The Sanctuary at Brooklyn Cent

MDH’s finding, as written: “Based on interview and record review the facility failed to establish and maintain a comprehensive tuberculosis (TB) infection control program according to the most current tuberculosis infection control guidelines issued by the United States Centers for Disease Control and Prevention (CDC). In addition, the licensee failed to ensure one of two employees (unlicensed personnel (ULP)-G) with records reviewed completed baseline TB screening. [...]”

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 [...]”

Summary: MDH found the licensee failed to provide the physical environment in a continuous state of good repair and operation with regard to the health, safety, and well-being of the residents.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to provide the physical environment in a continuous state of good repair and operation with regard to the health, safety, and well-being of the residents. This had the potential to directly affect 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 licensee failed to ensure the assisted living contract included designation of representatives in writing, with the required statutory language for six of six residents (R1, R2, R3, R4, R5, and R6) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the assisted living contract included designation of representatives in writing, with the required statutory language for six of six residents (R1, R2, R3, R4, R5, and R6) with records reviewed. [...]”

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 resident reassessment and monitoring was conducted as needed based on changes in the resident's condition, and failed to ensure reassessment and monitoring did not exceed 90 days from the last date of the assessment for two of six residents (R1 and R6) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure resident reassessment and monitoring was conducted as needed based on changes in the resident's condition, and failed to ensure reassessment and monitoring did not exceed 90 days from the last date of the assessment for two of six residents (R1 and R6) with records reviewed. [...]”

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 according to the service plan for two of six residents (R1 and R2) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure services were provided according to the service plan for two of six residents (R1 and R2) with records reviewed. [...]”

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 three of six residents (R4, R5 and R6) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the service plan included the required content for three of six residents (R4, R5 and R6) with records reviewed. [...]”

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 the individual medication management plan included the required content for one of six residents (R1) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure the individual medication management plan included the required content for one of six residents (R1) with records reviewed. [...]”

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. [...]”

Summary: MDH found the licensee failed to ensure medications were administered as prescribed, and when not administered as prescribed, documentation included any follow-up procedures provided in order to meet the resident's needs for two of six residents (R1 and R3) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure medications were administered as prescribed, and when not administered as prescribed, documentation included any follow-up procedures provided in order to meet the resident's needs for two of six residents (R1 and R3) 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 develop an individual treatment plan with the required contents for two of two residents (R2 and R1) who received treatments/therapies.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to develop an individual treatment plan with the required contents for two of two residents (R2 and R1) who received treatments/therapies. [...]”

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 ensure each treatment or therapy was documented, and when not documented as prescribed, the provider must document the reason why and any follow-up procedures that were provided to meet the resident's needs for two of two residents (R1 and R2) who received treatments/therapies.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure each treatment or therapy was documented, and when not documented as prescribed, the provider must document the reason why and any follow-up procedures that were provided to meet the resident's needs for two of two residents (R1 and R2) who received treatments/therapies. [...]”

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 ensure an up-to-date order included a description of the treatment/therapy, and other information needed to administer the treatment or therapy was obtained for one of two residents (R2) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure an up-to-date order included a description of the treatment/therapy, and other information needed to administer the treatment or therapy was obtained for one of two residents (R2) with records reviewed. [...]”

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 hazard vulnerability or safety risk assessment that included hazards identified on and around the property.

MDH’s finding, as written: “Based on document review and interview, the licensee failed to provide a hazard vulnerability or safety risk assessment that included hazards identified on and around the property. This had the potential to affect all dementia care 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 services were provided in a person-centered manner that promoted resident choice and dignity for one of three residents (R2) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure services were provided in a person-centered manner that promoted resident choice and dignity for one of three residents (R2) with records reviewed. [...]”

Rule cited: “(a) In addition to the minimum services required in section 144G.41, an assisted living facility with dementia care must also provide the following services: (1) assistance with activities of daily living that address the needs of each resident with dementia [...]”

Summary: MDH found the licensee failed to ensure assisted living services were provided based on the resident's needs and according to an up-to-date service plan an accepted health care standards for one of six residents (R1) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure assisted living services were provided based on the resident's needs and according to an up-to-date service plan an accepted health care standards for one of six residents (R1) with records reviewed. [...]”

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.”

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to report incidents of neglect of supervision to the Minnesota Adult Abuse Reporting Center (MAARC), for two of two residents (R8 and R9). [...]”

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 [...]”