The Moments of Lakeville

Summary: MDH found the licensee failed to ensure three of five employees (unlicensed personnel (ULP)-N, director of nursing (DON)-C, and ULP-O) received orientation to assisted living facility licensing requirements and regulations before providing services with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure three of five employees (unlicensed personnel (ULP)-N, director of nursing (DON)-C, and ULP-O) received orientation to assisted living facility licensing requirements and regulations before providing services with records reviewed. [...]”

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 PRN (as needed) medications had documentation of effectiveness after administration for two of four residents (R2, R4) with records reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure PRN (as needed) medications had documentation of effectiveness after administration for two of four residents (R2, R4) with records reviewed. In addition, the licensee failed to ensure medications were administered as prescribed for one of three residents (R4) with records reviewed. [...]”

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 provide the required documentation of the hazard vulnerability or safety risk assessment plan on and around the property.

MDH’s finding, as written: “Based on record review and interview, the licensee failed to provide the required documentation of the hazard vulnerability or safety risk assessment plan on and around the property. The hazards indicated on risk assessment must be reviewed and mitigated to protect all residents from harm. This has 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 ensure the required notice was posted at the main entry way of the establishment to display statutory language to disclose electronic monitoring activity, potentially affecting all current residents, staff and any visitors of the facility.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure the required notice was posted at the main entry way of the establishment to display statutory language to disclose electronic monitoring activity, potentially affecting all current residents, staff and any visitors of 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 [...]”

Summary: MDH found the licensee failed to support protection and safety by not posting information and phone numbers for reporting to the Minnesota Adult Abuse Reporting Center and failed to post the 911 emergency number in common areas and near telephones provided by the assisted living facility.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to support protection and safety by not posting information and phone numbers for reporting to the Minnesota Adult Abuse Reporting Center and failed to post the 911 emergency number in common areas and near telephones provided by the assisted living facility. This had the potential to affect all 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 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 completion of a health history and symptom screening, and a two-step TST (tuberculin skin test) or other TB screening such as a blood test or chest x-ray, upon hire, for one of four employees (licensed practical nurse (LPN)-I).

MDH’s finding, as written: “Based on observation, 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 completion of a health history and symptom screening, and a two-step TST (tuberculin skin test) or other TB screening such as a blood test or chest x-ray, upon hire, for one of four employees (licensed practical nurse (LPN)-I). [...]”

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 [...]”

MDH’s finding, as written: “Based on observation, interview, and record review the licensee failed to develop an all-hazards risk assessment emergency preparedness program and plan to include Appendix Z required elements. In addition, the licensee failed to post emergency exit diagrams and maintain testing and maintenance records for the emergency generator. 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 [...]”

MDH’s finding, as written: “Based on interview and record review the licensee failed to complete a discharge summary for one of one discharged resident (R5) 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 was issued at an isolated scope (when one or a limited number of residents are affected or one or a [...]”

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 properly install and maintain fire extinguishers under the State Fire Code as required by MN Statute 144G.45 subd.2(a)(2).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to properly install and maintain fire extinguishers under the State Fire Code as required by MN Statute 144G.45 subd.2(a)(2). This had the potential to directly affect all residents and staff. [...]”

Rule cited: “(2) install and maintain portable fire extinguishers in accordance with the State Fire Code; (3) install portable fire extinguishers having a minimum 2-A:10-B:C rating within Group R-3 occupancies, as defined by the State Fire Code, located so that the travel [...]”

Summary: MDH found the licensee failed to maintain the physical environment of the facility in a continuous state of good repair and operation to protect residents, staff, and visitors from potential harm.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to maintain the physical environment of the facility in a continuous state of good repair and operation to protect residents, staff, and visitors from potential harm. This has the potential to directly affect the health, safety, and well-being of 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 facility failed to provide the required fire safety and evacuation drills, as well as the required documentation on employee training on fire safety and evacuation plans.

MDH’s finding, as written: “Based on interview and record review, the facility failed to provide the required fire safety and evacuation drills, as well as the required documentation on employee training on fire safety and evacuation plans. This had the potential to directly affect the safety of 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 assisted living contract prior to providing assisted living services for four of four residents (R4, R3, R1, R2) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to develop and execute a written assisted living contract prior to providing assisted living services for four of four residents (R4, R3, R1, R2) 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 orientation to assisted living licensing requirements and regulations was provided prior to providing services for one of one employee (unlicensed personnel (ULP)-E) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure orientation to assisted living licensing requirements and regulations was provided prior to providing services for one of one employee (unlicensed personnel (ULP)-E) with records reviewed. [...]”

Rule cited: “All staff providing and supervising direct services must complete an orientation to assisted living facility licensing requirements and regulations before providing assisted living services to residents. [...]”

Summary: MDH found the licensee failed to ensure three of three employees (licensed practical nurse (LPN)-I, unlicensed personnel (ULP)-K and director of nursing (DON)-C) received orientation to assisted living facility licensing requirements and regulations before providing services with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure three of three employees (licensed practical nurse (LPN)-I, unlicensed personnel (ULP)-K and director of nursing (DON)-C) received orientation to assisted living facility licensing requirements and regulations before providing services with records reviewed. [...]”

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 as needed (PRN) medications had documentation of effectiveness after administration for one of four residents (R2) with records reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure as needed (PRN) medications had documentation of effectiveness after administration for one of four residents (R2) with records reviewed. In addition, the licensee failed to ensure medications were administered as prescribed for one of seven residents (R6) with records reviewed. [...]”

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 current written or electronically recorded prescriptions were obtained for all medications the provider had managed for one of nine residents (R6) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure current written or electronically recorded prescriptions were obtained for all medications the provider had managed for one of nine residents (R6) with records reviewed. [...]”

Rule cited: “There must be a current written or electronically recorded prescription as defined in section 151.01, subdivision 16a, for all prescribed medications that the assisted living facility is managing for the resident.”

Summary: MDH found the licensee failed to ensure time sensitive medications were dated when opened for one of one resident (R1) with insulin with records reviewed.

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 one of one resident (R1) with insulin with records reviewed. [...]”

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 medication including the medication's name, strength, prescription number as applicable, quantity, to whom the medications were given, date of disposition, and names of staff and other individuals involved in the disposition for one of one discharged resident (R5) with record review.

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 medication including the medication's name, strength, prescription number as applicable, quantity, to whom the medications were given, date of disposition, and names of staff and other individuals involved in the disposition for one of one discharged resident (R5) with record review. [...]”

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. [...]”

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure treatment or therapies were administered as directed, or to document the reason they were not administered, for one of three residents (R3) with records reviewed. [...]”

Rule cited: “Each treatment or therapy administered by an assisted living facility must be in the resident record. [...]”

Summary: MDH found the licensee failed to provide the required documentation of the hazard vulnerability or safety risk assessment plan on and around the property.

MDH’s finding, as written: “Based on record review and interview, the licensee failed to provide the required documentation of the hazard vulnerability or safety risk assessment plan on and around the property. The hazards indicated on risk assessment must be reviewed and mitigated to protect all residents from harm. This has 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 designate a qualified person to oversee staff training in the care of individuals with dementia.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to designate a qualified person to oversee staff training in the care of individuals with dementia. This had the potential to affect all residents, staff and visitors. [...]”

Rule cited: “Persons providing or overseeing staff training must have experience and knowledge in the care of individuals with dementia, including: (1) two years of work experience related to Alzheimer's disease or other dementias, or in health care, gerontology, or [...]”

Summary: MDH found the licensee failed to ensure the current Minnesota Bill of Rights for Assisted Living Residents was provided to the resident and a written acknowledgement received for four of four

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure the current Minnesota Bill of Rights for Assisted Living Residents was provided to the resident and a written acknowledgement received for four of four residents (R3 R4, R1, and R2) with records reviewed. This had the potential to affect all residents. [...]”

Rule cited: “(a) An assisted living facility must provide the resident a written notice of the rights under section 144G.91 before the initiation of services to that resident. [...]”

Summary: MDH found the licensee failed to ensure the required notice was posted at the main entry way of the establishment to display statutory language to disclose electronic monitoring activity, potentially affecting all current residents, staff and any visitors of the facility.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure the required notice was posted at the main entry way of the establishment to display statutory language to disclose electronic monitoring activity, potentially affecting all current residents, staff and any visitors of 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 [...]”