Tamarack Court of Bemidji

Survey completed February 29, 2024: 4 correction orders

• Tag 1470: 144G.63 Subd. 2 Content of required orientation Level 2, isolated scope, scope/level letter D · correction period: Twenty-one (21) days
  Details

  Summary: MDH found the licensee failed to ensure employees received orientation to include all required content for one of three employees (clinical nurse supervisor (CNS)-B).

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure employees received orientation to include all required content for one of three employees (clinical nurse supervisor (CNS)-B). [...]”

  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 [...]”

• Tag 1500: 144G.63 Subd. 5 Required annual training Level 2, isolated scope, scope/level letter D · correction period: Twenty-One (21) days
  Details

  Summary: MDH found the licensee failed to ensure an employee received all the required training for one of three employees (unlicensed personnel (ULP)-D).

  MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure an employee received all the required training for one of three employees (unlicensed personnel (ULP)-D). [...]”

  Rule cited: “(a) All staff that perform direct services must complete at least eight hours of annual training for each 12 months of employment. [...]”

• Tag 1640: 144G.70 Subd. 4 (a-e) Service plan, implementation and revisions to Level 2, widespread scope, scope/level letter F · correction period: Twenty-one (21) days
  Details

  Summary: MDH found the licensee failed to ensure the current service plan included a signature or other authentication by the resident and/or resident's representative to document agreement on the services to be provided for three of three residents (R1, R2, R3).

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the current service plan included a signature or other authentication by the resident and/or resident's representative to document agreement on the services to be provided for three of three residents (R1, R2, R3). [...]”

  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. [...]”

• Tag 1790: 144G.71 Subd. 10 Medication management for residents who will Level 2, widespread scope, scope/level letter F · correction period: Twenty-One (21) days
  Details

  Summary: MDH found the licensee failed to ensure two of two unlicensed personnel (ULP)-D, ULP-E) were trained and demonstrated competency to prepare and give medications for residents having unplanned time away when licensed nurse is not available.

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure two of two unlicensed personnel (ULP)-D, ULP-E) were trained and demonstrated competency to prepare and give medications for residents having unplanned time away when licensed nurse is not available. [...]”

  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 [...]”

From MDH’s letter: the letter says the facility is in substantial compliance; no immediate fines.

Allegation, as written: “The alleged perpetrator (AP), an unlicensed personnel (ULP) at the facility, neglected the resident when he failed to provide services as directed by the service plan. The AP documented he brought the resident to the bathroom; however, security camera footage showed the AP never entered the room. The resident fell and broke her hip.”

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

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

MDH’s conclusion, as written: “The Minnesota Department of Health determined neglect was inconclusive. It could not be determined whether the AP's failure to complete scheduled toileting and a safety check resulted in the resident's fall. When staff found the resident on the floor, staff contacted the nurse, and the resident was sent to the emergency room for evaluation.”

Action taken by facility: “The facility investigated the root cause of the resident's fall and through the investigation identified that the AP failed to enter the resident's room to perform scheduled toileting and a safety check. The facility suspended the AP and completed an internal investigation. The AP was retrained, and all facility staff received training on documentation. [...]”

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

Survey completed March 11, 2025: no correction orders issued.

Allegation, as written: “The alleged perpetrator (AP), a facility staff member, neglected the resident when she failed to complete scheduled safety checks per the resident's service plan. The resident fell and was admitted to the hospital with a subdural hematoma (bleeding in the brain).”

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

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

MDH’s conclusion, as written: “The Minnesota Department of Health determined neglect was inconclusive. Although the resident's service plan was not followed, it was unable to be determined if the resident's fall and injury were a direct result of staff's failure to implement the service plan. Following the fall, nursing staff monitored the resident and when a change in condition was observed, the resident was sent to the hospital for further evaluation.”

Action taken by facility: “The facility reported the incident, investigated the resident's fall, and determined the service plan was not followed at the time of the incident. The facility terminated the AP and retrained all staff on the importance of following the plan of care.”

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

Survey completed July 3, 2024: no correction orders issued.

Survey completed June 24, 2025: no correction orders issued.

Allegation, as written: “The alleged perpetrator (AP), an unlicensed personnel (ULP) at the facility, neglected the resident when she failed to transfer the resident according to their service plan. The resident fell and was transferred to the emergency room. The resident was diagnosed with a hip 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 had a fall while being transferred without a gait belt, the error was an isolated incident. The resident sustained a hip fracture and was hospitalized and returned to their baseline health condition.”

Action taken by facility: “The facility reported the incident to MAARC. The facility conducted an internal investigation and retrained the employee involved in the incident.”

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

Survey completed January 21, 2025: no correction orders issued.

Survey completed December 28, 2023: no correction orders issued.