The Legacy of St Michael

Summary: MDH found the licensee failed to ensure an individual abuse prevention plan was developed to include the required content for five of five residents (R2, R3, R4, R5, and R6).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure an individual abuse prevention plan was developed to include the required content for five of five residents (R2, R3, R4, R5, and R6). [...]”

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 support protection and safety through access to the state's systems for reporting suspected criminal activity and suspected vulnerable adult maltreatment as required.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to support protection and safety through access to the state's systems for reporting suspected criminal activity and suspected vulnerable adult maltreatment as required. This had the potential to affect all of the licensee's 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 the employee records contained the required content for four of four employees (clinical nurse supervisor (CNS)-B,

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the employee records contained the required content for four of four employees (clinical nurse supervisor (CNS)-B, registered nurse (RN)-F, unlicensed personnel (ULP)-C, and licensed practical nurse (LPN)-G). [...]”

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 have a written emergency preparedness (EP) plan with all of the required content.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to have a written emergency preparedness (EP) plan with all of the required content. This had the potential to affect all current 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 ensure the resident record included a discharge summary with the required content for one of one discharged resident (R1).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the resident record included a discharge summary with the required content for one of one discharged resident (R1). [...]”

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 required training to residents and employees for fire safety and evacuation, and failed to conduct required employee evacuation drills.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide required training to residents and employees for fire safety and evacuation, and failed to conduct required employee evacuation drills. This had the potential to affect all current residents, staff, and visitors to the facility. [...]”

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

Summary: MDH found the licensee failed to execute a written contract with the required content for five of five residents (R2, R3, R4, R5, R6).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to execute a written contract with the required content for five of five residents (R2, R3, R4, R5, R6). This practice resulted in a level one violation (a violation that has no potential to cause more than a minimal impact on the resident and does not affect 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 [...]”

Rule cited: “(a) The contract must include in a conspicuous place and manner on the contract the legal name and the license number of the facility. [...]”

Summary: MDH found the licensee failed to execute a written contract with the required content for five of five residents (R2, R3, R4, R5, R6).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to execute a written contract with the required content for five of five residents (R2, R3, R4, R5, R6). This practice resulted in a level one violation (a violation that has no potential to cause more than a minimal impact on the resident and does not affect health or safety), and was issued at a widespread scope (when problems are pervasive or represent a systemic failure that has affected or has potential to affect a large portion or [...]”

Rule cited: “(5) a description of the facility's policies related to medical assistance waivers under chapter 256S and section 256B.49 and the housing support program under chapter 256I, including: (i) whether the facility is enrolled with the commissioner of human [...]”

Summary: MDH found the licensee failed to ensure the assisted living contract for two of five residents (R3 and R6) did not include language waiving facility liability for resident health, safety, or personal property.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the assisted living contract for two of five residents (R3 and R6) did not include language waiving facility liability for resident health, safety, or personal property. [...]”

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 licensee failed to provide a written notice with the required content for an emergency relocation for two of two residents (R2 and R6) hospitalized.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide a written notice with the required content for an emergency relocation for two of two residents (R2 and R6) hospitalized. [...]”

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 staff completed the required amount of dementia care training in the required time frame for one of four employees (unlicensed personnel (ULP)-C).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure staff completed the required amount of dementia care training in the required time frame for one of four employees (unlicensed personnel (ULP)-C). [...]”

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 resident reassessment and monitoring no more than 14 calendar days after initiation of services for two of five residents (R4, R5), and within 90 calendar days from the date of the last review for one of five residents (R2), as required.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the registered nurse (RN) completed resident reassessment and monitoring no more than 14 calendar days after initiation of services for two of five residents (R4, R5), and within 90 calendar days from the date of the last review for one of five residents (R2), as required. In addition, the licensee failed to ensure the RN completed a reassessment based on changes in the needs of the resident for one of five 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 a current written service plan was revised to reflect the current services provided for one of five residents (R4).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure a current written service plan was revised to reflect the current services provided for one of five residents (R4). [...]”

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 service plans included the required content for three of five residents (R2, R3, and R6).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure service plans included the required content for three of five residents (R2, R3, and 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, but was not likely to cause serious injury, impairment, or death), and was issued at a pattern scope (when more than 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 develop and maintain current written medication management policies and procedures that were developed under the supervision and direction of a registered nurse (RN).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop and maintain current written medication management policies and procedures that were developed under the supervision and direction of a registered nurse (RN). [...]”

Rule cited: “(a) This section applies only to assisted living facilities that provide medication management services. [...]”

Summary: MDH found the licensee failed to develop and maintain a current individualized medication management record for one of five residents (R8).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop and maintain a current individualized medication management record for one of five residents (R8). This practice resulted in a level three violation (a violation that harmed a resident's health or safety, not including serious injury, impairment, or death, or a violation that has the potential to lead to serious injury, impairment, or death), and was issued at an isolated scope (when one or a limited number of residents are [...]”

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. [...]”

MDH’s finding, as written: “Based on interview and record review the facility failed to ensure follow-up procedures were provided to meet the resident's needs when ordered laboratory services and subsequent medication orders were not completed for one of one resident (R8). [...]”

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 develop and implement procedures for loss and spillage of all controlled substances defined in Minnesota Rules par 6800.4220.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to develop and implement procedures for loss and spillage of all controlled substances defined in Minnesota Rules par 6800.4220. [...]”

Rule cited: “(a) Assisted living facilities providing medication management must develop and implement procedures for loss or spillage of all controlled substances defined in Minnesota Rules, part 6800.4220. [...]”

Summary: MDH found the licensee failed to develop and maintain current written treatment and therapy management policies and procedures that were developed under the supervision and direction of a registered nurse (RN).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop and maintain current written treatment and therapy management policies and procedures that were developed under the supervision and direction of a registered nurse (RN). [...]”

Rule cited: “(a) An assisted living facility that provides treatment and therapy management services must develop, implement, and maintain up-to-date written treatment or therapy management policies and procedures. [...]”

Summary: MDH found the licensee failed to develop and implement a treatment or therapy management plan to include the required content for one of five residents (R4).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop and implement a treatment or therapy management plan to include the required content for one of five residents (R4). [...]”

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 conduct a hazard vulnerability or safety risk assessment on or around the facility property.

MDH’s finding, as written: “Based on [observation] interview and record review, the licensee failed to conduct a hazard vulnerability or safety risk assessment on or around the facility property. This had the potential to directly affect all residents, staff, 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 develop an individualized activity plan based on the activity evaluation, for five of five residents (R2, R3, R4, R5, and R6).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop an individualized activity plan based on the activity evaluation, for five of five residents (R2, R3, R4, R5, and R6). [...]”

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 the care and services were provided according to acceptable health care and medical or nursing standards, for two of two residents (R6, R5) with hospital bed with bedrails.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the care and services were provided according to acceptable health care and medical or nursing standards, for two of two residents (R6, R5) with hospital bed with bedrails. [...]”

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 immediately report an allegation of abuse to the Minnesota Adult Abuse Reporting Center (MAARC) for one of one resident (R7).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to immediately report an allegation of abuse to the Minnesota Adult Abuse Reporting Center (MAARC) for one of one resident (R7). [...]”

Rule cited: “(a) A mandated reporter who has reason to believe that a vulnerable adult is being or has been maltreated, or who has knowledge that a vulnerable adult has sustained a physical injury which is not reasonably explained shall immediately report the information [...]”