Vista Prairie at Goldfinch Est

Summary: MDH found the licensee failed to complete a 14-day assessment on one of one resident(R34) reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to complete a 14-day assessment on one of one resident(R34) reviewed. In addition, the licensee failed to complete 90 day assessments for seven of thirteen residents (R34, R29, R30, R26, R31, R32, R33) as required 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 one of seven residents' (R23) service plans were revised to reflect the current services provided.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure one of seven residents' (R23) service plans were revised to reflect the current services provided. In addition, the facility failed to ensure the service plan included a signature or other authentication by the resident and the facility to document agreement on the services provided for one of seven residents (R23) 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 have specified, in writing, specific instructions for each resident and documented those instructions in two of two residents' records (R25 and R24) for medication administration delegated to unlicensed personnel with records reviewed.

MDH’s finding, as written: “Based on interview and document review, the licensee failed to have specified, in writing, specific instructions for each resident and documented those instructions in two of two residents' records (R25 and R24) for medication administration delegated to unlicensed personnel 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 not expired for one of one medication cart reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medications were not expired for one of one medication cart reviewed. 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: “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 [...]”

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

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 the current Minnesota Bill of Rights for Assisted Living Residents and information about how to make a complaint was provided to the residents and a written acknowledgement received for one of seven residents (R24) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the current Minnesota Bill of Rights for Assisted Living Residents and information about how to make a complaint was provided to the residents and a written acknowledgement received for one of seven residents (R24) with records reviewed. [...]”

Rule cited: “(a) An assisted living facility must provide the resident a written notice of the rights under section 144G.91 before the initiation of services to that resident. [...]”

Summary: MDH found the licensee failed to ensure an individual abuse prevention plan was developed to include the required content for five of six residents (R2, R3, R4, R5, and R6) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure an individual abuse prevention plan was developed to include the required content for five of six residents (R2, R3, R4, R5, and R6) with records reviewed. [...]”

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 to include 911 in common areas and near telephones provided by the assisted living facility.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to support protection and safety by not posting information and phone numbers to include 911 in common areas and near telephones provided by the assisted living facility. This had the potential to affect all 119 residents receiving assisted living care services, 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 establish and maintain a tuberculosis (TB) prevention program, based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC) which included a facility TB risk assessment.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to establish and maintain a tuberculosis (TB) prevention program, based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC) which included a facility TB risk assessment. This had the potential to affect all current residents, staff and visitors. [...]”

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 complete a facility risk assessment and failed to have a comprehensive program for emergency preparedness that included all required components.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to complete a facility risk assessment and failed to have a comprehensive program for emergency preparedness that included all required components. This had the potential to affect all current 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 ensure the client record included a discharge summary for one of one resident (R10) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the client record included a discharge summary for one of one resident (R10) with records reviewed. 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 an isolated scope (when one or a limited number of residents are affected or one or a limited number of staff are involved, or the [...]”

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, [...]”

Summary: MDH found the licensee failed to maintain 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 as required by MN Statute 144G.45 subd.2(a)(4).

MDH’s finding, as written: “Based on observation and interview, the licensee failed to maintain 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 as required by MN Statute 144G.45 subd.2(a)(4). [...]”

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 [...]”

MDH’s finding, as written: “Based on observation, interview and record review the licensee failed to provide fire safety and evacuation training at least twice per year after hire to employees, failed to have fire safety and evacuation plans readily available at all times within the facility, failed to provide fire safety and evacuation training once per year to residents who are capable of assisting in their own evacuation, and failed to require evacuation drills twice per year per shift with at least one evacuation [...]”

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

Summary: MDH found the licensee failed to ensure four of four employees (unlicensed personnel (ULP)-A and ULP-E, licensed practical nurse (LPN)-F, and registered nurse (RN)-D) received orientation to assisted living facility licensing requirements and regulations with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure four of four employees (unlicensed personnel (ULP)-A and ULP-E, licensed practical nurse (LPN)-F, and registered nurse (RN)-D) received orientation to assisted living facility licensing requirements and regulations with records reviewed. [...]”

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 complete a 14 day assessment on two of two residents (R3 and R7) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and document review, the licensee failed to complete a 14 day assessment on two of two residents (R3 and R7) with records reviewed. In addition, the licensee failed to complete 90 day assessments for one of one residents (R2), and a change of condition assessment for one of one resident (R12) not resulting in significant injury. [...]”

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 have a signed service plan for one of eight residents (R12) with records reviewed

MDH’s finding, as written: “Based on interview and record review, the licensee failed to have a signed service plan for one of eight residents (R12) with records reviewed This practice resulted in a level one violation (a violation that has no potential to cause more than a minimal impact on the resident and does not affect health or safety), 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 or the situation has occurred only [...]”

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 have all required content on the service plan for two of eight residents (R3 and R7) with records reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to have all required content on the service plan for two of eight residents (R3 and R7) 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 implement their policy to ensure the security and accountability of controlled substances for one of two locked narcotic storage areas (memory care medication room).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to implement their policy to ensure the security and accountability of controlled substances for one of two locked narcotic storage areas (memory care medication room). This had the potential to affect all residents and staff in the memory care unit. [...]”

Rule cited: “(a) This section applies only to assisted living facilities that provide medication management services. [...]”

Summary: MDH found the licensee failed to have specified, in writing, specific instructions for each resident and documented those instructions in one of three resident's records (R4) for medication administration delegated to unlicensed personnel with records reviewed.

MDH’s finding, as written: “Based on interview and document review, the licensee failed to have specified, in writing, specific instructions for each resident and documented those instructions in one of three resident's records (R4) for medication administration delegated to unlicensed personnel 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 medication orders were

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure medication orders were transcribed to the medication administration record (MAR) accurately for one of nine residents (R5) 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 current written or electronically recorded prescriptions were obtained for all medications the provider had managed for one of eight residents (R5) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure current written or electronically recorded prescriptions were obtained for all medications the provider had managed for one of eight residents (R5) with records reviewed. [...]”

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 ensure medications were not expired for one of one medication cart reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medications were not expired for one of one medication cart reviewed. 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: “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 upon discharge, to document in the resident's record the disposition of the medication including the medication's name, strength, prescription number as applicable, quantity, to whom the medications were given, date of disposition, and names of staff and other individuals involved in the disposition for one of one discharged resident (R10) with record review.

MDH’s finding, as written: “Based on interview and record review, the licensee failed upon discharge, to document in the resident's record the disposition of the medication including the medication's name, strength, prescription number as applicable, quantity, to whom the medications were given, date of disposition, and names of staff and other individuals involved in the disposition for one of one discharged resident (R10) with record review. [...]”

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 have on the service plan a written statement of the treatment or therapy services provided for three of seven (R3, R4 and R6) residents receiving treatments with records reviewed.

MDH’s finding, as written: “Based on observation, interview and document review, the licensee failed to have on the service plan a written statement of the treatment or therapy services provided for three of seven (R3, R4 and R6) residents receiving treatments with records reviewed. [...]”

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 accurately specify written instructions for each resident and document in one of one resident's record (R4) who received an altered texture diet.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to accurately specify written instructions for each resident and document in one of one resident's record (R4) who received an altered texture diet. [...]”

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 [...]”

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 eight residents (R5) receiving treatments. [...]”

Rule cited: “There must be an up-to-date written or electronically recorded order from an authorized prescriber for all treatments and therapies. [...]”

MDH’s finding, as written: “Based on interview and record review the licensee failed to provide hazard vulnerability assessment or safety risk, as required by MN Statute 144G.81, Subd.1 (a). This had the potential to affect all current 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 ensure the current Minnesota Bill of Rights for Assisted Living Residents and information about how to make a complaint was provided to the residents and a written acknowledgement received for five of seven residents (R1, R2, R4, R5, R9) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the current Minnesota Bill of Rights for Assisted Living Residents and information about how to make a complaint was provided to the residents and a written acknowledgement received for five of seven residents (R1, R2, R4, R5, R9) with records reviewed. [...]”

Rule cited: “(a) An assisted living facility must provide the resident a written notice of the rights under section 144G.91 before the initiation of services to that resident. [...]”

Summary: MDH found the licensee failed to provide care in accordance with accepted healthcare standards for one of one resident (R6) by completing a change of condition assessment and failed to create and implement interventions which resulted in serious injury.

MDH’s finding, as written: “Based on interview and document review, the licensee failed to provide care in accordance with accepted healthcare standards for one of one resident (R6) by completing a change of condition assessment and failed to create and implement interventions which resulted in serious injury. [...]”

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 provide a dignified dining experience for one of one resident (R4) observed during dining.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to provide a dignified dining experience for one of one resident (R4) observed during dining. 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 [...]”

Rule cited: “Residents have the right to be treated with courtesy and respect, and to have the resident's property treated with respect.”

Summary: MDH found the licensee failed to immediately report to the Minnesota Adult Abuse Reporting Center (MAARC) suspected maltreatment for one of one resident (R6) with record reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to immediately report to the Minnesota Adult Abuse Reporting Center (MAARC) suspected maltreatment for one of one resident (R6) with record reviewed. [...]”

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 [...]”

Summary: MDH found the licensee failed to ensure the required notice was posted at the main entry way of the establishment to display statutory language to disclose electronic monitoring activity, potentially affecting all current residents, staff and any visitors of the facility.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure the required notice was posted at the main entry way of the establishment to display statutory language to disclose electronic monitoring activity, potentially affecting all current residents, staff and any visitors of the facility. [...]”

Rule cited: “Subd. 8.Notice to visitors. (a) A facility must post a sign at each facility entrance accessible to visitors that states: "Electronic monitoring devices, including security cameras and audio devices, may be present to record persons and activities." (b) The [...]”