Suite Living Senior Care

Survey completed May 24, 2023: 2 correction orders

• Tag 340: 144G.30 Subd. 5 Correction orders Level 3, widespread scope, scope/level letter I · correction period: IMMEDIATE
  Details

  Summary: MDH found the licensee failed to implement actions documented by the licensee as a plan of correction to comply with orders issued during a Provisional Survey completed on April 11 through 13, 2023.

  MDH’s finding, as written: “Based on interview and document review, the licensee failed to implement actions documented by the licensee as a plan of correction to comply with orders issued during a Provisional Survey completed on April 11 through 13, 2023. The lack of action to ensure compliance with regulations had the potential to affect all residents receiving services at the facility. [...]”

  Rule cited: “a) A correction order may be issued whenever the commissioner finds upon survey or during a complaint investigation that a facility, a managerial official, an agent of the facility, or an employee of the facility is not in compliance with this chapter. [...]”

• Tag 2070: 144G.81 Subd. 4 Awake staff requirement (re-issued) Level 2, widespread scope, scope/level letter I
  Details

  Summary: MDH found the licensee failed to ensure a staff member was

  MDH’s finding, as written: “Based on interview and document review, the licensee failed to ensure a staff member was physically present in the secure dementia unit 24 hours a day. The licensee scheduled two staff members for the night shift, which required a staff member to leave the secured dementia unit unattended to assist with two-person transfers with a mechanical lift for three of three residents (R1, R2, R3) who lived on the assisted living unit. [...]”

  Rule cited: “An assisted living facility with dementia care providing services in a secured dementia care unit must have an awake person who is physically present in the secured dementia care unit 24 hours per day, seven days per week, who is responsible for responding to [...]”

Survey completed April 13, 2023: 6 correction orders

• Tag 480: 144G.41 Subd 1 (13) (i) (B) Minimum requirements Level 2, widespread scope, scope/level letter F · correction period: Twenty-one (21) days
  Details

  Summary: MDH found the licensee failed to ensure food was prepared and served according to the Minnesota Food Code.

  MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure food was prepared and served according to the Minnesota Food Code. 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 portion or all the [...]”

  Rule cited: “(13) offer to provide or make available at least the following services to residents: (B) food must be prepared and served according to the Minnesota Food Code, Minnesota Rules, chapter 4626; and”

• Tag 640: 144G.42 Subd. 7 Posting information for reporting suspected c Level 2, widespread scope, scope/level letter F
  Details

  MDH’s finding, as written: “Based on observation, interview, and document review the licensee failed to post required information for reporting suspected crime. This deficient practice had the potential to affect all residents, staff, and visitors. [...]”

  Rule cited: “The facility shall support protection and safety through access to the state's systems for reporting suspected criminal activity and suspected vulnerable adult maltreatment by: (1) posting the 911 emergency number in common areas and near telephones provided [...]”

• Tag 680: 144G.42 Subd. 10 Disaster planning and emergency preparedness Level 2, widespread scope, scope/level letter F · correction period: Two (2) day
  Details

  MDH’s finding, as written: “Based on interview and document review the licensee failed to ensure a written emergency disaster plan contained all required content, including information for evacuation of three of three residents (R1, R2, and R3) reviewed who required assistance of two staff with a mechanical lift for transfers and relied on wheelchairs for mobility. [...]”

  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 [...]”

• Tag 790: 144G.45 Subd. 2 (a) (2)-(3) Fire protection and physical environment Level 2, widespread scope, scope/level letter F · correction period: Seven (7) days
  Details

  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 deficient condition had the ability to affect all staff, residents, and visitors. [...]”

  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 [...]”

• Tag 970: 144G.50 Subd. 5 Waivers of liability prohibited Level 2, pattern scope, scope/level letter E · correction period: Seven (7) days
  Details

  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 four of four residents (R1, R3, R5, and R6) reviewed for contracts.

  MDH’s finding, as written: “Based on interview and document 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 four of four residents (R1, R3, R5, and R6) reviewed for contracts. [...]”

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

• Tag 2070: 144G.81 Subd. 4 Awake staff requirement Level 3, widespread scope, scope/level letter I · correction period: Two (2) days
  Details

  Summary: MDH found the licensee failed to ensure a staff person was physically present in the secured dementia unit 24 hours a day.

  MDH’s finding, as written: “Based on interview and document review, the licensee failed to ensure a staff person was physically present in the secured dementia unit 24 hours a day. The licensee scheduled two staff members for the night shift, which required a staff member to leave the secured dementia unit unattended to assist with two-person transfers with a mechanical lift for resident (R)1, R2, and R3 who lived on the assisted living unit. [...]”

  Rule cited: “An assisted living facility with dementia care providing services in a secured dementia care unit must have an awake person who is physically present in the secured dementia care unit 24 hours per day, seven days per week, who is responsible for responding to [...]”

MDH letters in this report

• July 18, 2023: Notice Of Removal Of Conditional License
• June 1, 2023: Notice Of Conditional License

From MDH’s letter: the letter says the facility is not in substantial compliance; MDH granted the assisted living license.

Total fines assessed, as printed in the letter: $3,000.00.

Allegation, as written: “The alleged perpetrator (AP) physically abused and verbally abused a resident when the AP swore and struck out at the resident.”

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

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

MDH’s conclusion, as written: “The Minnesota Department of Health determined abuse was inconclusive. While the AP did not use verbal good clinical technique to de-escalate his behavior, the statements did not meet the definition of abuse. Additionally, there was a physical altercation between the resident and the AP, the video was obscured by furniture at the moment abuse may have occurred.”

Action taken by facility: “Caregiver is no longer employed by the facility. The resident later transferred to a different facility.”

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

Survey completed July 18, 2024: no correction orders issued.

Allegation, as written: “The alleged perpetrator (AP), a facility staff member neglected the resident when the AP failed to follow the resident's plan of care, and the resident sustained a left fractured tibia (the primary weight-bearing bone in the lower leg) and fibula (the smaller of the two bones in the lower leg).”

“The Minnesota Department of Health determined neglect was not substantiated.”

Summary: MDH looked into an allegation and found: neglect not substantiated.

MDH’s conclusion, as written: “The Minnesota Department of Health determined neglect was not substantiated. Although the AP did not follow the resident's plan of care of placing foot pedals on the resident's wheelchair, the error was an isolated incident. The resident sustained a fractured tibia, was hospitalized for two days, and returned to the resident's baseline health condition.”

Action taken by facility: “Following the incident, the resident was assessed and transported to the hospital for evaluation. In addition, the facility and the AP were educated on resident's that required foot pedals.”

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

Survey completed July 2, 2025: no correction orders issued.

Allegation, as written: “The facility neglected the resident resulting in an unwitnessed fall and sustained a fracture.”

“The Minnesota Department of Health determined neglect was not substantiated.”

Summary: MDH looked into an allegation and found: neglect not substantiated.

MDH’s conclusion, as written: “The Minnesota Department of Health determined neglect was not substantiated. Although the resident fell and sustained an injury, the facility had appropriate interventions in place to prevent falls and/or injury. While the resident wandered the unit continuously the staff members had provided safety checks, was aware the resident was at risk for falls, and contacted nursing to send resident to emergency department for evaluation appropriately when the fall occur”

Action taken by facility: “No action required.”

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

Survey completed July 18, 2024: no correction orders issued.