Twin Town Villa

Summary: MDH found the licensee failed to ensure the assisted living contract did not include language waiving the facility's liability for 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 facility's liability for 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 provide a written notice with required content to the resident, legal representative, and designated representative; and failed to provide the notification to the Office of Ombudsman for Long-Term Care (OOLTC) when the resident did not return from the emergency relocation within four days for two of two residents (R2, R6).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide a written notice with required content to the resident, legal representative, and designated representative; and failed to provide the notification to the Office of Ombudsman for Long-Term Care (OOLTC) when the resident did not return from the emergency relocation within four days for two of two residents (R2, R6). [...]”

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 one of five residents

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure one of five residents (R10) service plan was revised to include provided services. 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 pattern scope (when more than a limited number of residents are affected, more than a [...]”

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 provide specific resident instructions relating to the administration of medications for one of four residents (R5) with records reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to provide specific resident instructions relating to the administration of medications for one of four residents (R5) with records reviewed. [...]”

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 [...]”

Summary: MDH found the licensee failed to ensure medications were administered as directed for one of four residents (R6) with records reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medications were administered as directed for one of four 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 documentation of medication setup was completed accurately

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure documentation of medication setup was completed accurately and/or updated with changes for one of one resident (R10) with records reviewed. [...]”

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 up-to-date written or electronically recorded orders were maintained for one of one resident (R3) who received treatments managed be the provider.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure up-to-date written or electronically recorded orders were maintained for one of one resident (R3) who received treatments managed be the provider. [...]”

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 conduct a hazard vulnerability or safety risk assessment on or around the facility property.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to conduct a hazard vulnerability or safety risk assessment on or around the facility property. This had the potential to directly affect all residents, staff, 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 develop an individualized activity plan for one of two residents (R7) who resided in an assisted living with dementia care facility.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop an individualized activity plan for one of two residents (R7) who resided in an assisted living with dementia care facility. [...]”

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

Summary: MDH found the licensee failed to provide care and services according to acceptable health care, medication or nursing standards for one of five residents (R10) with medication management.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide care and services according to acceptable health care, medication or nursing standards for one of five residents (R10) with medication management. [...]”

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 privacy was maintained for one of four residents (R7) observed during medication administration.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure privacy was maintained for one of four residents (R7) observed during medication administration. [...]”

Rule cited: “(a) Residents have the right to consideration of their privacy, individuality, and cultural identity as related to their social, religious, and psychological well-being. [...]”

MDH’s finding, as written: “Based on observation and interview the licensee failed to ensure resident's medical information was kept private. 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 limited number of staff are involved [...]”

Rule cited: “(a) Residents have the right to have personal, financial, health, and medical information kept private, to approve or refuse release of information to any outside party, and to be advised of the assisted living facility's policies and procedures regarding [...]”