Vista Prairie at North Pointe

Summary: MDH found the licensee failed to ensure documentation of content in the resident's record as required for three of five residents (R3, R11, R10).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure documentation of content in the resident's record as required for three of five residents (R3, R11, R10). [...]”

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: “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 ensure direct supervision of staff performing delegated tasks was provided within 30 calendar days after the date on which the individual begins working for the facility for three of six unlicensed personnel (ULP-I, ULP-M,

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure direct supervision of staff performing delegated tasks was provided within 30 calendar days after the date on which the individual begins working for the facility for three of six unlicensed personnel (ULP-I, ULP-M, ULP-L). [...]”

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 five of five employees (unlicensed personnel (ULP)-G, ULP-H, ULP-I, ULP-M, ULP-L) received the required dementia care training.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure five of five employees (unlicensed personnel (ULP)-G, ULP-H, ULP-I, ULP-M, ULP-L) received the required dementia care training. [...]”

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) had completed and/or documented a comprehensive assessment for change in condition for four of five residents (R11, R18, R20, R21); failed to ensure comprehensive assessment to include required areas of assessment for three of three residents (R11, R3, R7) and failed to ensure the RN completed comprehensive reassessment and monitoring every 90 days as required for one of five residents (R10).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) had completed and/or documented a comprehensive assessment for change in condition for four of five residents (R11, R18, R20, R21); failed to ensure comprehensive assessment to include required areas of assessment for three of three residents (R11, R3, R7) and failed to ensure the RN completed comprehensive reassessment and monitoring every 90 days as required for one of five residents [...]”

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 revision of the service plan with changes in services for three of four residents (R3, R11, R10).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure revision of the service plan with changes in services for three of four residents (R3, R11, R10). [...]”

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 the service plan included all required content for two of four residents (R3, R11).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the service plan included all required content for two of four residents (R3, R11). 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: “(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 notification of physician,

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure notification of physician, investigation and corrective actions for medication errors for two of two residents (R16, R17). [...]”

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

Summary: MDH found the licensee failed to ensure assessment of medication management services included all required content for three of five residents (R3, R11, R10).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure assessment of medication management services included all required content for three of five residents (R3, R11, R10). [...]”

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 an individualized medication management plan included all required content for two of five residents (R3, R11).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure an individualized medication management plan included all required content for two of five residents (R3, R11). [...]”

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 medication was administered as prescribed for one of five residents (R11) and failed to ensure the amount of sliding scale insulin administered was documented for two of two residents (R4, R10).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medication was administered as prescribed for one of five residents (R11) and failed to ensure the amount of sliding scale insulin administered was documented for two of two residents (R4, R10). [...]”

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 prepare and include a treatment plan to include all required content for one of two residents (R11).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure prepare and include a treatment plan to include all required content for one of two residents (R11). [...]”

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 ensure an the registered nurse (RN) specified, in writing, specific instructions for each resident and documented those instructions in the resident's records for one of four residents (R11); and had instructed the unlicensed personnel in the proper methods with respect to each resident and five of five unlicensed personnel (ULP-G, ULP-H, ULP-I, ULP-J, ULP-P) has demonstrated the ability to competently follow the procedures.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure an the registered nurse (RN) specified, in writing, specific instructions for each resident and documented those instructions in the resident's records for one of four residents (R11); and had instructed the unlicensed personnel in the proper methods with respect to each resident and five of five unlicensed personnel (ULP-G, ULP-H, ULP-I, ULP-J, ULP-P) has demonstrated the ability to competently follow the [...]”

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 observation, interview, and record review the licensee failed to ensure clear prescriber's orders for treatment or therapy for three of three residents (R8, R11, R10) and failed to ensure a prescriber's order for treatment for one of four residents (R5). [...]”

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 immediately report to the Minnesota Adult Abuse Reporting Center

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 (R12). [...]”

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 post information related to the grievance procedure.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to post information related to the grievance procedure. 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 immediately report to the Minnesota Adult Abuse Reporting Center (MAARC) a significant medication error for one of one resident (R9).

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) a significant medication error for one of one resident (R9). [...]”

Rule cited: “144G.42 Subd. 6. Compliance with requirements for reporting maltreatment of vulnerable adults; abuse prevention plan. (a) The assisted living facility must comply with the requirements for the reporting of maltreatment of vulnerable adults in section 626.557. [...]”

Summary: MDH found the licensee failed to develop and implement an individual abuse prevention plan that included an individualized review or assessment of the person's susceptibility to abuse by another individual, including other vulnerable adults and the person's risk of abusing other vulnerable adults for five of five residents (R1, R2, R3, R4, R5).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to develop and implement an individual abuse prevention plan that included an individualized review or assessment of the person's susceptibility to abuse by another individual, including other vulnerable adults and the person's risk of abusing other vulnerable adults for five of five residents (R1, R2, R3, R4, R5). [...]”

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 failed to post the 911 emergency number in common areas and near telephones provided by the assisted living facility.

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 failed to post the 911 emergency number in common areas and near telephones provided by the assisted living facility. This had the potential to affect all 17 residents receiving assisted living 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 TB (tuberculosis) prevention and control program based on the most current guidelines issued by the centers for Disease Control and Prevention (CDC) guidelines.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to establish and maintain a TB (tuberculosis) prevention and control program based on the most current guidelines issued by the centers for Disease Control and Prevention (CDC) guidelines. This had the potential to affect all 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 ensure documentation of content in the resident's record as required for five of five residents (R1, R2, R3, R4, R5).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure documentation of content in the resident's record as required for five of five residents (R1, R2, R3, R4, R5). [...]”

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 develop a fire safety and evacuation plan with required elements, failed to provide required employee training on fire safety and evacuation, and failed to conduct required evacuation drills.

MDH’s finding, as written: “Based on a record review and interview, the licensee failed to develop a fire safety and evacuation plan with required elements, failed to provide required employee training on fire safety and evacuation, and failed to conduct required evacuation drills. This had the potential to affect all staff, residents, 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 ensure the licensee's contract included a disclosure of the category of assisted living facility license held by the facility for five of five residents (R1, R2, R3, R4, R5).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the licensee's contract included a disclosure of the category of assisted living facility license held by the facility for five of five residents (R1, R2, R3, R4, R5). [...]”

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 execute a written contract with the required content for five of five residents (R1, R2, R3, R4, R5).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to execute a written contract with the required content for five of five residents (R1, R2, R3, R4, R5). 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 a widespread scope (when problems are pervasive or represent a systemic failure that has affected or has potential to affect a large portion or [...]”

Rule cited: “(d) The contract must include a description of the facility's complaint resolution process available to residents, including the name and contact information of the person representing the facility who is designated to handle and resolve complaints. [...]”

Summary: MDH found the licensee failed to execute a written contract with the required content for five of five residents (R1, R2, R3, R4, R5).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to execute a written contract with the required content for five of five residents (R1, R2, R3, R4, R5). 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 a widespread scope (when problems are pervasive or represent a systemic failure that has affected or has potential to affect a large portion or [...]”

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 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 82 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 direct supervision of staff performing delegated tasks was provided within 30 calendar days after the date on which the individual begins working for the facility for two of three unlicensed personnel (ULP-H, ULP-I).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure direct supervision of staff performing delegated tasks was provided within 30 calendar days after the date on which the individual begins working for the facility for two of three unlicensed personnel (ULP-H, ULP-I). [...]”

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 [...]”

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure three of three employees (unlicensed personnel (ULP)-G, ULP-H, ULP-I) received the required amount of dementia care training. [...]”

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) had completed and/or documented a comprehensive assessment for change in condition (wounds, emergency room (ER) visits, readmission following hospitalization,

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) had completed and/or documented a comprehensive assessment for change in condition (wounds, emergency room (ER) visits, readmission following hospitalization, falls) for six of six residents (R1, R2, R3, R7, R4, R5) and failed to ensure the RN completed and/or documented comprehensive assessment and/or monitoring and reassessment for initial/14 day and 90 day as required for five of five [...]”

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 finalize a current written service plan within 14 calendar days for three of three residents (R1, R2, R3) and failed to ensure revision of the service plan with changes in services for four of four residents (R1, R2, R3, R4).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to finalize a current written service plan within 14 calendar days for three of three residents (R1, R2, R3) and failed to ensure revision of the service plan with changes in services for four of four residents (R1, R2, R3, R4). [...]”

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 the service plan included all 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 all 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 assessment of medication management services included all required content for five of five residents (R1, R2, R3, R4, R5).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure assessment of medication management services included all required content for five of five residents (R1, R2, R3, R4, R5). [...]”

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 an individualized medication management plan included all required content for five of five residents (R1, R2, R3, R4, R5).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure an individualized medication management plan included all required content for five of five residents (R1, R2, R3, R4, R5). [...]”

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 administered according to manufacturer's instructions observed with insulin administration for two of four residents (R8 and R2).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee administered according to manufacturer's instructions observed with insulin administration for two of four residents (R8 and R2). [...]”

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 documentation of medications were administered as ordered for two of four residents (R1 and R4).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure documentation of medications were administered as ordered for two of four residents (R1 and R4). [...]”

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 the registered nurse (RN) developed written procedures for providing medications for residents having unplanned time away, and the unlicensed personnel (ULP) providing medications when the licensed nurse was not available.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the registered nurse (RN) developed written procedures for providing medications for residents having unplanned time away, and the unlicensed personnel (ULP) providing medications when the licensed nurse was not available. In addition, the RN failed to ensure one of three unlicensed personnel (ULP-H) was trained and had demonstrated competency to prepare and give medications for residents having unplanned time away. [...]”

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 [...]”

MDH’s finding, as written: “Based on observation, interview, and record review the licensee failed to ensure prescriber's orders for medications for one of five 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 or a [...]”

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 prepare and include a treatment plan to include all required content for two of three residents (R1, R2).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure prepare and include a treatment plan to include all required content for two of three residents (R1, R2). [...]”

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 ensure an the registered nurse (RN) specified, in writing,

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure an the registered nurse (RN) specified, in writing, specific instructions for each resident and documented those instructions in the resident's records for two of three residents (R1, R2); and had instructed the unlicensed personnel in the proper methods with respect to each resident and three of three unlicensed personnel (ULP-G, ULP-H, ULP-I) has demonstrated the ability to competently follow the procedures. [...]”

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 ensure treatment services were documented for two of three residents (R1, R2).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure treatment services were documented for two of three residents (R1, 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 or [...]”

Rule cited: “Each treatment or therapy administered by an assisted living facility must be in the resident record. [...]”

MDH’s finding, as written: “Based on observation, interview, and record review the licensee failed to ensure clear prescriber's orders for treatment or therapy for three of three residents (R1, R2, R5). [...]”

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 care and services were provided according to acceptable health care and medical, or nursing standards with bedrails/side rails for three of four residents

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure care and services were provided according to acceptable health care and medical, or nursing standards with bedrails/side rails for three of four residents (R1, R2, R3). This resulted in an immediate correction order on October 20, 2022, at approximately 9:58 a.m. [...]”

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 immediately report to the Minnesota Adult Abuse Reporting Center (MAARC) a significant medication error for one of one resident (R9).

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) a significant medication error for one of one resident (R9). [...]”

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 [...]”