Sunrise of Edina

Summary: MDH found the licensee failed to have a written emergency disaster plan with all required content and failed to post an emergency plan prominently.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to have a written emergency disaster plan with all required content and failed to post an emergency plan prominently. This had the potential to affect all residents receiving assisted living services. [...]”

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 resident's personal health and medical information was kept private for eight of 18 memory care residents.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure resident's personal health and medical information was kept private for eight of 18 memory care residents. [...]”

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. [...]”

Summary: MDH found the licensee failed to ensure the resident record included a discharge summary for one of three discharged residents (R1).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the resident record included a discharge summary for one of three discharged 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 [...]”

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 immediately outside sleeping areas in the two-bedroom apartments and failed to ensure smoke alarms are interconnected so that the actuation of one alarm causes all alarms in the dwelling to actuate as required.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to provide smoke alarms immediately outside sleeping areas in the two-bedroom apartments and failed to ensure smoke alarms are interconnected so that the actuation of one alarm causes all alarms in the dwelling to actuate as required. This had the potential to directly affect all residents, staff, and visitors. [...]”

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 facility's physical environment in a continuous state of good repair and operation regarding the health, safety, and well-being of the residents.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to maintain the facility's physical environment in a continuous state of good repair and operation regarding the health, safety, and well-being of the residents. This had the potential to directly affect all residents, staff, and visitors. [...]”

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 develop and maintain fire safety and evacuation plans and failed to provide required training to residents and employees for fire safety and evacuation.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop and maintain fire safety and evacuation plans and failed to provide required training to residents and employees for fire safety and evacuation. This had the potential to affect all current residents, staff, and visitors to the facility. [...]”

Rule cited: “(b) Each assisted living facility shall develop and maintain fire safety and evacuation plans. [...]”

Summary: MDH found the licensee failed to provide a 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 resident (R3) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide a 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 resident (R3) 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 facility failed to provide a 30-day calendar day advance written notice to the resident and/or the resident's legal/designated representative, prior to initiating the transfer for three of three residents (R12, R13, R14).

MDH’s finding, as written: “Based on interview and record review, the facility failed to provide a 30-day calendar day advance written notice to the resident and/or the resident's legal/designated representative, prior to initiating the transfer for three of three residents (R12, R13, R14). [...]”

Rule cited: “(a) A facility must provide at least 30 calendar days' advance written notice to the resident and the resident's legal and designated representative of a facility-initiated transfer. [...]”

Summary: MDH found the licensee failed to provide notice to the Office of Ombudsman for Long-Term Care (OOLTC) or the Office of the Ombudsman for Mental Health and Developmental Disabilities (OMHDD) of corresponding transfers needed for curtailment (reducing or restricting), prior to notifying residents or residents representative for three of three residents (R12, R13, R14).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide notice to the Office of Ombudsman for Long-Term Care (OOLTC) or the Office of the Ombudsman for Mental Health and Developmental Disabilities (OMHDD) of corresponding transfers needed for curtailment (reducing or restricting), prior to notifying residents or residents representative for three of three residents (R12, R13, R14). [...]”

Rule cited: “(a) In situations where there is a curtailment, reduction, or capital improvement within a facility necessitating transfers, the facility must: (1) minimize the number of transfers it initiates to complete the project or change in operations; (2) consider [...]”

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 three employees (unlicensed personnel (ULP)-B and ULP-E).

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 three employees (unlicensed personnel (ULP)-B and ULP-E). [...]”

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. [...]”

MDH’s finding, as written: “Based on interview, and record review, licensee failed to provide delegated training by a registered nurse (RN) to unlicensed personal (ULP) for the use of an external female catheter for one of one resident (R7). [...]”

Rule cited: “(b) When the registered nurse or licensed health professional delegates tasks to unlicensed personnel, that person must ensure that prior to the delegation the unlicensed personnel is trained in the proper methods to perform the tasks or procedures for each [...]”

Summary: MDH found the licensee failed to ensure staff providing services completed an orientation to assisted living facility licensing requirements and regulations before providing services for three of three employees (registered nurse (RN)-A, unlicensed personnel (ULP)-B, ULP-E) with records reviewed.

MDH’s finding, as written: “Based on interview, and record review, the licensee failed to ensure staff providing services completed an orientation to assisted living facility licensing requirements and regulations before providing services for three of three employees (registered nurse (RN)-A, unlicensed personnel (ULP)-B, ULP-E) with records reviewed. [...]”

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 two of two employees (unlicensed personnel (ULP)-B and ULP-E).

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 two of two employees (unlicensed personnel (ULP)-B and ULP-E). [...]”

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 licensed staff conducted resident monitoring and review as needed based on changes with resident needs for one of four residents (R6) and failed to ensure the registered nurse conducted ongoing resident assessment and reassessment, not to exceed 90 calendar days from the last date of the assessment for three of four residents (R4, R6, and R7).

MDH’s finding, as written: “Based on interview, and record review, the licensee failed to ensure licensed staff conducted resident monitoring and review as needed based on changes with resident needs for one of four residents (R6) and failed to ensure the registered nurse conducted ongoing resident assessment and reassessment, not to exceed 90 calendar days from the last date of the assessment for three of four residents (R4, R6, and R7). [...]”

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 based on change of service for one of four residents (R6) and failed to ensure the current service plan included a signature or other authentication by the resident or resident's designated representative to document agreement on the services to be provided for three of four residents (R5, R6, R7).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the service plan was revised based on change of service for one of four residents (R6) and failed to ensure the current service plan included a signature or other authentication by the resident or resident's designated representative to document agreement on the services to be provided for three of four residents (R5, R6, R7). [...]”

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 ensure prior to delegating the task of medication administration, the registered nurse (RN) trained the unlicensed personnel (ULP) in the proper methods to perform the task or procedure for each resident and verified the ULPs were able to demonstrate the ability to competently follow the procedure for one of two employees, (ULP-G).

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

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 according to manufacturer's instructions for one of one resident (R4) with insulin administration and failed to administer

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medications were administered according to manufacturer's instructions for one of one resident (R4) with insulin administration and failed to administer medications according to provider orders for one of six residents (R9). [...]”

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 all medications were 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 all medications were securely locked in substantially constructed compartments and permitted only authorized personnel to have access. This had the potential to affect all 18 residents in the third-floor memory care unit. [...]”

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 medications were maintained bearing the original prescription label for one of three residents (R16) and failed to ensure time sensitive medications were labeled with the date opened for three of three residents (R15, R16, R17) within two of four medication carts (M3 and M4).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medications were maintained bearing the original prescription label for one of three residents (R16) and failed to ensure time sensitive medications were labeled with the date opened for three of three residents (R15, R16, R17) within two of four medication carts (M3 and M4). [...]”

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 provide documentation in the resident's record regarding the disposition of medication to include the medication strength, prescription number, and quantity for three of three discharged residents (R1, R2, R3).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide documentation in the resident's record regarding the disposition of medication to include the medication strength, prescription number, and quantity for three of three discharged residents (R1, R2, R3). [...]”

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 one or more persons were physically present and available 24 hours a day, seven days a week, who were responsible for responding to requests of residents for assistance in one of two secured dementia care (memory care) units.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure one or more persons were physically present and available 24 hours a day, seven days a week, who were responsible for responding to requests of residents for assistance in one of two secured dementia care (memory care) units. This resulted in an immediate correction order issued on January 10, 2023. [...]”

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 [...]”

Summary: MDH found the licensee failed to ensure policies and procedures for assisted living with dementia care (ALFDC) were provided to residents or the resident's legal and / or designated representative at the time of move-in for four of four residents (R4, R5, R6, R7).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure policies and procedures for assisted living with dementia care (ALFDC) were provided to residents or the resident's legal and / or designated representative at the time of move-in for four of four residents (R4, R5, R6, R7). [...]”

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 provide in written or electronic form to residents, families, or other persons who request it, an accurate description of the dementia care training program with the required content.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide in written or electronic form to residents, families, or other persons who request it, an accurate description of the dementia care training program with the required content. [...]”

Rule cited: “An assisted living facility with dementia care shall make available in written or electronic form, to residents and families or other persons who request it, a description of the training program and related training it provides, including the categories of [...]”