Thorne Crest Retirement Center (Assisted Living and Memory Care)

Summary: MDH found the licensee failed to post the required information related to the grievance procedure and contact information for the Office of Ombudsman for Long-Term Care and Mental Health and Developmental Disabilities.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to post the required information related to the grievance procedure and contact information for the Office of Ombudsman for Long-Term Care and Mental Health and Developmental Disabilities. This had the potential to affect all residents, staff, and visitors. [...]”

Rule cited: “All facilities must post in a conspicuous place information about the facilities' grievance procedure, and the name, telephone number, and e-mail contact information for the individuals who are responsible for handling resident grievances. [...]”

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

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 four of four residents (R2, R4, R5 and R3). [...]”

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 by not posting information and phone numbers for reporting to the Minnesota Adult Abuse Reporting Center (MAARC) and 911 emergency number as required.

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 (MAARC) and 911 emergency number as required. 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 post emergency exit diagrams in the required areas on each floor.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to post emergency exit diagrams in the required areas on each floor. 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 observation and interview the licensee failed to provide smoke alarms inside and outside sleeping area and ensure smoke alarms are interconnected so that actuation of one alarm causes all in the dwelling to actuate as required. This had the potential to directly affect all residents, staff, and visitors. [...]”

Rule cited: “(a) Each assisted living facility must comply with the State Fire Code in Minnesota Rules, chapter 7511, and: (1) for dwellings or sleeping units, as defined in the State Fire Code: (i) provide smoke alarms in each room used for sleeping purposes; (ii) [...]”

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

MDH’s finding, as written: “Based on interview and record review, the licensee failed to execute a written assisted living contract with the required content for four of four residents (R2, R4, R5, and R3). [...]”

Rule cited: “(c) The contract must include: (1) a disclosure of the category of assisted living facility license held by the facility and, if the facility is not an assisted living facility with dementia care, a disclosure that it does not hold an assisted living facility [...]”

Summary: MDH found the licensee failed to ensure the licensee provided the required notice for right to designated representative on a document separate from the contract for four for four residents (R2, R4, R5, and R3).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the licensee provided the required notice for right to designated representative on a document separate from the contract for four for four residents (R2, R4, R5, and R3). In addition, the licensee failed to document on the assisted living contract that a resident declined to name a designated representative for four of four residents (R2, R4, R5, and R3). [...]”

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 provide a written notice with required content for an emergency relocation and failed to notify the Office of Ombudsman for Long-Term Care of the emergency relocation for two of two residents (R3, R4).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide a written notice with required content for an emergency relocation and failed to notify the Office of Ombudsman for Long-Term Care of the emergency relocation for two of two residents (R3, 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 training and competency evaluations were completed as required prior to providing direct care for three of three unlicensed personnel (ULP-J, ULP-F, ULP-H).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure training and competency evaluations were completed as required prior to providing direct care for three of three unlicensed personnel (ULP-J, ULP-F, ULP-H). [...]”

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) [...]”

MDH’s finding, as written: “Based on interview and record review the licensee failed to ensure training and competency evaluations contained all the required training for three of three unlicensed personnel (ULP-J, ULP-H, ULP-F). [...]”

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) conducted direct supervision of three of three unlicensed personnel (ULP-F, ULP-H, ULP-J) performing delegated nursing or therapy tasks within 30 days of first providing those services.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) conducted direct supervision of three of three unlicensed personnel (ULP-F, ULP-H, ULP-J) performing delegated nursing or therapy tasks within 30 days of first providing those services. [...]”

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 three of three unlicensed personnel (ULP-F, ULP-H, ULP-J) received orientation to assisted living facility licensing requirements and regulations before providing services.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure three of three unlicensed personnel (ULP-F, ULP-H, ULP-J) received orientation to assisted living facility licensing requirements and regulations before providing services. [...]”

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 staff completed the required amount of dementia care training in the required time frame for three of three employees (unlicensed personnel (ULP)-H, ULP-J, and ULP-F).

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

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 a registered nurse (RN) conducted an initial assessment for one of one resident (R4) prior to initiation of services.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure a registered nurse (RN) conducted an initial assessment for one of one resident (R4) prior to initiation of services. [...]”

Rule cited: “(a) Residents who are not receiving any services shall not be required to undergo an initial nursing assessment. [...]”

Summary: MDH found the licensee failed to ensure the registered nurse (RN) completed a reassessment not to exceed 90 days for two of four residents (R5, R3).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the registered nurse (RN) completed a reassessment not to exceed 90 days for two of four residents (R5, R3). [...]”

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 initiate a temporary service plan for one of one resident (R4) recently admitted to the facility.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to initiate a temporary service plan for one of one resident (R4) recently admitted to the facility. 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 [...]”

Rule cited: “When a facility initiates services and the individualized assessment required in subdivision 2 has not been completed, the facility must complete a temporary plan and agreement with the resident for services. [...]”

Summary: MDH found the licensee failed to ensure the service plan included

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the service plan included all the required content for four of four residents (R2, R4, R5, R3). 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 a widespread scope (when problems are pervasive or represent a systemic failure that has affected or has the potential to affect a large [...]”

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 registered nurse (RN) conducted a face-to-face medication management assessment to include all required content for four of four residents (R4, R2, R5, R3) prior to providing medication management services.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) conducted a face-to-face medication management assessment to include all required content for four of four residents (R4, R2, R5, R3) prior to providing medication management services. [...]”

Rule cited: “(a) For each resident who requests medication management services, the facility shall, prior to providing medication management services, have a registered nurse, licensed health professional, or authorized prescriber under section 151.37 conduct an [...]”

Summary: MDH found the licensee failed to ensure the medication management plan had all required content for four of four residents (R4, R2, R5, R3) who received medication management services.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the medication management plan had all required content for four of four residents (R4, R2, R5, R3) who received medication management services. [...]”

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 for one of six residents (R2).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medications were administered as prescribed for one of six residents (R2). 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 [...]”

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 documentation of medication setup included all the required content for one of one resident (R4).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure documentation of medication setup included all the required content for one of one resident (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 a widespread scope (when problems are pervasive or represent a systemic failure that has affected or has the potential to affect a large [...]”

Rule cited: “Documentation of dates of medication setup, name of medication, quantity of dose, times to be administered, route of administration, and name of person completing medication setup must be done at the time of setup.”

Summary: MDH found the licensee failed to ensure the registered nurse (RN) developed training and competencies for the unlicensed personnel (ULP) providing medications for residents with unplanned time away from home when the licensed nurse was not available for one of one unlicensed personnel (ULP-F).

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 the unlicensed personnel (ULP) providing medications for residents with unplanned time away from home when the licensed nurse was not available for one of one unlicensed personnel (ULP-F). [...]”

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 [...]”

Summary: MDH found the licensee failed to ensure a current written or electronically recorded prescription was obtained

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure a current written or electronically recorded prescription was obtained for all medications the provider had managed for one of six residents (R8). [...]”

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 have on the service plan a written statement of the treatment or therapy services provided for one of four (R3) residents receiving treatments.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to have on the service plan a written statement of the treatment or therapy services provided for one of four (R3) residents receiving treatments. [...]”

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 [...]”

MDH’s finding, as written: “Based on observation, interview, and record review the licensee failed to ensure clarification of prescriber orders for one of one resident (R3). 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: “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 policies and procedures required in the licensing of assisted living facilities

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure policies and procedures required in the licensing of assisted living facilities with dementia care were provided to each resident and/or the resident's legal and designated representative at the time of move-in for four of four residents (R2, R3, R4, R5). [...]”

Rule cited: “(a) In addition to the policies and procedures required in the licensing of all facilities, the assisted living facility with dementia care licensee must develop and implement policies and procedures that address the: (1) philosophy of how services are [...]”

Summary: MDH found the licensee failed to designate a qualified person to

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 conduct an individualized written activity evaluation that addressed all six provisions and failed to develop an individualized activity plan based on the evaluation, for two of two residents (R2, R5) who resided in the assisted living with dementia care facility.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to conduct an individualized written activity evaluation that addressed all six provisions and failed to develop an individualized activity plan based on the evaluation, for two of two residents (R2, R5) who resided in the assisted living with dementia care facility. [...]”

Rule cited: “(b) Each resident must be evaluated for activities according to the licensing rules of the facility. [...]”