Sugar Loaf Senior Living

Summary: MDH found the licensee failed to establish and maintain a tuberculosis (TB) prevention program, based on

MDH’s finding, as written: “Based on interview and record review, the licensee failed to establish and maintain a tuberculosis (TB) prevention program, based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC) which included documentation of a completed health history and symptom screening for three of four employees (unlicensed personnel (ULP)-E, ULP-F, and ULP-G). [...]”

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 ensure documentation of wound condition and measurements and failed to document collaboration of care with the home health agency and hospice agency for one of one resident (R14) receiving wound care services.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure documentation of wound condition and measurements and failed to document collaboration of care with the home health agency and hospice agency for one of one resident (R14) receiving wound care services. [...]”

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 facility failed to maintain the facility in good repair in regards to resident health and safety in accordance with maintenance and repair program.

MDH’s finding, as written: “Based on observation, and staff interview, the facility failed to maintain the facility in good repair in regards to resident health and safety in accordance with maintenance and repair program. This deficient condition has the ability to affect all staff and residents. [...]”

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 ensure the assisted living contract did not include language waiving the facility's liability for health, safety, or personal property of a resident for one of five residents (R13).

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 for one of five residents (R13). [...]”

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

Summary: MDH found the licensee failed to provide a written notice with required content, to the resident, legal representative, and designated representative, for an emergency relocation for two of two residents (R14, R20).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide a written notice with required content, to the resident, legal representative, and designated representative, for an emergency relocation for two of two residents (R14, R20). In addition, the licensee failed to notify the Office of Ombudsman for Long-Term Care of the relocation within four days as required. [...]”

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 complete a change of condition assessment for two of two residents (R14, R12) resulting in actual harm to R14.

MDH’s finding, as written: “Based on observation, interview, and document review, the licensee failed to complete a change of condition assessment for two of two residents (R14, R12) resulting in actual harm to R14. In addition, the licensee failed to complete comprehensive assessments on three of three residents (R13, R6, and R15) every 90 days. [...]”

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 plan was revised to include the treatment of vascular boots and hospice services for one of five (R14) records reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the service plan was revised to include the treatment of vascular boots and hospice services for one of five (R14) records reviewed. Additionally the Service Plan dated August 16, 2022, lacked the licensee and designated representative signatures. [...]”

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. [...]”

Summary: MDH found the licensee failed to have a medication assessment for four of four residents (R6, R12, R13, and R14) that included interventions needed in management of medications to prevent diversion of medication by the resident or others who may have access to the medications and provide instructions to the resident and legal or designated representatives on interventions to manage the resident's medications to prevent diversion of medications.

MDH’s finding, as written: “Based on interview and document review, the licensee failed to have a medication assessment for four of four residents (R6, R12, R13, and R14) that included interventions needed in management of medications to prevent diversion of medication by the resident or others who may have access to the medications and provide instructions to the resident and legal or designated representatives on interventions to manage the resident's medications to prevent diversion of medications. [...]”

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 monitor and reassess the resident's medication management services at least annually for one of five residents (R13) receiving medication administration.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to monitor and reassess the resident's medication management services at least annually for one of five residents (R13) receiving medication administration. [...]”

Rule cited: “The assisted living facility must monitor and reassess the resident's medication management services as needed under subdivision 2 when the resident presents with symptoms or other issues that may be medication-related and, at a minimum, annually.”

Summary: MDH found the licensee failed to develop an individualized medication management record with the documentation of special instructions for two of five residents (R12, R14) with medications provided.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to develop an individualized medication management record with the documentation of special instructions for two of five residents (R12, R14) with medications provided. [...]”

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 ensure prescriber orders were transcribed as ordered for one of five residents (R12) observed for medication administration.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure prescriber orders were transcribed as ordered for one of five residents (R12) observed for medication administration. [...]”

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. [...]”

MDH’s finding, as written: “Based on observation, interview, and record review the licensee failed to ensure signed prescriber's orders for medications for one of five 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 [...]”

Rule cited: “There must be a current written or electronically recorded prescription as defined in section 151.01, subdivision 16a, for all prescribed medications that the assisted living facility is managing for the resident.”

Summary: MDH found the licensee failed to ensure medications securely locked in substantially constructed compartments and permitted only authorized personnel to have access.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medications securely locked in substantially constructed compartments and permitted only authorized personnel to have access. This had the potential to affect all residents. [...]”

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 ensure time sensitive medications were dated when opened and had a pharmacy label for five of five residents' (R6, R4, R5, R11, and R13) medication cupboards.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure time sensitive medications were dated when opened and had a pharmacy label for five of five residents' (R6, R4, R5, R11, and R13) medication cupboards. [...]”

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 ensure expired medications were disposed of for two of five residents (R4 and R12).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure expired medications were disposed of for two of five residents (R4 and R12). 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: “(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 and implement a treatment or therapy management plan to include all required content for one of four residents (R14) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop and implement a treatment or therapy management plan to include all required content for one of four residents (R14) with records reviewed. [...]”

Rule cited: “For each resident receiving management of ordered or prescribed treatments or therapy services, the assisted living facility must prepare and include in the service plan a written statement of the treatment or therapy services that will be provided to the [...]”

Summary: MDH found the licensee failed to ensure treatment services were documented for one of four residents (R14).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure treatment services were documented for one of four 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 [...]”

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 ensure policies and procedures required in the licensing of 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 two of three residents (R13, R14) with records reviewed.

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 provided to each resident and/or the resident's legal and designated representative at the time of move-in for two of three residents (R13, R14) with records reviewed. [...]”

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 ensure the current Minnesota Bill of Rights for Assisted Living Residents was provided to the resident and a written acknowledgement received for two of five residents (R6 and R15).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the current Minnesota Bill of Rights for Assisted Living Residents was provided to the resident and a written acknowledgement received for two of five residents (R6 and R15). [...]”

Rule cited: “(a) An assisted living facility must provide the resident a written notice of the rights under section 144G.91 before the initiation of services to that resident. [...]”

Summary: MDH found the licensee failed to provide care and services according to acceptable health care, medical, or nursing standards for three of three residents (R14, R15, R9) with bed rails.

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 three of three residents (R14, R15, R9) with bed rails. This resulted in an immediate order issued on November 30, 2022, at approximately 4:07 p.m.. [...]”

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.”