Villa Court

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

Rule cited: “(b) Each assisted living facility shall develop and maintain fire safety and evacuation plans. [...]”

Summary: MDH found the licensee failed to maintain a written assisted living contract, with the required content in a resident record for one of five residents (R3).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to maintain a written assisted living contract, with the required content in a resident record for one of five residents (R3). [...]”

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 orientation to assisted living statutes included all the required content for one of two employees (unlicensed personnel (ULP)-G.)

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure orientation to assisted living statutes included all the required content for one of two employees (unlicensed personnel (ULP)-G.) 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 [...]”

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 two of four employees (unlicensed personnel (ULP)-F, registered nurse (RN)-C) received the required amount of dementia care training in the required time frame.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure two of four employees (unlicensed personnel (ULP)-F, registered nurse (RN)-C) received the required amount of dementia care training in the required time frame. [...]”

Rule cited: “(a) All assisted living facilities must meet the following training requirements: (1) supervisors of direct-care staff must have at least eight hours of initial training on topics specified under paragraph (b) within 120 working hours of the employment start [...]”

Summary: MDH found the licensee failed to ensure the registered nurse (RN) reassessed two of two residents with change of condition (R3, R9), and failed to ensure the RN assessed one of one resident (R9) with chair or floor alarms.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) reassessed two of two residents with change of condition (R3, R9), and failed to ensure the RN assessed one of one resident (R9) with chair or floor alarms. [...]”

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 the service plan included the required content for five of five residents (R1, R2, R3, R4, R9).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the service plan included the required content for five of five residents (R1, R2, R3, R4, R9). [...]”

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 three of three employees (unlicensed personnel (ULP)-D, ULP-F, ULP-G) were trained and had demonstrated competency to prepare and give medications for residents having unplanned time away.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure three of three employees (unlicensed personnel (ULP)-D, ULP-F, ULP-G) were trained and had demonstrated competency to prepare and give medications for residents having unplanned time away. This had the potential to affect all forty-nine residents. [...]”

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 maintain the facility's fire safety and evacuation plan with required elements.

MDH’s finding, as written: “Based on record review and interview, the licensee failed to maintain the facility's fire safety and evacuation plan with required elements. 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 maintain a written assisted living contract, with the required content in a resident record for one of four residents (R3).

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

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 execute a written assisted living contract with the required content for two of two residents (R1, R2).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to execute a written assisted living contract with the required content for two of two residents (R1, R2). This had the potential to affect all 49 residents. [...]”

Rule cited: “(5) a description of the facility's policies related to medical assistance waivers under chapter 256S and section 256B.49 and the housing support program under chapter 256I, including: (i) whether the facility is enrolled with the commissioner of human [...]”

Summary: MDH found the licensee failed to provide a written notice with the required content for an emergency relocation to one of one resident (R1), legal representative, or designated representative.

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 to one of one resident (R1), legal representative, or designated representative. [...]”

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 orientation to

MDH’s finding, as written: “Based on observation, interview. and record review, the licensee failed to ensure orientation to assisted living statutes included all the required content for one of two employees (unlicensed personnel (ULP)-G. [...]”

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 an employee received all of the required annual training content for each 12 months of employment for two of five employees (unlicensed personnel (ULP)-D, ULP-G).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure an employee received all of the required annual training content for each 12 months of employment for two of five employees (unlicensed personnel (ULP)-D, ULP-G). [...]”

Rule cited: “(a) All staff that perform direct services must complete at least eight hours of annual training for each 12 months of employment. [...]”

Summary: MDH found the licensee failed to ensure five of five employees (unlicensed personnel (ULP)-D, ULP-F, ULP-G, registered nurse (RN)-C) received the required amount of dementia care training in the required time frame.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure five of five employees (unlicensed personnel (ULP)-D, ULP-F, ULP-G, registered nurse (RN)-C) received the required amount of dementia care training in the required time frame. [...]”

Rule cited: “(a) All assisted living facilities must meet the following training requirements: (1) supervisors of direct-care staff must have at least eight hours of initial training on topics specified under paragraph (b) within 120 working hours of the employment start [...]”

Summary: MDH found the licensee failed to ensure employees not providing direct care received at least two hours of annual dementia training for one of one employee (maintenance (M)-E).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure employees not providing direct care received at least two hours of annual dementia training for one of one employee (maintenance (M)-E). [...]”

Rule cited: “(4) staff who do not provide direct care, including maintenance, housekeeping, and food service staff, must have at least four hours of initial training on topics specified under paragraph (b) within 160 working hours of the employment start date, and must [...]”

Summary: MDH found the licensee failed to ensure the registered nurse (RN) reassessed two of two residents (R1, R2) with falls, two of two residents with change of condition (R2, R3), and failed to

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) reassessed two of two residents (R1, R2) with falls, two of two residents with change of condition (R2, R3), and failed to ensure the RN assessed one of two residents (R4) with chair or floor alarms. [...]”

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 the service plan included the required content for four of four residents (R1, R2, R3, R4).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the service plan included the required content for four of four residents (R1, R2, R3, R4). [...]”

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 two unlicensed personnel ((ULP)-D, ULP-G) documented medication administration after administering medication to residents.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure two of two unlicensed personnel ((ULP)-D, ULP-G) documented medication administration after administering medication to residents. In addition, the licensee failed to ensure as needed (PRN) medications were administered as prescribed and had documentation of effectiveness after administration for one of four residents (R3). [...]”

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 three of three employees (unlicensed personnel (ULP)-D, ULP-F, ULP-G) were trained and had demonstrated competency to prepare and give medications for residents having unplanned time away.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure three of three employees (unlicensed personnel (ULP)-D, ULP-F, ULP-G) were trained and had demonstrated competency to prepare and give medications for residents having unplanned time away. This had the potential to affect all forty-nine (49) residents. [...]”

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 refrigerated medications were maintained at manufacturer recommended temperatures by failing to monitor and document medication refrigerator

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure refrigerated medications were maintained at manufacturer recommended temperatures by failing to monitor and document medication refrigerator temperatures for one of two medication refrigerators. [...]”

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.”

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medications included the open date and expiration date for time sensitive medications for eight residents (R1, R3, R7, R8, R9, R10, R11, R12). In addition, the licensee failed to ensure medication containers had the original prescription labels in one of two medication carts. [...]”

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 to document in the resident's

MDH’s finding, as written: “Based on interview and record review, the licensee failed to document in the resident's record the disposition of the medications as required for one of one resident (R5) upon discharge. [...]”

Rule cited: “(a) Any current medications being managed by the assisted living facility must be provided to the resident when the resident's service plan ends or medication management services are no longer part of the service plan. [...]”

Summary: MDH found the licensee failed to ensure unlicensed personnel were trained and demonstrated competency in treatments to a registered nurse (RN) for one of one unlicensed personnel ((ULP)-G).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure unlicensed personnel were trained and demonstrated competency in treatments to a registered nurse (RN) for one of one unlicensed personnel ((ULP)-G). In addition, the licensee failed to ensure instructions, specified in writing, for each resident and documented those instructions in the resident's record for one of one resident (R3) who received blood glucose monitoring. [...]”

Rule cited: “Ordered or prescribed treatments or therapies must be administered by a nurse, physician, or other licensed health professional authorized to perform the treatment or therapy, or may be delegated or assigned to unlicensed personnel by the licensed health [...]”

Summary: MDH found the licensee failed to provide care and services according to acceptable health care standards, medical or nursing standards for three of three unlicensed personnel ((ULP)-D, ULP-F, ULP-G) who performed medication setup for later administration.

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 standards, medical or nursing standards for three of three unlicensed personnel ((ULP)-D, ULP-F, ULP-G) who performed medication setup for later administration. [...]”

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 two of two residents (R3, R7) were treated with dignity and respect when unlicensed personnel (ULP)-D,

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure two of two residents (R3, R7) were treated with dignity and respect when unlicensed personnel (ULP)-D, ULP-G provided treatment and medication management services to residents in a public setting. [...]”

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. [...]”