Sunrise Village of Milaca

MDH’s finding, as written: “No further action required.”

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

Summary: MDH found the licensee failed to ensure prior to delegating nursing tasks, the registered nurse (RN) trained unlicensed personnel (ULP) in the proper methods to perform the task or procedure of carbohydrate counting for the administration of insulin for a resident and ensured ULP were able to demonstrate the ability to competently follow the procedure for three of three employees (ULP-K, ULP-L, ULP-M) with records reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure prior to delegating nursing tasks, the registered nurse (RN) trained unlicensed personnel (ULP) in the proper methods to perform the task or procedure of carbohydrate counting for the administration of insulin for a resident and ensured ULP were able to demonstrate the ability to competently follow the procedure for three of three employees (ULP-K, ULP-L, ULP-M) with records reviewed. [...]”

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 unlicensed personnel (ULP) administered medications as ordered for one of one resident (R6) with record reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure unlicensed personnel (ULP) administered medications as ordered for one of one resident (R6) with record reviewed. [...]”

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, licensee failed to date time-sensitive medications with an opened-on date for one of one resident (R6), and the licensee failed to ensure medication containers had the original prescription label for one of one resident (R6). [...]”

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 treatments or therapies were administered as prescribed for one of one resident (R6) with blood glucose (sugar) monitoring managed by the provider.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure treatments or therapies were administered as prescribed for one of one resident (R6) with blood glucose (sugar) monitoring managed by the provider. [...]”

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 have daily programs of social and recreational activities based on individual and group interests, physical, mental, and psychosocial needs, that created opportunities for residents to actively participate in the community at large.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to have daily programs of social and recreational activities based on individual and group interests, physical, mental, and psychosocial needs, that created opportunities for residents to actively participate in the community at large. This had the potential to affect all thirty (30) residents receiving assisted living services. [...]”

Rule cited: “(ii) weekly housekeeping; (iii) weekly laundry service; (iv) upon the request of the resident, provide direct or reasonable assistance with arranging for transportation to medical and social services appointments, shopping, and other recreation, and provide [...]”

Summary: MDH found the licensee failed to ensure that a registered nurse was available on-call 24 hours a day, seven days per week.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to ensure that a registered nurse was available on-call 24 hours a day, seven days per week. This had the potential to affect all thirty (30) residents and staff of the facility. [...]”

Rule cited: “(14) provide staff access to an on-call registered nurse 24 hours per day, seven days per week.”

Summary: MDH found the licensee failed to post the required information related to the grievance procedure, as well as information for reporting suspected maltreatment to the Minnesota Adult Abuse Reporting Center (MAARC).

MDH’s finding, as written: “Based on observation and interview, the licensee failed to post the required information related to the grievance procedure, as well as information for reporting suspected maltreatment to the Minnesota Adult Abuse Reporting Center (MAARC). This had the potential to affect all thirty (30) residents, staff and visitors. [...]”

Rule cited: “All facilities must post in a conspicuous place information about the facilities' grievance procedure, and the name, telephone number, and e-mail contact information for the individuals who are responsible for handling resident grievances. [...]”

MDH’s finding, as written: “Based on interview and record review, licensee failed to maintain records or required receipts for resident funds that were exchanged between licensee and resident (R2). [...]”

Rule cited: “(a) A facility may assist residents with household budgeting, including paying bills and purchasing household goods, but may not otherwise manage a resident's property. [...]”

Summary: MDH found the licensee failed to post the required content in common areas to include: posting the 911 emergency number in common areas and near telephones provided by the assisted living facility; and posting information and the reporting number for the Minnesota Adult Abuse Reporting Center (MAARC) to report suspected maltreatment of a vulnerable adult under section 626.557.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to post the required content in common areas to include: posting the 911 emergency number in common areas and near telephones provided by the assisted living facility; and posting information and the reporting number for the Minnesota Adult Abuse Reporting Center (MAARC) to report suspected maltreatment of a vulnerable adult under section 626.557. This had the potential to affect all thirty (30) 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 [...]”

Summary: MDH found the licensee failed to maintain employee records with all required content for each individual contractor providing assisted living services for one of one contracted unlicensed personnel ((ULP)-H) and one of one non-contracted employee (ULP-G) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to maintain employee records with all required content for each individual contractor providing assisted living services for one of one contracted unlicensed personnel ((ULP)-H) and one of one non-contracted employee (ULP-G) with records reviewed. [...]”

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). The licensee failed to complete a facility risk assessment and ensure employees completed TB training for three of four employees (unlicensed personnel (ULP)-E, ULP-G and ULP-H) with employee records reviewed. [...]”

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 have a written emergency preparedness plan with all the required content and post an emergency preparedness plan prominently.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to have a written emergency preparedness plan with all the required content and post an emergency preparedness plan prominently. This had the potential to affect all thirty (30) residents receiving services under the assisted living license. [...]”

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 licensee's staff documented provided resident services according to the residents' service plans for three of three residents (R1, R2 and R3) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure licensee's staff documented provided resident services according to the residents' service plans for three of three residents (R1, R2 and R3) with records reviewed. [...]”

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, 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 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 maintain 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, 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 provide the required training, drills, and plans for fire safety and evacuation.

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

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

Summary: MDH found the licensee failed to ensure staff providing nursing services under a purported license had current credentials from the health licensing board while providing those services.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure staff providing nursing services under a purported license had current credentials from the health licensing board while providing those services. Additionally, the licensee failed to ensure staff providing assisted living services used the correct authentication with name and title of the person making the entry for one of four employees (unlicensed personnel (ULP)-E) with records reviewed. [...]”

Rule cited: “(a) Licensed health professionals and nurses providing services as employees of a licensed facility must possess a current Minnesota license or registration to practice. [...]”

Summary: MDH found the licensee failed to ensure three of four unlicensed personnel ((ULP)-D, ULP-E and ULP-G) completed training and competency evaluations prior to providing delegated nursing tasks to

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure three of four unlicensed personnel ((ULP)-D, ULP-E and ULP-G) completed training and competency evaluations prior to providing delegated nursing tasks to residents, with records reviewed. This had the potential to affect all thirty (30) residents receiving assisted living services. [...]”

Rule cited: “(b) Unlicensed personnel performing delegated nursing tasks in an assisted living facility must: (1) have successfully completed training and demonstrated competency by successfully completing a written or oral test of the topics in section 144G.61, [...]”

Summary: MDH found the licensee failed to ensure contracted staff met all requirements for personnel employed by the licensee for one of one unlicensed personnel (ULP)-H) with records reviewed.

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

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 that a registered nurse was available for consultation to staff performing delegated nursing tasks and services including therapies.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure that a registered nurse was available for consultation to staff performing delegated nursing tasks and services including therapies. This had the potential to affect all thirty (30) residents and staff of the facility. [...]”

Rule cited: “(a) Assisted living facilities must have a registered nurse available for consultation by staff performing delegated nursing tasks and must have an appropriate licensed health professional available if performing other delegated services such as therapies.”

Summary: MDH found the licensee failed to ensure the registered nurse (RN) conducted training and competency evaluations for unlicensed personnel (ULP) prior to perfoming delegated nursing tasks for two of four employees (ULP-D and ULP-H) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the registered nurse (RN) conducted training and competency evaluations for unlicensed personnel (ULP) prior to perfoming delegated nursing tasks for two of four employees (ULP-D and ULP-H) with records reviewed. [...]”

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 a registered nurse (RN) conducted direct supervision of staff carrying out a delegated task within 30 days of providing nursing services for three of four employees (unlicensed personnel (ULP)-E, ULP-G and ULP-I) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure a registered nurse (RN) conducted direct supervision of staff carrying out a delegated task within 30 days of providing nursing services for three of four employees (unlicensed personnel (ULP)-E, ULP-G and ULP-I) with records reviewed. [...]”

Rule cited: “(a) Staff who perform delegated nursing or therapy tasks must be supervised by an appropriate licensed health professional or a registered nurse according to the assisted living facility's policy where the services are being provided to verify that the work [...]”

Summary: MDH found the licensee failed to provide staff orientation to assisted living licensing requirements and regulations for three of four employees (unlicensed personnel (ULP)-D, ULP-G, and ULP-H) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide staff orientation to assisted living licensing requirements and regulations for three of four employees (unlicensed personnel (ULP)-D, ULP-G, and ULP-H) with records reviewed. This has the potential to affect all thirty (30) residents. [...]”

Rule cited: “All staff providing and supervising direct services must complete an orientation to assisted living facility licensing requirements and regulations before providing assisted living services to residents. [...]”

Summary: MDH found the licensee failed to ensure three of four employees (unlicensed personnel (ULP)-D, ULP-G and ULP-H) received the required amount of dementia care training in the required time frame with records reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure three of four employees (unlicensed personnel (ULP)-D, ULP-G and ULP-H) received the required amount of dementia care training in the required time frame with records reviewed. This had the potential to affect all thirty (30) residents. [...]”

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 develop and maintain a current individualized medication management record for each resident to include all required content for three of three residents (R1, R2 and R3) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to develop and maintain a current individualized medication management record for each resident to include all required content for three of three residents (R1, R2 and R3) with records reviewed. [...]”

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 unlicensed personnel (ULP) were trained and competency tested prior to a registered nurse (RN) delegating medication administration to two of four employees (ULP-G and ULP-H) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure unlicensed personnel (ULP) were trained and competency tested prior to a registered nurse (RN) delegating medication administration to two of four employees (ULP-G and ULP-H) with records reviewed. [...]”

Rule cited: “Medications may be administered by a nurse, physician, or other licensed health practitioner authorized to administer medications or by unlicensed personnel who have been delegated medication administration tasks by a registered nurse.”

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 client, and were able to demonstrate the ability to competently follow the procedure for two of two employees (ULP-G and ULP-H) with records reviewed.

MDH’s finding, as written: “Based on 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 client, and were able to demonstrate the ability to competently follow the procedure for two of two employees (ULP-G and ULP-H) with records reviewed. [...]”

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 staff administered medications as ordered for two of three residents (R1 and R2) with records reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure staff administered medications as ordered for two of three residents (R1 and R2) with records reviewed. The licensee also failed to ensure staff administered medications according to manufacturer's instructions with insulin administration via a prefilled insulin pen, for one of three residents (R1) observed. [...]”

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 residents' refrigerated medications were maintained at the manufacturer's recommended temperatures by failing to monitor and document medication refrigerator temperatures for the refrigerator located in the nurse's office.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure residents' refrigerated medications were maintained at the manufacturer's recommended temperatures by failing to monitor and document medication refrigerator temperatures for the refrigerator located in the nurse's office. The licensee also failed to properly secure, monitor and include a daily narcotic count of 288 tablets of various narcotic medications. [...]”

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.”

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to properly dispose of various medications, overfilling a 30-gallon trash bag and a three-gallon plastic container located in the nursing office. Additionally, the licensee failed to dispose of narcotic medications that remained at the facility five (5) months after the discharge of one of one resident (R5) 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 develop individual treatment management plans with all required content for three of three residents (R1, R2 and R3) who received ordered treatments.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to develop individual treatment management plans with all required content for three of three residents (R1, R2 and R3) who received ordered treatments. [...]”

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 a registered nurse (RN) trained and verified competency with treatments and therapies for unlicensed personnel (ULP) for two of four employees (ULP-D and ULP-H) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure a registered nurse (RN) trained and verified competency with treatments and therapies for unlicensed personnel (ULP) for two of four employees (ULP-D and ULP-H) with records reviewed. [...]”

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 [...]”

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 medication dosage box set-up. This had the potential to affect all thirty (30) residents. [...]”

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.”