The Homestead at Rochester

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

Rule cited: “(g) Existing construction or elements, including assisted living facilities that were registered as housing with services establishments under chapter 144D prior to August 1, 2021, shall be permitted to continue in use provided such use does not constitute a [...]”

Summary: MDH found the licensee failed to ensure a registered nurse (RN) conducted direct supervision of staff performing a delegated task within 30 days of providing services for one of three unlicensed personnel (ULP-R).

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 performing a delegated task within 30 days of providing services for one of three unlicensed personnel (ULP-R). [...]”

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 two of four unlicensed personnel (ULP-R, ULP-I) received orientation to include the required content.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure two of four unlicensed personnel (ULP-R, ULP-I) received orientation to include the required content. [...]”

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 one of three unlicensed personnel (ULP-R) received the required amount of dementia care training.

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

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 one of three unlicensed personnel (ULP-R) dementia care training in the required topics.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure one of three unlicensed personnel (ULP-R) dementia care training in the required topics. [...]”

Rule cited: “(5) new employees may satisfy the initial training requirements by producing written proof of previously completed required training within the past 18 months. [...]”

Summary: MDH found the licensee failed to ensure a reassessment not to exceed 90 days was completed for one of four residents (R2).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure a reassessment not to exceed 90 days was completed for one of four residents (R2). 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 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 has occurred [...]”

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 current service plan included a signature or other authentication by the resident and the facility to document agreement on the services to be provided for three of five residents (R2, R16, R18).

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 the facility to document agreement on the services to be provided for three of five residents (R2, R16, R18). [...]”

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 documentation of medication setup was completed for two of two residents (R8, R13).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure documentation of medication setup was completed for two of two residents (R8, R13). 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 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 [...]”

Rule cited: “Documentation of dates of medication setup, name of medication, quantity of dose, times to be administered, route of administration, and name of person completing medication setup must be done at the time of setup.”

Summary: MDH found the licensee failed to ensure one of one medication cart (memory care unit) was securely locked in substantially constructed compartments and permitted only authorized personnel to have access with records reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure one of one medication cart (memory care unit) was securely locked in substantially constructed compartments and permitted only authorized personnel to have access with records reviewed. This had the potential to affect all residents residing in the memory care unit and any 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 ensure time sensitive medications were dated when opened for three of four medication carts (assisted living, memory care three, memory care one).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure time sensitive medications were dated when opened for three of four medication carts (assisted living, memory care three, memory care one). [...]”

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 [...]”

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

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 post an emergency preparedness plan prominently and failed to conduct two full scale drills in the last year.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to post an emergency preparedness plan prominently and failed to conduct two full scale drills in the last year. 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 develop fire safety and evacuation plans with the required elements; failed to provide the required training frequency for employees and residents on fire safety and evacuation; and failed to meet the evacuation drill frequency requirements.

MDH’s finding, as written: “Based on observation, record review, and interview, the licensee failed to develop fire safety and evacuation plans with the required elements; failed to provide the required training frequency for employees and residents on fire safety and evacuation; and failed to meet the evacuation drill frequency requirements. This deficient condition had the potential to affect all staff, residents, and visitors. [...]”

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

Summary: MDH found the licensee failed to provide facilities that were not a distinct hazard to life.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to provide facilities that were not a distinct hazard to life. This had the potential to directly affect all residents and staff. [...]”

Rule cited: “(g) Existing construction or elements, including assisted living facilities that were registered as housing with services establishments under chapter 144D prior to August 1, 2021, shall be permitted to continue in use provided such use does not constitute a [...]”

Summary: MDH found the licensee failed to ensure three of four resident's (R2, R3, R4) assisted living contract included a notice with the required verbiage for the residents to identify a designated representative.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure three of four resident's (R2, R3, R4) assisted living contract included a notice with the required verbiage for the residents to identify a designated representative. This had the potential to affect all residents who received services at the facility. [...]”

Rule cited: “(a) Before or at the time of execution of an assisted living contract, an assisted living facility must offer the resident the opportunity to identify a designated representative in writing in the contract and must provide the following verbatim notice on a [...]”

Summary: MDH found the licensee failed to ensure a background study was completed and cleared prior to staff providing services for one of five employees (unlicensed personnel (ULP)-J).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure a background study was completed and cleared prior to staff providing services for one of five employees (unlicensed personnel (ULP)-J). This had the potential to affect all residents. This resulted in an immediate correction order on June 27, 2023, at 4:32 p.m. [...]”

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 facility failed to ensure orientation to assisted living licensing and requirements was completed for one of one agency staff (unlicensed personnel (ULP)-P) prior to providing services for residents

MDH’s finding, as written: “Based on interview and record review, the facility failed to ensure orientation to assisted living licensing and requirements was completed for one of one agency staff (unlicensed personnel (ULP)-P) prior to providing services for residents 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 an isolated scope (when one or a limited number of residents [...]”

Rule cited: “When a facility contracts with a temporary staffing agency, those individuals must meet the same requirements required by this section for personnel employed by the facility and shall be treated as if they are staff of the facility.”

Summary: MDH found the licensee failed to ensure training and competency evaluations for one of three unlicensed personnel (ULP-J) providing assisted living services were conducted by a registered nurse (RN).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure training and competency evaluations for one of three unlicensed personnel (ULP-J) providing assisted living services were conducted by a registered nurse (RN). [...]”

Rule cited: “Instructors and competency evaluators must meet the following requirements: (1) training and competency evaluations of unlicensed personnel who only provide assisted living services specified in section 144G.08, subdivision 9, clauses (1) to (5), must be [...]”

Summary: MDH found the licensee failed to ensure two of three unlicensed personnel (ULP-D, ULP-H) completed training and competency evaluations in all required training topics.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure two of three unlicensed personnel (ULP-D, ULP-H) completed training and competency evaluations in all required training topics. [...]”

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 two of three unlicensed personnel (ULP-D, and ULP-H) completed training and competency evaluations in all required training topics.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure two of three unlicensed personnel (ULP-D, and ULP-H) completed training and competency evaluations in all required training topics. [...]”

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 a registered nurse (RN) conducted direct supervision of staff performing a delegated task within 30 days of providing services for three of three unlicensed personnel (ULP-H, ULP-J, and ULP-D).

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 performing a delegated task within 30 days of providing services for three of three unlicensed personnel (ULP-H, ULP-J, and ULP-D). [...]”

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 three of three unlicensed personnel (ULP-D, ULP-H, and ULP-J) received orientation to include the required content.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure three of three unlicensed personnel (ULP-D, ULP-H, and ULP-J) received orientation to include the required content. [...]”

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 to individual residents 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 staff providing assisted living services were oriented specifically to each individual resident and the services to be provided to individual residents for one of one unlicensed personnel (ULP-D). [...]”

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 employees received at least eight hours of annual training for each 12 months of employment and training failed to include all required topics for one of one unlicensed personnel (ULP-H).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure employees received at least eight hours of annual training for each 12 months of employment and training failed to include all required topics for one of one unlicensed personnel (ULP-H). [...]”

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 three unlicensed personnel (ULP-J and ULP-D) received the required amount of dementia care training.

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

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 two of three unlicensed personnel (ULP-J and ULP-D) received dementia care training in all required topics.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure two of three unlicensed personnel (ULP-J and ULP-D) received dementia care training in all required topics. [...]”

Rule cited: “(5) new employees may satisfy the initial training requirements by producing written proof of previously completed required training within the past 18 months. [...]”

Summary: MDH found the licensee failed to ensure a change in condition assessment was completed for one of one resident (R4) in addition, the licensee failed to ensure a reassessment not to exceed 90 days was completed for one of three residents (R2).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure a change in condition assessment was completed for one of one resident (R4) in addition, the licensee failed to ensure a reassessment not to exceed 90 days was completed for one of three residents (R2). [...]”

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 the required content for two of two residents (R4, R5).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the service plan included the required content for two of two residents (R4, R5). 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 affected [...]”

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 one of three unlicensed personnel (ULP-H) completed training and competency evaluations for medication administration.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure one of three unlicensed personnel (ULP-H) completed training and competency evaluations for medication administration. This had the potential to affect all residents receiving medication administration. This resulted in an immediate correction order identified on June 28, 2023, at 9:05 a.m. [...]”

Rule cited: “When administration of medications is delegated to unlicensed personnel, the assisted living facility must ensure that the registered nurse has: (1) instructed the unlicensed personnel in the proper methods to administer the medications, and the unlicensed [...]”

Summary: MDH found the licensee failed to ensure mediations were administered as prescribed for one of ten residents (R4) observed during medication administration.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure mediations were administered as prescribed for one of ten residents (R4) observed during medication administration. [...]”

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 documentation of medication setup was completed for one of one resident (R8).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure documentation of medication setup was completed for one of one resident (R8). 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 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 has [...]”

Rule cited: “Documentation of dates of medication setup, name of medication, quantity of dose, times to be administered, route of administration, and name of person completing medication setup must be done at the time of setup.”

Summary: MDH found the licensee failed to ensure time sensitive medications were dated when opened for two of two residents (R4 and R5).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure time sensitive medications were dated when opened for two of two residents (R4 and R5). [...]”

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 document in the resident's record the disposition of the medications as required for one of one resident (R1) upon discharge.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to document in the resident's record the disposition of the medications as required for one of one resident (R1) upon discharge. [...]”

Rule cited: “(a) Any current medications being managed by the assisted living facility must be provided to the resident when the resident's service plan ends or medication management services are no longer part of the service plan. [...]”

Summary: MDH found the licensee failed to ensure two of two unlicensed personnel (ULP-H and ULP-J) completed training and competency evaluations for blood glucose testing.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure two of two unlicensed personnel (ULP-H and ULP-J) completed training and competency evaluations for blood glucose testing. [...]”

Rule cited: “Ordered or prescribed treatments or therapies must be administered by a nurse, physician, or other licensed health professional authorized to perform the treatment or therapy, or may be delegated or assigned to unlicensed personnel by the licensed health [...]”

Summary: MDH found the licensee failed to ensure a written prescriber's order for blood glucose monitoring was obtained for one of two residents (R4).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure a written prescriber's order for blood glucose monitoring was obtained for one of two residents (R4). [...]”

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 provide a safety risk assessment or hazard vulnerability assessment of the physical environment on and around the property.

MDH’s finding, as written: “Based on record review and interview, the licensee failed to provide a safety risk assessment or hazard vulnerability assessment of the physical environment on and around the property. This deficient practice had the ability to affect all staff, residents, and visitors. [...]”

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 ensure policies and procedures required in the licensing of assisted living facilities with dementia care were provided to four of four residents (R2, R3, R4, R5) and the legal and designated representatives at the time of move in.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure policies and procedures required in the licensing of assisted living facilities with dementia care were provided to four of four residents (R2, R3, R4, R5) and the legal and designated representatives at the time of move in. [...]”

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 conduct an evaluation for activities that addressed all provisions and failed to develop an individualized activity plan with required content based on the evaluation, for one of two residents (R2) who received services under an assisted living with dementia care license.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to conduct an evaluation for activities that addressed all provisions and failed to develop an individualized activity plan with required content based on the evaluation, for one of two residents (R2) who received services under an assisted living with dementia care license. [...]”

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 ensure care and services were provided according to acceptable health care and medical or nursing standards for two of two residents (R2, R3) with siderails.

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 two of two residents (R2, R3) with siderails. This resulted in an immediate correction order on June 28, 2023, at approximately 8:50 a.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.”