The Beatitudes Homes

Summary: MDH found the licensee failed to ensure one of two employees (unlicensed personnel (ULP)-F) received orientation to assisted living facility licensing requirements and regulations before providing services.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure one of two employees (unlicensed personnel (ULP)-F) received orientation to assisted living facility licensing requirements and regulations before providing services. [...]”

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 label a time sensitive medication with an opened date or included a

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to label a time sensitive medication with an opened date or included a proper label for one of one resident (R1) with medication administration. [...]”

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 care and services were provided according to acceptable health care and medical or nursing standards for

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure care and services were provided according to acceptable health care and medical or nursing standards for one of two residents (R5) with side rails. [...]”

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.”

Summary: MDH found the licensee failed to support protection and safety by not posting 911 emergency number 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 support protection and safety by not posting 911 emergency number 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 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 employee records included evidence of training/competency content for blood sugar monitoring for one of one unlicensed personnel (ULP-D).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure employee records included evidence of training/competency content for blood sugar monitoring for one of one unlicensed personnel (ULP-D). [...]”

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 establish and maintain a tuberculosis (TB) prevention program, based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC) which included documentation of a completed health history and symptom screening for two of two unlicensed personnel (ULP-D, ULP-E).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to establish and maintain a tuberculosis (TB) prevention program, based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC) which included documentation of a completed health history and symptom screening for two of two unlicensed personnel (ULP-D, ULP-E). [...]”

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 develop an all-hazards risk assessment emergency preparedness program and plan to include Appendix Z required elements.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to develop an all-hazards risk assessment emergency preparedness program and plan to include Appendix Z required elements. This had the potential to affect all residents, staff, and 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 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 facility failed to develop and execute an assisted living written contract to include the required content for one of one resident (R1).

MDH’s finding, as written: “Based on interview and record review, the facility failed to develop and execute an assisted living written contract to include the required content for one of one resident (R1). [...]”

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 the assisted living contract did not include language waiving the facility's liability for health, safety, or personal property for one of one resident (R1).

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

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

Summary: MDH found the facility failed to provide proof that a pre-termination meeting occurred seven days prior to issuing a notice of termination for one of one resident (R1).

MDH’s finding, as written: “Based on interview and record review, the facility failed to provide proof that a pre-termination meeting occurred seven days prior to issuing a notice of termination for one of one resident (R1). [...]”

Rule cited: “(a) Before issuing a notice of termination of an assisted living contract, a facility must schedule and participate in a meeting with the resident and the resident's legal representative and designated representative. [...]”

Summary: MDH found the licensee failed to send a copy of the termination notice to the Office of Ombudsman for Long-Term Care as required for one of one resident (R1).

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

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

MDH’s finding, as written: “Based on interview and record review, the licensee failed to include the required content of a written termination notice for one of one resident (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) 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 [...]”

Rule cited: “The notice required under subdivision 7 must contain, at a minimum: (1) the effective date of the termination of the assisted living contract; (2) a detailed explanation of the basis for the termination, including the clinical or other supporting rationale; [...]”

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 of the emergency relocation for one of one resident (R1).

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 of the emergency relocation for one of one resident (R1). [...]”

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 licensee failed to ensure two of three employees (unlicensed personnel (ULP)-D, ULP-F) were affiliated with the assisted living license as required.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure two of three employees (unlicensed personnel (ULP)-D, ULP-F) were affiliated with the assisted living license as required. This had the potential to affect the licensee's three current residents. [...]”

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. [...]”

Summary: MDH found the licensee failed to ensure training and competency evaluations for the required topics were completed by one of two unlicensed personnel (ULP-D) prior to providing direct cares.

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

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 training and evaluations were completed by one of two unlicensed personnel (ULP-D) prior to providing direct cares.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure competency training and evaluations were completed by one of two unlicensed personnel (ULP-D) prior to providing direct cares. [...]”

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 one of one employee (unlicensed personnel (ULP)-D) received orientation to assisted living facility licensing requirements and regulations before providing services.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure one of one employee (unlicensed personnel (ULP)-D) received orientation to assisted living facility licensing requirements and regulations before providing services. [...]”

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 a registered nurse (RN) conducted an initial assessment for one of one resident (R1) prior to the initiation of services.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure a registered nurse (RN) conducted an initial assessment for one of one resident (R1) prior to the initiation of services. [...]”

Rule cited: “(a) Residents who are not receiving any assisted living services shall not be required to undergo an initial nursing assessment. [...]”

Summary: MDH found the licensee failed to ensure the registered nurse (RN) completed an assessment for a change in condition following hospitalizations and a reassessment not to exceed 90 days for one of one resident (R1).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the registered nurse (RN) completed an assessment for a change in condition following hospitalizations and a reassessment not to exceed 90 days for one of one resident (R1). [...]”

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 included a signature or other authentication by the resident and the facility to document agreement on the services provided for one of one resident (R1).

MDH’s finding, as written: “Based on observation, 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 one of one resident (R1). [...]”

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. [...]”

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee's registered nurse (RN) failed to ensure training and competency evaluations for preparing medications for resident unplanned times away were completed as required for one of two unlicensed personnel (ULP-D). [...]”

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 all medications were securely locked in substantially constructed compartments permitting only authorized personnel 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 permitting only authorized personnel access. This had the potential to affect the licensee's current residents, staff, and visitors. [...]”

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 label a time sensitive medication with an opened date or included a proper label for one of one resident (R1) with medication administration.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to label a time sensitive medication with an opened date or included a proper label for one of one resident (R1) with medication administration. [...]”

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 up-to-date written or electronically recorded orders were maintained for one of one resident (R1) receiving treatments.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure up-to-date written or electronically recorded orders were maintained for one of one resident (R1) receiving treatments. [...]”

Rule cited: “There must be an up-to-date written or electronically recorded order from an authorized prescriber for all treatments and therapies. [...]”

Summary: MDH found the licensee failed to ensure care and services were provided according to acceptable health care and medical or nursing standards for one of one resident (R1) with side rails.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure care and services were provided according to acceptable health care and medical or nursing standards for one of one resident (R1) with side rails. [...]”

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.”

Summary: MDH found the licensee failed to ensure signage was posted at the main entry of the building of the establishment to display statutory language to disclose electronic monitoring activity, potentially affecting all three residents, staff, and visitors of the licensee.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to ensure signage was posted at the main entry of the building of the establishment to display statutory language to disclose electronic monitoring activity, potentially affecting all three residents, staff, and visitors of the licensee. [...]”

Rule cited: “(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 facility is responsible for [...]”