Well Care Health Services, 73rd Avenue

Summary: MDH found the licensee failed to ensure the employee record contained the required content for three of three unlicensed personnel ((ULP)-A, ULP-B, ULP-D).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the employee record contained the required content for three of three unlicensed personnel ((ULP)-A, ULP-B, ULP-D). [...]”

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 establish and maintain a tuberculosis (TB) infection control program based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC) which included facility TB risk assessment, TB training, and TB testing results for two of two employees (unlicensed personnel (ULP)-A, ULP-B).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to establish and maintain a tuberculosis (TB) infection control program based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC) which included facility TB risk assessment, TB training, and TB testing results for two of two employees (unlicensed personnel (ULP)-A, ULP-B). [...]”

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 develop and maintain a written emergency preparedness (EPP) plan with all the required content as defined in Appendix Z. In addition, the licensee failed to post the EPP prominently.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to develop and maintain a written emergency preparedness (EPP) plan with all the required content as defined in Appendix Z. In addition, the licensee failed to post the EPP prominently. 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 ensure the physical environment of the facility was maintained in compliance with the requirements of Minnesota Statute 144G.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the physical environment of the facility was maintained in compliance with the requirements of Minnesota Statute 144G. [...]”

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 ensure the physical environment of the facility was maintained in compliance with the requirements of Minnesota Statute 144G.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the physical environment of the facility was maintained in compliance with the requirements of Minnesota Statute 144G. [...]”

Rule cited: “(a) Each assisted living facility must comply with the State Fire Code in Minnesota Rules, chapter 7511, and: (1) for dwellings or sleeping units, as defined in the State Fire Code: (i) provide smoke alarms in each room used for sleeping purposes; (ii) [...]”

Summary: MDH found the licensee failed to ensure the physical environment of the facility was maintained in compliance with the requirements of Minnesota Statute 144G.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the physical environment of the facility was maintained in compliance with the requirements of Minnesota Statute 144G. [...]”

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

Summary: MDH found the licensee failed to ensure required training was completed and documented for two of two unlicensed personnel ((ULP)-A, ULP-B).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure required training was completed and documented for two of two unlicensed personnel ((ULP)-A, ULP-B). This had the potential to affect all residents living in the facility. [...]”

Rule cited: “(a) Unlicensed personnel providing assisted living services must have: (1) successfully completed a training and competency evaluation appropriate to the services provided by the facility and the topics listed in section 144G.61, subdivision 2, paragraph (a); [...]”

Summary: MDH found the licensee failed to provide orientation to assisted living licensing requirements and regulations prior to providing services for two of two unlicensed personnel ((ULP)-A, ULP-B).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to provide orientation to assisted living licensing requirements and regulations prior to providing services for two of two unlicensed personnel ((ULP)-A, ULP-B). [...]”

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 annual training included all required topics for each 12 months of employment for one of one unlicensed personnel (ULP)-A.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure annual training included all required topics for each 12 months of employment for one of one unlicensed personnel (ULP)-A. [...]”

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 all employees received eight hours of initial dementia care training within the first 160 working hours of employment for direct care employees as required for two of two unlicensed personnel ((ULP)-A, ULP-B); failed to ensure all employees received two hours of annual dementia care training for direct care employees as required for one of one unlicensed personnel (ULP-A); and

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure all employees received eight hours of initial dementia care training within the first 160 working hours of employment for direct care employees as required for two of two unlicensed personnel ((ULP)-A, ULP-B); failed to ensure all employees received two hours of annual dementia care training for direct care employees as required for one of one unlicensed personnel (ULP-A); and failed to ensure direct care staff [...]”

Rule cited: “(a) All assisted living facilities must meet the following dementia care, mental illness, and de-escalation training requirements: (1) supervisors of direct-care staff must have at least eight hours of initial training on dementia topics specified under [...]”

Summary: MDH found the licensee failed to ensure the registered nurse (RN) completed a comprehensive nursing assessment within the required 90-day timeframe for two of two residents (R2, R3).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) completed a comprehensive nursing assessment within the required 90-day timeframe for two of two residents (R2, R3). [...]”

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 develop an individualized medication management plan (IMMP) with the required content for one of one resident (R2).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop an individualized medication management plan (IMMP) with the required content for one of one resident (R2). [...]”

Rule cited: “(a) For each resident receiving medication management services, a registered nurse, advanced practice registered nurse, or qualified staff delegated the task by a registered nurse must prepare and include in the service plan a written statement of the [...]”

Summary: MDH found the licensee failed to ensure accurate transcription for a changed prescription for one of one resident (R2) who had medication management services.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure accurate transcription for a changed prescription for one of one resident (R2) who had medication management services. [...]”

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 medications were stored securely for residents with medication management services for two of two residents (R2, R3); and failed to monitor a medication refrigerator to ensure temperatures were maintained according to the manufacturer's instructions for one of one resident (R2) with medications stored in medication refrigerator.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medications were stored securely for residents with medication management services for two of two residents (R2, R3); and failed to monitor a medication refrigerator to ensure temperatures were maintained according to the manufacturer's instructions for one of one resident (R2) with medications stored in medication refrigerator. [...]”

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 ensure the resident records included a disposition of medications for one of one resident (R1); and failed to dispose of any medications that remained with the facility that were discontinued, expired or upon the termination of services or resident's death for all current and past residents.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the resident records included a disposition of medications for one of one resident (R1); and failed to dispose of any medications that remained with the facility that were discontinued, expired or upon the termination of services or resident's death for all current and past residents. [...]”

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 develop an individualized treatment management record with all required content for one of one resident (R2).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop an individualized treatment management record with all required content for one of one resident (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 the required notice was posted at the main entry way of the facility to display statutory language to disclose electronic monitoring activity.

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

Rule cited: “(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. [...]”