Wesley Residence of Duluth

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) and Minnesota Department of Health (MDH), including completion of a two-step TST (tuberculin skin test) or other evidence of TB screening such as a blood test for three of three employees (unlicensed personnel (ULP)-D, ULP-E, ULP-H).

MDH’s finding, as written: “Based on observation, 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) and Minnesota Department of Health (MDH), including completion of a two-step TST (tuberculin skin test) or other evidence of TB screening such as a blood test for three of three employees (unlicensed personnel (ULP)-D, ULP-E, ULP-H). [...]”

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 include documentation of incidents involving the resident and actions taken in response to the needs of the resident, including reporting to the appropriate supervisor or health care professional for one of one resident (R2) with a medication error.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to include documentation of incidents involving the resident and actions taken in response to the needs of the resident, including reporting to the appropriate supervisor or health care professional for one of one resident (R2) with a medication error. [...]”

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 provide smoke alarms outside in the immediate vicinity of all sleeping rooms in the facility.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to provide smoke alarms outside in the immediate vicinity of all sleeping rooms in the facility. This had the potential to directly affect a limited number of residents and staff. [...]”

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 maintain the facility's physical environment in a continuous state of good repair and operation regarding the health, safety, and well-being of the residents.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to maintain the facility's physical environment in a continuous state of good repair and operation regarding the health, safety, and well-being of the residents. This had the potential to directly affect all residents, staff, 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 develop the fire safety and evacuation plan with required content, make the plan readily available, provide required training and drills.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to develop the fire safety and evacuation plan with required content, make the plan readily available, provide required training and drills. This had the potential to directly affect all residents, staff, and visitors. [...]”

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

Summary: MDH found the licensee failed to provide facilities that were not a distinct hazard to life.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to provide facilities that were not a distinct hazard to life. This had the potential to directly affect all residents, staff, and visitors. [...]”

Rule cited: “(g) Existing construction or elements, including assisted living facilities that were registered as housing with services establishments under chapter 144D prior to August 1, 2021, shall be permitted to continue in use provided such use does not constitute a [...]”

Summary: MDH found the licensee failed to provide written notice with required content to the resident, legal representative, and designated representative, and failed to provide the notification to the Office of Ombudsman for Long-Term Care (OOLTC) when the resident did not return from the emergency relocation within four days for one of one resident (R4) reviewed for a hospitalization.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide written notice with required content to the resident, legal representative, and designated representative, and failed to provide the notification to the Office of Ombudsman for Long-Term Care (OOLTC) when the resident did not return from the emergency relocation within four days for one of one resident (R4) reviewed for a hospitalization. [...]”

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 background clearance studies were conducted for six of seven contracted agency employees (unlicensed personnel (ULP)-D, ULP-E, ULP-I, ULP-J, ULP-L, ULP-M).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure background clearance studies were conducted for six of seven contracted agency employees (unlicensed personnel (ULP)-D, ULP-E, ULP-I, ULP-J, ULP-L, ULP-M). In addition, the licensee failed to ensure a background study was submitted and clearance was received in affiliation with the assisted living license for one of two employees (clinical nurse supervisor (CNS) -B). [...]”

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 contracted staff met all requirements for training and competency evaluation, as identified in 144G.60, Subd. 4 and 144G.61 Subd 1. and 2, for seven of seven unlicensed personnel (ULP-D, ULP-E, ULP-I, ULP-J, ULP-K, ULP-L, ULP-M).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure contracted staff met all requirements for training and competency evaluation, as identified in 144G.60, Subd. 4 and 144G.61 Subd 1. and 2, for seven of seven unlicensed personnel (ULP-D, ULP-E, ULP-I, ULP-J, ULP-K, ULP-L, ULP-M). This had the potential to affect all 33 residents receiving medication and treatment services. [...]”

Rule cited: “When a facility contracts with a temporary staffing agency, those individuals must meet the same requirements required by this section for personnel employed by the facility and shall be treated as if they are staff of the facility.”

Summary: MDH found the licensee failed to ensure training and competency evaluations included all the required training for one of one unlicensed personnel (ULP)-H.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure training and competency evaluations included all the required training for one of one unlicensed personnel (ULP)-H. [...]”

Rule cited: “(a) Training and competency evaluations for all unlicensed personnel must include the following: (1) documentation requirements for all services provided; (2) reports of changes in the resident's condition to the supervisor designated by the facility; (3) [...]”

Summary: MDH found the licensee failed to ensure training and competency evaluations included all the required training for one of one unlicensed personnel (ULP)-H.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure training and competency evaluations included all the required training for one of one unlicensed personnel (ULP)-H. [...]”

Rule cited: “(b) In addition to paragraph (a), training and competency evaluation for unlicensed personnel providing assisted living services must include: (1) observing, reporting, and documenting resident status; (2) basic knowledge of body functioning and changes in [...]”

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

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 licensee for one of one unlicensed personnel (ULP)-H. [...]”

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 employees not providing direct care received at least two hours of annual dementia training for one of one employee (cook (C)-F).

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

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

Summary: MDH found the licensee failed to ensure residents were assessed for self-administration of medications for one of one resident (R3) who self-administered insulin after set up.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure residents were assessed for self-administration of medications for one of one resident (R3) who self-administered insulin after set up. [...]”

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 prior to delegating the nursing task of medication administration, unlicensed personnel (ULP)-D received training and demonstrated competency for administering medications.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure prior to delegating the nursing task of medication administration, unlicensed personnel (ULP)-D received training and demonstrated competency for administering medications. In addition, the licensee failed to ensure specific instructions were in the resident record related to administering medications according to manufacturer's instructions for one of one resident (R5). [...]”

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 one of two unlicensed personnel (ULP)-D administered medications per the manufacturer's instructions for two of two residents (R5, R3) observed during medication administration and failed to administer medications as ordered by prescriber for one of one resident (R2) reviewed for medication errors.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure one of two unlicensed personnel (ULP)-D administered medications per the manufacturer's instructions for two of two residents (R5, R3) observed during medication administration and failed to administer medications as ordered by prescriber for one of one resident (R2) reviewed for medication errors. [...]”

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 date time-sensitive medications with opened or expiration dates for R2, R6, R7, R8, R11.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to date time-sensitive medications with opened or expiration dates for R2, R6, R7, R8, R11. In addition, the licensee failed to monitor for expired medications. [...]”

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 ensure instructions, specified in writing for each resident, and documented those instructions in the resident's record for three of three residents (R1, R2, R3) who received blood glucose monitoring by the facility.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure instructions, specified in writing for each resident, and documented those instructions in the resident's record for three of three residents (R1, R2, R3) who received blood glucose monitoring by the facility. [...]”

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 [...]”