The Kenwood

Summary: MDH found the licensee failed to maintain 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.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to maintain 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. This deficient condition had the potential to affect all staff, residents, 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 licensee failed to develop the fire safety and evacuation plan with the required

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to develop the fire safety and evacuation plan with the required content and provide the required training and drills. This had the potential to directly affect all residents, staff, 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 ensure the employee had a cleared Minnesota (MN) Department of Human Services (DHS) NETStudy 2.0 background study for one of four employees (dining director (DD)-E).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the employee had a cleared Minnesota (MN) Department of Human Services (DHS) NETStudy 2.0 background study for one of four employees (dining director (DD)-E). This had the potential to affect all residents in the facility. [...]”

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 agency (also known as temporary or contracted) staff met the same training requirements as licensee personnel for one of one agency staff (clinical nurse supervisor (CNS)-B).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure agency (also known as temporary or contracted) staff met the same training requirements as licensee personnel for one of one agency staff (clinical nurse supervisor (CNS)-B). [...]”

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 was completed for all required areas, prior to providing services, for two of three unlicensed personnel ((ULP)-D, ULP-G).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure training was completed for all required areas, prior to providing services, for two of three unlicensed personnel ((ULP)-D, ULP-G). [...]”

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 training was completed for all required areas, prior to providing services, for two of three unlicensed personnel ((ULP)-D, ULP-G).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure training was completed for all required areas, prior to providing services, for two of three unlicensed personnel ((ULP)-D, ULP-G). [...]”

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 the registered nurse (RN) completed supervision of a ULP within 30 calendar days of beginning to provide delegated tasks and thereafter as needed based on performance 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 the registered nurse (RN) completed supervision of a ULP within 30 calendar days of beginning to provide delegated tasks and thereafter as needed based on performance for one of three employees (unlicensed personnel (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 employee's received orientation to include all required content for two of three employees (unlicensed personnel (ULP)-D, ULP-G).

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

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 an employee received at least eight hours of annual training for each 12 months of employment for one of two 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 at least eight hours of annual training for each 12 months of employment for one of two 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. [...]”

Summary: MDH found the licensee failed to ensure employees had completed at least eight (8) hours of initial dementia training within 160 working hours of the employment start date 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 employees had completed at least eight (8) hours of initial dementia training within 160 working hours of the employment start date for one of three employees (unlicensed personnel (ULP-D). [...]”

Rule cited: “(a) All assisted living facilities must meet the following training requirements: (1) supervisors of direct-care staff must have at least eight hours of initial training on topics specified under paragraph (b) within 120 working hours of the employment start [...]”

Summary: MDH found the licensee failed to ensure a registered nurse (RN) conducted an initial nursing assessment of the physical and cognitive needs of a prospective resident prior to the date the resident moved in for two of three residents (R2, R3).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure a registered nurse (RN) conducted an initial nursing assessment of the physical and cognitive needs of a prospective resident prior to the date the resident moved in for two of three residents (R2, R3). [...]”

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 medication administration was documented accurately for one of three residents (R4).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medication administration was documented accurately for one of three residents (R4). 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 [...]”

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 prescriptions were renewed at least every 12 months for one of three residents (R4).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure prescriptions were renewed at least every 12 months for one of three residents (R4). 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: “Prescriptions must be renewed at least every 12 months or more frequently as indicated by the assessment in subdivision 2. Prescriptions for controlled substances must comply with chapter 152.”

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medications were stored according to manufacturer's instructions for one of one medication refrigerator. [...]”

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 monitor for expired medications for two of three residents (R4, R5).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to monitor for expired medications for two of three 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 or one or a limited [...]”

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 provide care and services according to acceptable health care, medical or nursing standards for two of two residents who utilized consumer bed rails (R2, R4).

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 two of two residents who utilized consumer bed rails (R2, R4). This resulted in issuance of an immediate correction order on July 23, 2024. [...]”

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.”