensee failed to provide care and services according to acceptable health care, medical, or nursing standards for two of three residents (R1, R2) when the nurse was not notified of changes in condition.

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide care and services according to acceptable health care, medical, or nursing standards for two of three residents (R1, R2) when the nurse was not notified of changes in condition. [...]”

  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.”

Allegation, as written: “The alleged perpetrator neglected the resident when they failed to follow delegated medication administration tasks as ordered, resulting in the resident receiving too much medication. An equal opportunity employer.”

“The Minnesota Department of Health determined neglect was inconclusive.”

Summary: MDH looked into an allegation and found: neglect inconclusive.

MDH’s conclusion, as written: “The Minnesota Department of Health determined neglect was inconclusive. A medication error occurred when an unlicensed personnel (ULP)/alleged perpetrator (AP) took an order from a hospice nurse over the phone, resulting in the resident receiving a double dose of an as-needed (PRN) pain medication. The resident was lethargic and non-responsive after receiving several doses of prescribed PRN medications and had vital signs monitored hourly. However, the PRN medications given were within the parameters of the resident's existing orders. The resident returned to baseline the next day.”

Action taken by facility: “No actions were taken by the facility.”

Action taken by MDH: “The facility was found to be in noncompliance.”

Survey completed September 28, 2022: 3 correction orders

• Tag 1760: 144G.71 Subd. 8 Documentation of administration of medication Level 3, isolated scope, scope/level letter G · correction period: Seven (7) days
  Details

  Summary: MDH found the licensee failed to ensure medications were administered as prescribed for one of one resident (R3) with records reviewed.

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure medications were administered as prescribed for one of one resident (R3) with records reviewed. This practice resulted in a level three violation (a violation that harmed a resident's health or safety, not including serious injury, impairment, or death, or a violation that has the potential to lead to serious injury, impairment, or death), and was issued at an isolated scope (when one or a limited number of residents are [...]”

  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. [...]”

• Tag 1840: 144G.71 Subd. 15 Verbal prescription orders Level 2, isolated scope, scope/level letter D · correction period: Two (2) days
  Details

  Summary: MDH found the licensee failed to ensure verbal prescription orders from an authorized prescriber were received by a nurse or pharmacist for one of one resident (R3).

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure verbal prescription orders from an authorized prescriber were received by a nurse or pharmacist for one of one resident (R3). [...]”

  Rule cited: “Verbal prescription orders from an authorized prescriber must be received by a nurse or pharmacist. The order must be handled according to Minnesota Rules, part 6800.6200.”

• Tag 2310: 144G.91 Subd. 4 Appropriate care and services Level 3, pattern scope, scope/level letter H · correction period: Seven (7) days
  Details

  Summary: MDH found the licensee failed to provide care and services according to acceptable health care, medical, or nursing standards for two of three residents (R1, R2) when the nurse was not notified of changes in condition.

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide care and services according to acceptable health care, medical, or nursing standards for two of three residents (R1, R2) when the nurse was not notified of changes in condition. [...]”

  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.”

Allegation, as written: “The resident was neglected when the unlicensed personnel (ULP)/alleged perpetrator (AP) failed to report a change in condition to the registered nurse (RN), resulting in the resident passing away.”

“The Minnesota Department of Health determined neglect was inconclusive.”

Summary: MDH looked into an allegation and found: neglect inconclusive.

MDH’s conclusion, as written: “The Minnesota Department of Health determined neglect was inconclusive. It is unable to be determined if the resident's condition would have improved had the AP reported the change in a timely manner. The AP failed to notify the nurse after the resident's oxygen levels dropped An equal opportunity employer. below normal ranges. However, the AP applied supplemental oxygen as ordered to the resident. The resident was on hospice services. When the hospice nurse was made aware of the drop in oxygen, no changes were made to the resident's end of life care plan. The facility nurse and hospice nurse stated no additional treatment measures would have been taken had the AP notified the nurse at the time the change was observed.”

Action taken by facility: “No actions were taken by the facility.”

Action taken by MDH: “The facility was found to be in noncompliance.”

Survey completed September 28, 2022: 3 correction orders

• Tag 1760: 144G.71 Subd. 8 Documentation of administration of medication Level 3, isolated scope, scope/level letter G · correction period: Seven (7) days
  Details

  Summary: MDH found the licensee failed to ensure medications were administered as prescribed for one of one resident (R3) with records reviewed.

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure medications were administered as prescribed for one of one resident (R3) with records reviewed. This practice resulted in a level three violation (a violation that harmed a resident's health or safety, not including serious injury, impairment, or death, or a violation that has the potential to lead to serious injury, impairment, or death), and was issued at an isolated scope (when one or a limited number of residents are [...]”

  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. [...]”

• Tag 1840: 144G.71 Subd. 15 Verbal prescription orders Level 2, isolated scope, scope/level letter D · correction period: Two (2) days
  Details

  Summary: MDH found the licensee failed to ensure verbal prescription orders from an authorized prescriber were received by a nurse or pharmacist for one of one resident (R3).

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure verbal prescription orders from an authorized prescriber were received by a nurse or pharmacist for one of one resident (R3). [...]”

  Rule cited: “Verbal prescription orders from an authorized prescriber must be received by a nurse or pharmacist. The order must be handled according to Minnesota Rules, part 6800.6200.”

• Tag 2310: 144G.91 Subd. 4 Appropriate care and services Level 3, pattern scope, scope/level letter H · correction period: Seven (7) days
  Details

  Summary: MDH found the licensee failed to provide care and services according to acceptable health care, medical, or nursing standards for two of three residents (R1, R2) when the nurse was not notified of changes in condition.

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide care and services according to acceptable health care, medical, or nursing standards for two of three residents (R1, R2) when the nurse was not notified of changes in condition. [...]”

  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.”

Allegation, as written: “The resident was neglected when facility staff failed to toilet the resident as directed, resulting in the development of a pressure ulcer and urinary retention.”

“The Minnesota Department of Health determined neglect was inconclusive.”

Summary: MDH looked into an allegation and found: neglect inconclusive.

MDH’s conclusion, as written: “The Minnesota Department of Health determined neglect was inconclusive. Although the resident developed an open area on her coccyx (tailbone) the specific cause could not be determined. The resident was not diagnosed with urinary retention.”

Action taken by facility: “No action was taken.”

Action taken by MDH: “No further action taken at this time.”

Survey completed September 28, 2022: 3 correction orders

• Tag 1760: 144G.71 Subd. 8 Documentation of administration of medication Level 3, isolated scope, scope/level letter G · correction period: Seven (7) days
  Details

  Summary: MDH found the licensee failed to ensure medications were administered as prescribed for one of one resident (R3) with records reviewed.

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure medications were administered as prescribed for one of one resident (R3) with records reviewed. This practice resulted in a level three violation (a violation that harmed a resident's health or safety, not including serious injury, impairment, or death, or a violation that has the potential to lead to serious injury, impairment, or death), and was issued at an isolated scope (when one or a limited number of residents are [...]”

  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. [...]”

• Tag 1840: 144G.71 Subd. 15 Verbal prescription orders Level 2, isolated scope, scope/level letter D · correction period: Two (2) days
  Details

  Summary: MDH found the licensee failed to ensure verbal prescription orders from an authorized prescriber were received by a nurse or pharmacist for one of one resident (R3).

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure verbal prescription orders from an authorized prescriber were received by a nurse or pharmacist for one of one resident (R3). [...]”

  Rule cited: “Verbal prescription orders from an authorized prescriber must be received by a nurse or pharmacist. The order must be handled according to Minnesota Rules, part 6800.6200.”

• Tag 2310: 144G.91 Subd. 4 Appropriate care and services Level 3, pattern scope, scope/level letter H · correction period: Seven (7) days
  Details

  Summary: MDH found the licensee failed to provide care and services according to acceptable health care, medical, or nursing standards for two of three residents (R1, R2) when the nurse was not notified of changes in condition.

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide care and services according to acceptable health care, medical, or nursing standards for two of three residents (R1, R2) when the nurse was not notified of changes in condition. [...]”

  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.”