Wellstead Senior Living Place

Summary: MDH found the licensee failed to ensure the assisted living contract did not include language waiving the

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 licensee's liability for health, safety, or personal property of a resident for five of five residents (R1, R4, R7, R22, R23). [...]”

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 employees received orientation to assisted living facility licensing requirements and regulations prior to providing services for one of five employees (registered nurse (RN)-U).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure employees received orientation to assisted living facility licensing requirements and regulations prior to providing services for one of five employees (registered nurse (RN)-U). [...]”

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 [...]”

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the service plan was revised to include all services being provided for one of five residents (R23). [...]”

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 medications were securely locked in a substantially constructed compartment and permitted only authorized personnel to have access for five of five residents (R1, R25, R26, R27, R28).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medications were securely locked in a substantially constructed compartment and permitted only authorized personnel to have access for five of five residents (R1, R25, R26, R27, R28). [...]”

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 expired medications were properly disposed from the medication cart for one of two residents (R24).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure expired medications were properly disposed from the medication cart for one of two residents (R24). [...]”

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 develop and implement a treatment or therapy management plan to include all required content for one of two residents (R23).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop and implement a treatment or therapy management plan to include all required content for one of two residents (R23). [...]”

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 policies and procedures for assisted living with dementia care (ALFDC) were provided to residents and the residents' legal and designated representatives at the time of move in for five of five residents (R1, R4, R7, R22, R23).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure policies and procedures for assisted living with dementia care (ALFDC) were provided to residents and the residents' legal and designated representatives at the time of move in for five of five residents (R1, R4, R7, R22, R23). [...]”

Rule cited: “(a) In addition to the policies and procedures required in the licensing of all facilities, the assisted living facility with dementia care licensee must develop and implement policies and procedures that address the: (1) philosophy of how services are [...]”

Summary: MDH found the licensee failed to ensure food was prepared and served according to the Minnesota Food Code.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure food was prepared and served according to the Minnesota Food Code. This had the potential to affect all residents. [...]”

Rule cited: “(13) offer to provide or make available at least the following services to residents: (i) at least three nutritious meals daily with snacks available seven days per week, according to the recommended dietary allowances in the United States Department of [...]”

Summary: MDH found the licensee failed to offer at least three nutritious meals daily, according to the recommended dietary allowances in the United Stated Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables and failed to ensure a menu was prepared a week in advance and provided to the residents.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to offer at least three nutritious meals daily, according to the recommended dietary allowances in the United Stated Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables and failed to ensure a menu was prepared a week in advance and provided to the residents. This had the potential to affect all residents. [...]”

Rule cited: “(13) offer to provide or make available at least the following services to residents: (i) at least three nutritious meals daily with snacks available seven days per week, according to the recommended dietary allowances in the United States Department of [...]”

Summary: MDH found the licensee failed to have a daily program of social and recreational activities based on individual and group interests, physical, mental, and psychosocial needs, that create opportunities for active participation in the

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to have a daily program of social and recreational activities based on individual and group interests, physical, mental, and psychosocial needs, that create opportunities for active participation in the community at large. This had the potential to affect all residents of the licensee. [...]”

Rule cited: “(ii) weekly housekeeping; (iii) weekly laundry service; (iv) upon the request of the resident, provide direct or reasonable assistance with arranging for transportation to medical and social services appointments, shopping, and other recreation, and provide [...]”

Summary: MDH found the licensee failed to establish and maintain an effective infection control program to

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to establish and maintain an effective infection control program to comply with acceptable health care, medical, and nursing standards for infection control. This deficient practice had the potential to affect all of the licensee's residents, staff, and visitors. [...]”

Rule cited: “(a) All assisted living facilities must establish and maintain an infection control program that complies with accepted health care, medical, and nursing standards for infection control. [...]”

Summary: MDH found the licensee failed to ensure an individual abuse prevention plan (IAPP) was developed to include all required content for two of five residents (R4, R5).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure an individual abuse prevention plan (IAPP) was developed to include all required content for two of five residents (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 ensure training and competency documentation was maintained for one of two unlicensed personnel ((ULP)-C) to include all required content.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure training and competency documentation was maintained for one of two unlicensed personnel ((ULP)-C) to include all required content. [...]”

Rule cited: “(a) The facility must maintain current records of each paid employee, each regularly scheduled volunteer providing services, and each individual contractor providing services. [...]”

Summary: MDH found the licensee failed to ensure residents' personal health and medical information was kept private.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure residents' personal health and medical information was kept private. This had the potential to affect all residents on the Bluebird memory care unit and three of three residents (R15, R16, R20) on the Hummingbird memory care unit. [...]”

Rule cited: “(b) Resident records, whether written or electronic, must be protected against loss, tampering, or unauthorized disclosure in compliance with chapter 13 and other applicable relevant federal and state laws. [...]”

Summary: MDH found the licensee failed to document services that had been provided as identified in the service plan for one of five residents.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to document services that had been provided as identified in the service plan for one of five residents. [...]”

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 regarding the health, safety, comfort, and well-being of the residents.

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 regarding the health, safety, comfort, and well-being of the residents. This deficient condition had the potential to affect all staff, residents, and visitors. [...]”

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 [...]”

Summary: MDH found the licensee failed to provide the required documentation of employee and resident training on fire safety and evacuation drills.

MDH’s finding, as written: “Based on a record review and interview, the licensee failed to provide the required documentation of employee and resident training on fire safety and 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 develop and execute a written contract with the required content post 144G Statute for five of five residents (R1, R2, R4, R7, R8).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop and execute a written contract with the required content post 144G Statute for five of five residents (R1, R2, R4, R7, R8). [...]”

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. [...]”

MDH’s finding, as written: “Based interview and record review, the licensee failed to ensure a notice with required content was provided to the resident/representative for one of one resident (R14) who had an emergency relocation out of the facility. [...]”

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 a background study was conducted prior to staff providing services for three of five employees (unlicensed personnel (ULP)-C, ULP-E, ULP-H).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure a background study was conducted prior to staff providing services for three of five employees (unlicensed personnel (ULP)-C, ULP-E, ULP-H). [...]”

Rule cited: “(a) Employees, contractors, and regularly scheduled volunteers of the facility are subject to the background study required by section 144.057 and may be disqualified under chapter 245C. [...]”

Summary: MDH found the licensee failed to ensure unlicensed personnel (ULPs) were trained in the proper methods to perform the tasks or procedures and were able to demonstrate the ability to competently follow the procedures and perform the tasks to a registered nurse (RN) for one of one ULP (ULP-C) who performed delegated tasks.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure unlicensed personnel (ULPs) were trained in the proper methods to perform the tasks or procedures and were able to demonstrate the ability to competently follow the procedures and perform the tasks to a registered nurse (RN) for one of one ULP (ULP-C) who performed delegated tasks. [...]”

Rule cited: “(b) When the registered nurse or licensed health professional delegates tasks to unlicensed personnel, that person must ensure that prior to the delegation the unlicensed personnel is trained in the proper methods to perform the tasks or procedures for each [...]”

Summary: MDH found the licensee failed to ensure direct supervision of staff performing delegated tasks was provided within 30 calendar days after the task was delegated for one of two unlicensed personnel ((ULP)-C).

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 task was delegated for one of two unlicensed personnel ((ULP)-C). [...]”

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 two of three employees (registered nurse (RN)-B, unlicensed personnel (ULP)-C), received orientation to assisted living facility licensing requirements before providing services.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure two of three employees (registered nurse (RN)-B, unlicensed personnel (ULP)-C), received orientation to assisted living facility licensing requirements before providing services. [...]”

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 employees received at least eight (8) hours of annual training for each 12 months of employment for one of three employees (unlicensed personnel (ULP)-C).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure employees received at least eight (8) hours of annual training for each 12 months of employment for one of three employees (unlicensed personnel (ULP)-C). [...]”

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 direct-care staff completed the required amount of dementia care training in the required time frame for one of three employees (unlicensed personnel (ULP)-C).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure direct-care staff completed the required amount of dementia care training in the required time frame for one of three employees (unlicensed personnel (ULP)-C). [...]”

Rule cited: “(3) for assisted living facilities with dementia care, direct-care employees must have completed at least eight hours of initial training on topics specified under paragraph (b) within 80 working hours of the employment start date. [...]”

Summary: MDH found the licensee failed to ensure the registered nurse (RN) conducted a

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) conducted a comprehensive re-assessment following a change of condition for one of one resident (R3). [...]”

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 current service plan

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the current service plan included a signature or other authentication by the resident or resident's designated representative and the licensee to document agreement on the services to be provided for three of five residents (R3, R5, R22). [...]”

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 six of six residents (R1, R2, R3, R4, R5, R7).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the service plan included all required content for six of six residents (R1, R2, R3, R4, R5, R7). This had the potential to affect all residents. [...]”

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 the registered nurse (RN) conducted an individualized medication assessment with the required content for six of six residents (R1, R2, R3, R4, R5, R7).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) conducted an individualized medication assessment with the required content for six of six residents (R1, R2, R3, R4, R5, R7). [...]”

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 the registered nurse (RN) completed a reassessment when there was a change in the resident's medications for one of two residents (R3).

MDH’s finding, as written: “Based on interview, and record review, the licensee failed to ensure the registered nurse (RN) completed a reassessment when there was a change in the resident's medications for one of two residents (R3). [...]”

Rule cited: “The assisted living facility must monitor and reassess the resident's medication management services as needed under subdivision 2 when the resident presents with symptoms or other issues that may be medication-related and, at a minimum, annually.”

Summary: MDH found the licensee failed to develop and maintain a current individualized medication management record for each resident to include 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 develop and maintain a current individualized medication management record for each resident to include 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 failed to ensure prior to delegating the task of medication administration, the registered nurse (RN) trained the unlicensed personnel (ULP) in the proper methods to perform the task or procedure for each resident and verified the ULPs were able to demonstrate the ability to competently follow the procedure for three of four employees (ULP-C, ULP-I, ULP-J).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure prior to delegating the task of medication administration, the registered nurse (RN) trained the unlicensed personnel (ULP) in the proper methods to perform the task or procedure for each resident and verified the ULPs were able to demonstrate the ability to competently follow the procedure for three of four employees (ULP-C, ULP-I, ULP-J). [...]”

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 staff administered scheduled medications as ordered for two of five residents (R7, R22).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure staff administered scheduled medications as ordered for two of five residents (R7, R22). [...]”

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 store prescription medication securely and permit only authorized personnel to have access for two of four medication carts.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to store prescription medication securely and permit only authorized personnel to have access for two of four medication carts. [...]”

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, licensee failed to date time-sensitive medications with an opened-on date and failed to ensure medications were labeled with residents' information for two of four 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 [...]”

MDH’s finding, as written: “Based on observation, interview, and record review the licensee failed to ensure a prescription medication supply for one resident was not being saved for use by another, other than the resident prescribed for one of one resident (R23). [...]”

Rule cited: “No prescription drug supply for one resident may be used or saved for use by anyone other than the resident.”

Summary: MDH found the licensee failed to develop a treatment management plan to include all required content for two of two residents (R2, R3).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to develop a treatment management plan to include all required content for two of two residents (R2, R3). [...]”

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 prior to delegating nursing tasks of prescribed treatment administration, the unlicensed personnel (ULP) were trained in the proper methods to perform the task or procedure for each resident, and were able to demonstrate, to the registered nurse (RN), the ability to competently follow the procedure for one of two employees (unlicensed

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure prior to delegating nursing tasks of prescribed treatment administration, the unlicensed personnel (ULP) were trained in the proper methods to perform the task or procedure for each resident, and were able to demonstrate, to the registered nurse (RN), the ability to competently follow the procedure for one of two employees (unlicensed personnel (ULP)-C). [...]”

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 treatments were performed as ordered for one of three residents (R3).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure treatments were performed as ordered for one of three residents (R3). 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 situation has occurred only [...]”

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

Summary: MDH found the licensee failed to maintain a resident's dignity for dining and toileting cares for two of four residents (R4, R21).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to maintain a resident's dignity for dining and toileting cares for two of four residents (R4, R21). [...]”

Rule cited: “The licensee of an assisted living facility with dementia care is responsible for the care and housing of the persons with dementia and the provision of person-centered care that promotes each resident's dignity, independence, and comfort. [...]”

Summary: MDH found the licensee failed to ensure policies and procedures for assisted living with dementia care (ALFDC) were provided to residents and the residents' legal and designated representatives at the time

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure policies and procedures for assisted living with dementia care (ALFDC) were provided to residents and the residents' legal and designated representatives at the time of move in for five of five residents (R1, R2, R3, R4, R5). [...]”

Rule cited: “(a) In addition to the policies and procedures required in the licensing of all facilities, the assisted living facility with dementia care licensee must develop and implement policies and procedures that address the: (1) philosophy of how services are [...]”

Summary: MDH found the licensee failed to provide care and services according to acceptable health care, medical, or nursing standards for one of one resident (R3) with oxygen.

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, medical, or nursing standards for one of one resident (R3) with oxygen. [...]”

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.”