The Emeralds at Grand Rapids A

Summary: MDH found the licensee failed to develop an individual abuse prevention plan with the required content for six of six residents (R1, R2, R3, R7, R8, R9) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to develop an individual abuse prevention plan with the required content for six of six residents (R1, R2, R3, R7, R8, R9) with records 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 post the required information to include: (1) posting the 911 emergency number in common areas and near telephones provided by the assisted living facility; and (2) 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 information to include: (1) posting the 911 emergency number in common areas and near telephones provided by the assisted living facility; and (2) 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 current 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 contained the required content for two of three employees (unlicensed personnel (ULP)-D, ULP-G) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure employee records contained the required content for two of three employees (unlicensed personnel (ULP)-D, 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). [...]”

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 prominently post an emergency disaster plan, emergency exit diagrams and failed to provide residents with exit diagrams.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to prominently post an emergency disaster plan, emergency exit diagrams and failed to provide residents with exit diagrams. [...]”

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 a resident record included a discharge summary for one of one discharged resident (R6) with record reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure a resident record included a discharge summary for one of one discharged resident (R6) with record 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 and staff. [...]”

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

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

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

Summary: MDH found the licensee failed to develop and execute a written contract with the required content for three of three residents (R1, R2, R3) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to develop and execute a written contract with the required content for three of three residents (R1, R2, R3) with records 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 background study was submitted and received for one of one employee (unlicensed personnel (ULP)-D) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure a background study was submitted and received for one of one employee (unlicensed personnel (ULP)-D) with records reviewed. [...]”

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

MDH’s finding, as written: “Based on observation, 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 three employees (unlicensed personnel (ULP)-D, ULP-H, ULP-G) 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 ensure employees received orientation to 144G licensing requirements for three of three employees (unlicensed personnel (ULP)-G, ULP-D and ULP-H) with employee records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure employees received orientation to 144G licensing requirements for three of three employees (unlicensed personnel (ULP)-G, ULP-D and ULP-H) with employee records reviewed. This had potential to affect all thirty-eight (38) residents. [...]”

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 two of three employees (unlicensed personnel (ULP)-D, 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 interview and record review, the licensee failed to ensure two of three employees (unlicensed personnel (ULP)-D, ULP-H) received the required amount of dementia care training in the required time frame with records reviewed. [...]”

Rule cited: “(3) for assisted living facilities with dementia care, direct-care employees must have completed at least eight hours of initial training on topics specified under paragraph (b) within 80 working hours of the employment start date. [...]”

Summary: MDH found the licensee failed to ensure the registered nurse (RN) completed ongoing

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure the registered nurse (RN) completed ongoing resident reassessments and did not exceed 90 days for three of three residents (R3, R2, R1) as required with records 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 ensure the service plan included all required content for three of

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

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure prescription medications were stored according to the manufacturer's directions. 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 is issued at a widespread scope (when problems are pervasive or represent a systemic [...]”

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 develop an individual treatment management plan to include all required content for two of three residents (R2, R3) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to develop an individual treatment management plan to include all required content for two of three residents (R2, R3) with records reviewed. [...]”

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 provide a hazard vulnerability or safety risk assessment that included hazards identified on and around the property.

MDH’s finding, as written: “Based on document review and interview, the licensee failed to provide a hazard vulnerability or safety risk assessment that included hazards identified on and around the property. Mitigation of property hazards to protect residents from harm was not included. This had the potential to directly affect all residents and staff. [...]”

Rule cited: “An assisted living facility with dementia care that has a secured dementia care unit must meet the requirements of section 144G.45 and the following additional requirements: (1) a hazard vulnerability assessment or safety risk must be performed on and around [...]”

Summary: MDH found the licensee failed to develop and implement all required policies and procedures related to dementia care.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop and implement all required policies and procedures related to dementia care. This had the potential to affect all residents in the facility. [...]”

Rule cited: “(a) In addition to the policies and procedures required in the licensing of all facilities, the assisted living facility with dementia care licensee must develop and implement policies and procedures that address the: (1) philosophy of how services are [...]”

Summary: MDH found the licensee failed to have an evaluation for an activity plan for three of three residents (R1, R2, R3) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to have an evaluation for an activity plan for three of three residents (R1, R2, R3) with records 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 is issued at a widespread scope (when problems are pervasive or represent a systemic [...]”

Rule cited: “(b) Each resident must be evaluated for activities according to the licensing rules of the facility. [...]”

Summary: MDH found the licensee failed to provide care and services according to acceptable health care, medical, or nursing standards for five of five residents (R1, R2, R3, R4, R5) with bedrails.

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 five of five residents (R1, R2, R3, R4, R5) with bedrails. This resulted in an immediate correction order on March 16, 2022, at approximately 12:58 p.m. [...]”

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 a required notice was posted at the main entry way of the facility to display statutory language to disclose electronic monitoring activity.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to ensure a required notice was posted at the main entry way of the facility to display statutory language to disclose electronic monitoring activity. This had the potential to affect all current residents, staff, and visitors to the facility. [...]”

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 [...]”