The Prairie Lodge at Earle Bro

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

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 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 [...]”

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

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. [...]”

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

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. [...]”

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

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 [...]”

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

Rule cited: “(c) Resident reassessment and monitoring must be conducted no more than 14 calendar days after initiation of services. [...]”

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

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. [...]”

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

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 prescribed follow-up of abnormal clinical monitoring results for four out of nine residents (R3, R12, R14, R18).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure prescribed follow-up of abnormal clinical monitoring results for four out of nine residents (R3, R12, R14, R18). Furthermore, the licensee failed to document administration or refusal of medications according to provider orders for one of nine residents (R18) and failed to ensure medications were administered per prescriber order or manufacturer recommendations for two of nine residents (R14, R25). [...]”

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. [...]”

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

Rule cited: “(2) for unplanned time away, when the pharmacy is not able to provide the medications, a licensed nurse or unlicensed personnel shall provide medications in amounts and dosages needed for the length of the anticipated absence, not to exceed seven calendar [...]”

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

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 medications were maintained to include the opened-on date for time sensitive medication storage for two of eight residents (R18, R20).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medications were maintained to include the opened-on date for time sensitive medication storage for two of eight residents (R18, R20). [...]”

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: “There must be an up-to-date written or electronically recorded order from an authorized prescriber for all treatments and therapies. [...]”

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

Rule cited: “Residents have the right to be treated with courtesy and respect, and to have the resident's property treated with respect”

Summary: MDH found the licensee failed to maintain a written emergency preparedness plan (EPP)with all the required content as defined in Appendix Z. This had the potential to affect all residents, staff, and visitors.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to maintain a written emergency preparedness plan (EPP)with all the required content as defined in Appendix Z. 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 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 a fire safety and evacuation plan with the required elements and failed to provide required employee and resident training on fire safety and evacuation.

MDH’s finding, as written: “Based on a record review and interview, the licensee failed to develop a fire safety and evacuation plan with the required elements and failed to provide required employee and resident training on fire safety and evacuation. This 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 a written notice with the required content for an emergency relocation for one of one hospitalized resident (R4).

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 one of one hospitalized resident (R4). [...]”

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 a background study was submitted and received in affiliation with the assisted living licensee for two of six employees (unlicensed personnel (ULP)-K and ULP-L).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure a background study was submitted and received in affiliation with the assisted living licensee for two of six employees (unlicensed personnel (ULP)-K and ULP-L). [...]”

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 the registered nurse (RN) provided direct supervision of staff performing delegated tasks within 30 calendar days after tasks were delegated for one of three unlicensed personnel ((ULP)-J).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the registered nurse (RN) provided direct supervision of staff performing delegated tasks within 30 calendar days after tasks were delegated for one of three unlicensed personnel ((ULP)-J). [...]”

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 the registered nurse (RN) conducted ongoing resident assessment and reassessment, not to exceed 90 calendar days from the last date of the assessment for three of six residents (R2, R16, R17) and failed to conduct an ongoing resident reassessment and monitoring, as needed based on changes in the needs of the resident for one of six residents (R5).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) conducted ongoing resident assessment and reassessment, not to exceed 90 calendar days from the last date of the assessment for three of six residents (R2, R16, R17) and failed to conduct an ongoing resident reassessment and monitoring, as needed based on changes in the needs of the resident for one of six residents (R5). [...]”

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 services were provided as required in the current service plan for one of five residents (R5).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure services were provided as required in the current service plan for one of five residents (R5). In addition, the licensee failed to ensure the current service plan included a signature or other authentication by the licensee and the resident or resident's designated representative to document agreement on the services to be provided for two of five residents (R8, R16). [...]”

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 the service plan included the required content for one of six residents (R17).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the service plan included the required content for one of six residents (R17). 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: “(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 two of four unlicensed personnel ((ULP)-B, ULP-C) administered medications per the licensee's policy and procedure, and failed to administer medications as prescribed for three of twenty-six residents (R11, R12, and R8) observed during medication administration.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure two of four unlicensed personnel ((ULP)-B, ULP-C) administered medications per the licensee's policy and procedure, and failed to administer medications as prescribed for three of twenty-six residents (R11, R12, and R8) 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 the registered nurse (RN) developed training and competencies for unlicensed personnel (ULP) providing medications to residents for unplanned time away from home when the licensed nurse was not available for one of one employee (unlicensed personnel (ULP)-B).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the registered nurse (RN) developed training and competencies for unlicensed personnel (ULP) providing medications to residents for unplanned time away from home when the licensed nurse was not available for one of one employee (unlicensed personnel (ULP)-B). [...]”

Rule cited: “(2) for unplanned time away, when the pharmacy is not able to provide the medications, a licensed nurse or unlicensed personnel shall provide medications in amounts and dosages needed for the length of the anticipated absence, not to exceed seven calendar [...]”

MDH’s finding, as written: “Based on observation, interview, and record review the licensee failed to ensure all medications were securely locked in substantially constructed compartments and permitted only authorized personnel to have access for three of seven residents (R4, R19, R20). The licensee also failed to ensure cycle fill medications (medications supplied by pharmacy on scheduled basis) were securely locked from all residents, visitors, and families. [...]”

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 medications were maintained to include the opened-on date for time sensitive medication storage for six of ten residents (R11, R12, R14, R15, R19, R20), and bearing the original prescription label with legible information for one of ten residents (R12).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medications were maintained to include the opened-on date for time sensitive medication storage for six of ten residents (R11, R12, R14, R15, R19, R20), and bearing the original prescription label with legible information for one of ten residents (R12). In addition, the licensee failed to dispose of expired medications on two of two medication carts in house two. [...]”

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 ensure up-to-date written or electronically recorded orders were maintained for one of three residents (R4) who received a treatment.

MDH’s finding, as written: “Based on interview and record review, the licensee failed ensure up-to-date written or electronically recorded orders were maintained for one of three residents (R4) who received a treatment. [...]”

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 ensure a resident's property was treated with courtesy and respect when staff used a resident's blood glucose machine (R7) to check blood sugar readings for another resident (R9) observed during medication pass.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure a resident's property was treated with courtesy and respect when staff used a resident's blood glucose machine (R7) to check blood sugar readings for another resident (R9) observed during medication pass. [...]”

Rule cited: “Residents have the right to be treated with courtesy and respect, and to have the resident's property treated with respect”