Sunset Homes Assisted Living, 11th Avenue Nw

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

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 [...]”

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 execute a written contract with the required content for one of one resident (R2) with record reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to execute a written contract with the required content for one of one resident (R2) with record reviewed. This practice resulted in a level one violation (a violation that has no potential to cause more than a minimal impact on the resident and does not affect health or safety), and was issued at an isolated scope (when one or a limited number of residents are affected or one or a limited number of staff are involved or the situation [...]”

Rule cited: “(a) An assisted living facility may not offer or provide housing or assisted living services to any individual unless it has executed a written contract with the resident. [...]”

Summary: MDH found the licensee failed to execute a written contract with the required content for one of one resident (R2)

MDH’s finding, as written: “Based on interview and record review, the licensee failed to execute a written contract with the required content for one of one resident (R2) with record reviewed. This practice resulted in a level one violation (a violation that has no potential to cause more than a minimal impact on the resident and does not affect health or safety), and was issued at a widespread scope (when problems are pervasive or represent a systemic failure that has affected or has potential to affect a large portion [...]”

Rule cited: “(c) The contract must include: (1) a disclosure of the category of assisted living facility license held by the facility and, if the facility is not an assisted living facility with dementia care, a disclosure that it does not hold an assisted living facility [...]”

Summary: MDH found the licensee failed to execute a written contract with the required content for one of one resident (R2) with record reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to execute a written contract with the required content for one of one resident (R2) with record reviewed. This practice resulted in a level one violation (a violation that has no potential to cause more than a minimal impact on the resident and does not affect health or safety), and was issued at a widespread scope (when problems are pervasive or represent a systemic failure that has affected or has potential to affect a large portion [...]”

Rule cited: “(d) The contract must include a description of the facility's complaint resolution process available to residents, including the name and contact information of the person representing the facility who is designated to handle and resolve complaints. [...]”

Summary: MDH found the licensee failed to execute a written contract with the required content for one of one resident (R2) with record reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to execute a written contract with the required content for one of one resident (R2) with record reviewed. This practice resulted in a level one violation (a violation that has no potential to cause more than a minimal impact on the resident and does not affect health or safety), and was issued at a widespread scope (when problems are pervasive or represent a systemic failure that has affected or has potential to affect a large portion [...]”

Rule cited: “(5) a description of the facility's policies related to medical assistance waivers under chapter 256S and section 256B.49 and the housing support program under chapter 256I, including: (i) whether the facility is enrolled with the commissioner of human [...]”

Summary: MDH found the licensee failed to ensure competency evaluations were completed as required prior to providing direct care for two of two unlicensed personnel (ULP-D, ULP-E) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure competency evaluations were completed as required prior to providing direct care for two of two unlicensed personnel (ULP-D, ULP-E) with records reviewed. [...]”

Rule cited: “(b) In addition to paragraph (a), training and competency evaluation for unlicensed personnel providing assisted living services must include: (1) observing, reporting, and documenting resident status; (2) basic knowledge of body functioning and changes in [...]”

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 two of two unlicensed personnel (ULP-D, 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 two of two unlicensed personnel (ULP-D, 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 one of two employees (unlicensed personnel (ULP)-D) with records reviewed.

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 one of two employees (unlicensed personnel (ULP)-D) with records reviewed. [...]”

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 the service plan included a signature or other authentication by the resident and the facility to document agreement on the services provided for two of two residents (R2, R3) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the service plan included a signature or other authentication by the resident and the facility to document agreement on the services provided for two of two residents (R2, R3) with records reviewed. [...]”

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 the service plan included all required content for one of one resident (R2) with record reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure the service plan included all required content for one of one resident (R2) with record reviewed. [...]”

Rule cited: “(f) The service plan must include: (1) a description of the services to be provided, the fees for services, and the frequency of each service, according to the resident's current assessment and resident preferences; (2) the identification of staff or [...]”

Summary: MDH found the licensee failed to ensure competency evaluations were completed as required for two of two unlicensed personnel (ULP-D, ULP-E) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure competency evaluations were completed as required for two of two unlicensed personnel (ULP-D, ULP-E) with records reviewed. [...]”

Rule cited: “(2) for unplanned time away, when the pharmacy is not able to provide the medications, a licensed nurse or unlicensed personnel shall provide medications in amounts and dosages needed for the length of the anticipated absence, not to exceed seven calendar [...]”

Summary: MDH found the licensee failed to ensure the required notice was posted at the main entry way of the establishment to display statutory language to disclose electronic monitoring activity, potentially affecting all current residents in the assisted living facility, staff and any visitors of the licensee.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to ensure the required notice was posted at the main entry way of the establishment to display statutory language to disclose electronic monitoring activity, potentially affecting all current residents in the assisted living facility, staff and any visitors of the licensee. [...]”

Rule cited: “Subd. 8.Notice to visitors. (a) A facility must post a sign at each facility entrance accessible to visitors that states: "Electronic monitoring devices, including security cameras and audio devices, may be present to record persons and activities." (b) The [...]”

Summary: MDH found the licensee failed to have a daily program of social and recreational activities.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to have a daily program of social and recreational activities. This had the potential to affect all six 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 establish and maintain an effective infection control program to comply with current recommendations for COVID-19.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to establish and maintain an effective infection control program to comply with current recommendations for COVID-19. This had the potential to affect all residents, staff and visitors. [...]”

Rule cited: “(a) All assisted living facilities must establish and maintain an infection control program that complies with accepted health care, medical, and nursing standards for infection control. [...]”

Summary: MDH found the licensee failed to post information related to the grievance procedure, resident advocacy information, and information for reporting suspected maltreatment.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to post information related to the grievance procedure, resident advocacy information, and information for reporting suspected maltreatment. This had the potential to affect all 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. [...]”

Summary: MDH found the licensee failed to engage in and maintain documentation of quality management activity.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to engage in and maintain documentation of quality management activity. This had the potential to affect all six (6) residents receiving assisted living services. [...]”

Rule cited: “The facility shall engage in quality management appropriate to the size of the facility and relevant to the type of services provided. [...]”

Summary: MDH found the licensee failed to develop and implement an individual abuse prevention plan that included an individualized review or assessment of the person's susceptibility to abuse by another individual, including other vulnerable adults and the person's risk of abusing other vulnerable adults for one of one resident (R1) with record reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to develop and implement an individual abuse prevention plan that included an individualized review or assessment of the person's susceptibility to abuse by another individual, including other vulnerable adults and the person's risk of abusing other vulnerable adults for one of one resident (R1) with record reviewed. [...]”

Rule cited: “(b) The facility must develop and implement an individual abuse prevention plan for each vulnerable adult. [...]”

Summary: MDH found the licensee failed to ensure posting information and the reporting number for the Minnesota Adult Abuse Reporting Center to report suspected maltreatment of a vulnerable adult under section 626.557 as required.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure posting information and the reporting number for the Minnesota Adult Abuse Reporting Center to report suspected maltreatment of a vulnerable adult under section 626.557 as required. This had the potential to affect all six (6) 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 ensure an annual performance evaluation was completed for one of two unlicensed personnel (ULP-D) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure an annual performance evaluation was completed for one of two unlicensed personnel (ULP-D) 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. [...]”

MDH’s finding, as written: “Based on interview and record review the licensee failed to establish and maintain a TB (tuberculosis) prevention and control program based on the most current guidelines issued by the centers for Disease Control and Prevention (CDC) guidelines. This had the potential to affect all residents, staff and visitors. [...]”

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 emergency exit diagrams were posted and provided to residents.

MDH’s finding, as written: “Based on observation, interview and document review, the licensee failed to ensure emergency exit diagrams were posted and provided to residents. In addition, the licensee failed to develop an all-hazards emergency preparedness (EP) program and plan to include Appendix Z required elements. This had the potential to affect all six (6) residents, staff and any visitors. [...]”

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 documentation of services provided for one of one resident (R1) with record reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure documentation of services provided for one of one resident (R1) with record reviewed. 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 [...]”

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 and maintain the building physical environment, including walls, floors, and ceiling, in a continuous state of good repair and operation for health, comfort, and well-being of residents in accordance with a maintenance and repair program.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to provide and maintain the building physical environment, including walls, floors, and ceiling, in a continuous state of good repair and operation for health, comfort, and well-being of residents in accordance with a maintenance and repair program. This had the potential to affect all residents of the facility and staff. [...]”

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, failed to provide required training to residents and employees for fire safety and evacuation, and failed to conduct required employee evacuation drills.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop and maintain fire safety and evacuation plans, failed to provide required training to residents and employees for fire safety and evacuation, and failed to conduct required employee evacuation drills. 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 execute a written contract prior to providing assisted living services for one of one resident (R1) with record reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to execute a written contract prior to providing assisted living services for one of one resident (R1) with record reviewed. [...]”

Rule cited: “(a) An assisted living facility may not offer or provide housing or assisted living services to any individual unless it has executed a written contract with the resident. [...]”

Summary: MDH found the licensee failed to ensure a copy of the termination notice to the Office of Ombudsman for Long-Term Care for one of one resident (R1) with record reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure a copy of the termination notice to the Office of Ombudsman for Long-Term Care for one of one resident (R1) with record reviewed. [...]”

Rule cited: “(a) A facility terminating a contract must issue a written notice of termination according to this section. [...]”

Summary: MDH found the licensee failed to ensure competency evaluations were completed as required prior to providing direct care for two of two unlicensed personnel (ULP-C, ULP-D) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure competency evaluations were completed as required prior to providing direct care for two of two unlicensed personnel (ULP-C, ULP-D) with records reviewed. [...]”

Rule cited: “(a) Training and competency evaluations for all unlicensed personnel must include the following: (1) documentation requirements for all services provided; (2) reports of changes in the resident's condition to the supervisor designated by the facility; (3) [...]”

Summary: MDH found the licensee failed to ensure competency evaluations were completed as required prior to providing direct care for two of two unlicensed personnel (ULP-C, ULP-D) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure competency evaluations were completed as required prior to providing direct care for two of two unlicensed personnel (ULP-C, ULP-D) with records reviewed. [...]”

Rule cited: “(b) In addition to paragraph (a), training and competency evaluation for unlicensed personnel providing assisted living services must include: (1) observing, reporting, and documenting resident status; (2) basic knowledge of body functioning and changes in [...]”

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 two of two unlicensed personnel (ULP-C, ULP-D) with records reviewed.

MDH’s finding, as written: “Based on observation, 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 two of two unlicensed personnel (ULP-C, ULP-D) 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 staff providing assisted living services were oriented specifically to each individual resident and the services to be provided for two of two unlicensed personnel (ULP-C, ULP-D) with records reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure staff providing assisted living services were oriented specifically to each individual resident and the services to be provided for two of two unlicensed personnel (ULP-C, ULP-D) with records reviewed. [...]”

Rule cited: “Staff providing assisted living services must be oriented specifically to each individual resident and the services to be provided. This orientation may be provided in person, orally, in writing, or electronically.”

Summary: MDH found the licensee failed to ensure annual training included all required topics for each 12 months of employment for one of two employees (unlicensed personnel (ULP)-D) with records reviewed.

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 one of two employees (unlicensed personnel (ULP)-D) with records reviewed. [...]”

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 two of two unlicensed personnel (ULP-C, ULP-D) received the required amount of dementia care training with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure two of two unlicensed personnel (ULP-C, ULP-D) received the required amount of dementia care training with records reviewed. [...]”

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 ensure the registered nurse (RN) conducted ongoing client monitoring and reassessment, not to exceed 90 calendar days from the last date of the assessment, and failed to ensure the RN completed a comprehensive reassessment to include all areas identified on the uniform assessment tool (UDALSA) for one of one resident (R1) with record reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) conducted ongoing client monitoring and reassessment, not to exceed 90 calendar days from the last date of the assessment, and failed to ensure the RN completed a comprehensive reassessment to include all areas identified on the uniform assessment tool (UDALSA) for one of one resident (R1) with record reviewed. [...]”

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 finalize a current written service plan within 14 calendar days for

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to finalize a current written service plan within 14 calendar days for one of one resident (R1) with record reviewed. [...]”

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 the service

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure the service plan included all required content for one of one resident (R1) with record reviewed. [...]”

Rule cited: “(f) The service plan must include: (1) a description of the services to be provided, the fees for services, and the frequency of each service, according to the resident's current assessment and resident preferences; (2) the identification of staff or [...]”

Summary: MDH found the licensee failed to ensure the registered nurse (RN) conducted an individualized assessment to determine what medication management services would be provided, and how the services would be provided for one of one resident (R1) with record reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the registered nurse (RN) conducted an individualized assessment to determine what medication management services would be provided, and how the services would be provided for one of one resident (R1) with record reviewed. [...]”

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 one resident (R1) with record reviewed.

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 one resident (R1) with record reviewed. [...]”

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 ensure medication was not administered as ordered for one of one resident (R1) with record reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure medication was not administered as ordered for one of one resident (R1) 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. [...]”

Summary: MDH found the licensee failed to ensure competency evaluations were completed as required two of two unlicensed personnel (ULP-C, ULP-D) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure competency evaluations were completed as required two of two unlicensed personnel (ULP-C, ULP-D) with records reviewed. [...]”

Rule cited: “(2) for unplanned time away, when the pharmacy is not able to provide the medications, a licensed nurse or unlicensed personnel shall provide medications in amounts and dosages needed for the length of the anticipated absence, not to exceed seven calendar [...]”

Summary: MDH found the licensee failed to ensure prescriptions were renewed at least every 12 months for one of one resident (R1) with record reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure prescriptions were renewed at least every 12 months for one of one resident (R1) with record reviewed. [...]”

Rule cited: “Prescriptions must be renewed at least every 12 months or more frequently as indicated by the assessment in subdivision 2. Prescriptions for controlled substances must comply with chapter 152.”

Summary: MDH found the licensee failed to ensure access to keys for a medication cart was secure.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure access to keys for a medication cart was secure. This had the potential to affect all six 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 the current Minnesota Bill of Rights for Assisted Living Residents was provided to the resident and a written acknowledgement received for one of one residents (R1) with record reviewed.

MDH’s finding, as written: “Based on observation, 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 one of one residents (R1) with record reviewed. This had the potential to affect all residents. [...]”

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 in written or electronic form to residents, families, or other persons who request it, a description of the dementia care training program, the categories of employees trained, the frequency of training, and the basic topics covered with records reviewed.

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, a description of the dementia care training program, the categories of employees trained, the frequency of training, and the basic topics covered with records reviewed. [...]”

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 [...]”

Summary: MDH found the licensee failed to ensure the required notice was posted at the main entry way of the establishment to display statutory language to disclose electronic monitoring activity, potentially affecting all current residents in the assisted living facility, staff and any visitors of the licensee.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to ensure the required notice was posted at the main entry way of the establishment to display statutory language to disclose electronic monitoring activity, potentially affecting all current residents in the assisted living facility, staff and any visitors of the licensee. [...]”

Rule cited: “Subd. 8.Notice to visitors. (a) A facility must post a sign at each facility entrance accessible to visitors that states: "Electronic monitoring devices, including security cameras and audio devices, may be present to record persons and activities." (b) The [...]”