Triple Angels Healthcare

Summary: MDH found the licensee failed to ensure a registered nurse (RN) was readily available for consultation to the staff performing delegated nursing tasks and services 24-hours a day, seven days per week.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure a registered nurse (RN) was readily available for consultation to the staff performing delegated nursing tasks and services 24-hours a day, seven days per week. This had the potential to affect all eight residents receiving services under the Assisted Living Facility with Dementia Care license. [...]”

Rule cited: “(13) provide staff access to an on-call registered nurse 24 hours per day, seven days per week.”

Summary: MDH found the licensee failed to develop and implement current policies and procedures as required.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop and implement current policies and procedures as required. 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 is issued at a widespread scope (when problems are pervasive or represent a systemic failure that has affected or has the [...]”

Rule cited: “Each assisted living facility must have policies and procedures in place to address the following and keep them current: (1) requirements in section 626.557, reporting of maltreatment of vulnerable adults; (2) conducting and handling background studies on [...]”

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, as well as information for reporting suspected maltreatment to the Minnesota Adult Abuse Reporting Center (MAARC).

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, as well as information for reporting suspected maltreatment to the Minnesota Adult Abuse Reporting Center (MAARC). This had the potential to affect all the licensee's current 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 email 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 (IAPP) was developed to include the required content for five of eight residents (R2, R4, R6, R8, R9).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure an individual abuse prevention plan (IAPP) was developed to include the required content for five of eight residents (R2, R4, R6, R8, R9). [...]”

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 ensure employee records contained the required content for two of two employees (unlicensed personnel (ULP)-C, ULP-F).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure employee records contained the required content for two of two employees (unlicensed personnel (ULP)-C, ULP-F). [...]”

Rule cited: “(a) The facility must maintain current records of each paid staff member, each regularly scheduled volunteer providing services, and each individual contractor providing services. [...]”

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 complete a discharge summary for one of one discharged resident (R1).

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 (R1). 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 portion or all of the residents). [...]”

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, [...]”

MDH’s finding, as written: “Based on interview and record review, the licensee failed to comply with the current State Fire Code in Minnesota Rules, chapter 7511. The licensee failed to provide sprinkler system inspection records, smoke alarm inspection records, and generator maintenance records. This had the potential to directly affect all residents, staff, and visitors. [...]”

Rule cited: “Each assisted living facility must comply with the State Fire Code in Minnesota Rules, chapter 7511, and:”

Summary: MDH found the licensee failed to provide a smoke alarm in all resident sleeping rooms.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to provide a smoke alarm in all resident sleeping rooms. This deficient condition had the ability to affect all staff, residents, and visitors. [...]”

Rule cited: “for dwellings or sleeping units, as defined in the State Fire Code: (i) provide smoke alarms in each room used for sleeping purposes; (ii) provide smoke alarms outside each separate sleeping area in the immediate vicinity of bedrooms; (iii) provide smoke [...]”

Summary: MDH found the licensee failed to maintain fire extinguishers as required for the facility.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to maintain fire extinguishers as required for the facility. This had the potential to affect all current residents, staff, and visitors. [...]”

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 develop the fire safety and evacuation plan (FSEP) with the required content, to make the FSEP readily accessible, to provide the required training, and to provide the required drills.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to develop the fire safety and evacuation plan (FSEP) with the required content, to make the FSEP readily accessible, to provide the required training, and to provide the required drills. This had the potential to directly affect all residents, staff, 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 develop and execute a written assisted living contract with the required content for five of eight residents (R2, R3, R4, R5, R9).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop and execute a written assisted living contract with the required content for five of eight residents (R2, R3, R4, R5, R9). [...]”

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 the assisted living contract did not include language waiving the licensee's liability for the health, safety, or personal property of a resident.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the assisted living contract did not include language waiving the licensee's liability for the health, safety, or personal property of a resident. This had the potential to affect all residents. [...]”

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 ensure a background study was conducted prior to staff providing services for five of nine employees (administrator (A)-A, unlicensed personnel (ULP)-C, ULP-D, registered nurse (RN)-E, and licensed practical nurse (LPN)-H).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure a background study was conducted prior to staff providing services for five of nine employees (administrator (A)-A, unlicensed personnel (ULP)-C, ULP-D, registered nurse (RN)-E, and licensed practical nurse (LPN)-H). [...]”

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: “Based on observation, interview, and record review the licensee failed to ensure a registered nurse (RN), who was providing services as an employee of the licensed facility, had a current Minnesota license or registration to practice, for one of two employees (RN-E), which had the potential to affect all residents and staff. [...]”

Rule cited: “(a) Licensed health professionals and nurses providing services as staff members of a licensed facility must possess a current Minnesota license or registration to practice. [...]”

Summary: MDH found the licensee failed to ensure training and competency evaluations were completed for all required skill areas, prior to providing services, for two of two unlicensed personnel (unlicensed personnel (ULP)-C, ULP-F).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure training and competency evaluations were completed for all required skill areas, prior to providing services, for two of two unlicensed personnel (unlicensed personnel (ULP)-C, ULP-F). [...]”

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) [...]”

Summary: MDH found the licensee failed to ensure training and competency evaluations were completed for all required skill areas, prior to providing services, for two of two unlicensed personnel (unlicensed personnel (ULP)-C, ULP-F).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure training and competency evaluations were completed for all required skill areas, prior to providing services, for two of two unlicensed personnel (unlicensed personnel (ULP)-C, 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 employees received orientation to 144G licensing requirements for two of two employees (unlicensed personnel (ULP)-C, ULP-F) with employee records reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure employees received orientation to 144G licensing requirements for two of two employees (unlicensed personnel (ULP)-C, ULP-F) with employee records reviewed. [...]”

Rule cited: “(a) 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 the required eight hours of dementia care training was completed within 80 hours of the employment start date for one of one employee (unlicensed personnel (ULP)-C) with record reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the required eight hours of dementia care training was completed within 80 hours of the employment start date for one of one employee (unlicensed personnel (ULP)-C) with record reviewed. [...]”

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 a conduct a nursing assessment by a registered nurse (RN) of the physical and cognitive needs for one of eight residents (R2) on or before the admission date.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to a conduct a nursing assessment by a registered nurse (RN) of the physical and cognitive needs for one of eight residents (R2) on or before the admission date. [...]”

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

Summary: MDH found the licensee failed to ensure a licensed registered nurse (RN) completed ongoing resident reassessments that did not exceed 90 days for all residents residing within the facility as required.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure a licensed registered nurse (RN) completed ongoing resident reassessments that did not exceed 90 days for all residents residing within the facility as required. [...]”

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 each resident had a current service plan with a signature or other authentication by the resident to document agreement on the services to be provided for all residents.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure each resident had a current service plan with a signature or other authentication by the resident to document agreement on the services to be provided for all residents. [...]”

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 prior to delegating the task of medication administration, the registered nurse (RN) trained in the proper methods to perform the task or procedure for each resident and verified the unlicensed personnel (ULP) were able to demonstrate the ability to competently follow the procedure for one of three employees (ULP-F).

MDH’s finding, as written: “Based on interview, and record review, the licensee failed to ensure prior to delegating the task of medication administration, the registered nurse (RN) trained in the proper methods to perform the task or procedure for each resident and verified the unlicensed personnel (ULP) were able to demonstrate the ability to competently follow the procedure for one of three employees (ULP-F). [...]”

Rule cited: “When administration of medications is delegated to unlicensed personnel, the assisted living facility must ensure that the registered nurse has: (1) instructed the unlicensed personnel in the proper methods to administer the medications, and the unlicensed [...]”

MDH’s finding, as written: “Based on observation and interview the licensee failed to store all prescription medications securely to permit only authorized personnel to have access. 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 widespread scope (when problems are pervasive or represent a systemic failure [...]”

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 provide hazard vulnerability assessment or safety risk assessment of the physical environment on and around the property for the facility.

MDH’s finding, as written: “Based on record review and interview, the licensee failed to provide hazard vulnerability assessment or safety risk assessment of the physical environment on and around the property for the facility. This deficient practice had the ability to affect all staff, residents, 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 provide care and services according to acceptable health care, medical or nursing standards for three of three residents (R2, R7, R8) who utilized bed rails when they failed to ensure a licensed registered nurse conducted timely bed rail assessments and failed to ensure bed rail assessments contained all necessary information to mitigate the safety risks.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to provide care and services according to acceptable health care, medical or nursing standards for three of three residents (R2, R7, R8) who utilized bed rails when they failed to ensure a licensed registered nurse conducted timely bed rail assessments and failed to ensure bed rail assessments contained all necessary information to mitigate the safety risks. [...]”

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 ensure residents had the right to come and go from the facility as they choose.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure residents had the right to come and go from the facility as they choose. This affected four of eight residents (R2, R3, R4, R9) whom the licensee had admitted to their secured dementia care unit without a dementia related diagnosis and/or for reasons not related to their diagnoses. [...]”

Rule cited: “Residents have the right to enter and leave the facility as they choose. This right may be restricted only as allowed by other law and consistent with a resident's service plan.”