The Elms

Survey completed June 11, 2024: 5 correction orders

• Tag 480: 144G.41 Subd 1 (13) (i) (B) Minimum requirements Level 2, widespread scope, scope/level letter F · correction period: Please refer to the FBEIR for any compliance dates
  Details

  Summary: MDH found the licensee failed to ensure food was prepared and served according to the Minnesota Food Code.

  MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure food was prepared and served according to the Minnesota Food Code. 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 the [...]”

  Rule cited: “(13) offer to provide or make available at least the following services to residents: (B) food must be prepared and served according to the Minnesota Food Code, Minnesota Rules, chapter 4626; and”

• Tag 510: 144G.41 Subd. 3 Infection control program Level 2, widespread scope, scope/level letter F · correction period: Seven (7) days · fine: $500.00 assessed
  Details

  Summary: MDH found the licensee failed to establish and maintain written evidence of the infection control program that complied with accepted health care, medical, and nursing standards for infection control.

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to establish and maintain written evidence of the infection control program that complied with accepted health care, medical, and nursing standards for infection control. This had the potential to affect all residents and staff. [...]”

  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. [...]”

• Tag 660: 144G.42 Subd. 9 Tuberculosis prevention and control Level 2, widespread scope, scope/level letter F · correction period: Twenty-one (21) days
  Details

  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 baseline TB screening for two of two employees (clinical nurse supervisor (CNS)-A and unlicensed personnel (ULP)-C).

  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 baseline TB screening for two of two employees (clinical nurse supervisor (CNS)-A and unlicensed personnel (ULP)-C). [...]”

  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 [...]”

• 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 all staff that perform

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure all staff that perform direct services completed at least eight hours of annual training for each 12 months of employment for one of two employees (unlicensed personnel (ULP)-C). [...]”

  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 1890: 144G.71 Subd. 20 Prescription drugs Level 2, widespread scope, scope/level letter F · correction period: Seven (7) days
  Details

  Summary: MDH found the licensee failed to ensure expired medications were disposed of for four of four residents (R1, R4, R5, R6).

  MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure expired medications were disposed of for four of four residents (R1, R4, R5, R6). 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 [...]”

  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 [...]”

From MDH’s letter: the letter says the facility is in substantial compliance.

Fines assessed by MDH

• Tag 510 (144g.41 Subd. 3 - Infection Control Program): $500.00

Total fines assessed, as printed in the letter: $500.00.