West Saint Paul (Assisted Living and Memory Care)

MDH’s finding, as written: “Based on observation, interview, and record review the licensee failed to establish and maintain an infection control program that complies with accepted health care, medical and nursing standards for infection control during medication administration by one of two unlicensed personnel (ULP-G). [...]”

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 post, in a conspicuous place, the facility's grievance procedure.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to post, in a conspicuous place, the facility's grievance procedure. 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 is issued at a widespread scope (when problems are pervasive or represent a systemic failure that has affected [...]”

Rule cited: “All facilities must post in a conspicuous place information about the facilities' grievance procedure, and the name, telephone number, and email contact information for the individuals who are responsible for handling resident grievances. [...]”

Summary: MDH found the licensee failed to ensure employee records included the required content for one of one employee (unlicensed personnel (ULP)-C).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure employee records included the required content for one of one employee (unlicensed personnel (ULP)-C). [...]”

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 have a written emergency preparedness plan (EPP) with the required content.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to have a written emergency preparedness plan (EPP) with the required content. In addition, the licensee failed to post the emergency preparedness plan (EPP). 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 entries in resident records were authenticated with the name and title of the person making the entry for two of two residents (R1, R2).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure entries in resident records were authenticated with the name and title of the person making the entry for two of two residents (R1, R2). [...]”

Rule cited: “(a) Assisted living facilities must maintain records for each resident for whom it is providing services. [...]”

Summary: MDH found the licensee failed to ensure resident records were protected against unauthorized disclosure written records.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure resident records were protected against unauthorized disclosure written records. 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 [...]”

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 provided as identified on the service plan for two of two residents (R1, R2).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to document services provided as identified on the service plan for two of two residents (R1, R2). [...]”

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 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:”

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 have a signed contract for four of four residents (R1, R2, R6, R7) prior to providing assisted living services as required.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to have a signed contract for four of four residents (R1, R2, R6, R7) prior to providing assisted living services as required. [...]”

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. [...]”

Summary: MDH found the licensee failed to ensure a background study was submitted through Department of Human Services (DHS) NETStudy 2.0 and received in affiliation with the assisted living license for three of three employees (unlicensed personnel (ULP)-C, ULP-D, and ULP-E).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure a background study was submitted through Department of Human Services (DHS) NETStudy 2.0 and received in affiliation with the assisted living license for three of three employees (unlicensed personnel (ULP)-C, ULP-D, and ULP-E). This resulted in an immediate correction order on March 9, 2026. [...]”

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 the registered nurse (RN) conducted direct supervision of staff performing delegated nursing

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) conducted direct supervision of staff performing delegated nursing or therapy tasks within 30 days of first providing those services for one of two unlicensed personnel (ULP-G). [...]”

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 the one

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the one contracted agency staff (registered nurse (RN)-B) completed an orientation to assisted living facility licensing requirements and regulations before providing services to residents. [...]”

Rule cited: “(a) All staff providing and supervising direct services must complete an orientation to assisted living facility licensing requirements and regulations before providing assisted living services to residents. [...]”

Summary: MDH found the licensee failed to ensure annual training included all required topics for each 12 months of employment for one of one employee (unlicensed personnel (ULP)-C).

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 employee (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 two of two employees (unlicensed personnel (ULP)-C and ULP-G) received the required amount of dementia, mental illness, and de-escalation training in the required time frame.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure two of two employees (unlicensed personnel (ULP)-C and ULP-G) received the required amount of dementia, mental illness, and de-escalation training in the required time frame. [...]”

Rule cited: “(3) for assisted living facilities with dementia care, direct-care staff 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) completed a 14-day assessment as required for five of five residents (R1, R2, R5, R6, R7).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) completed a 14-day assessment as required for five of five residents (R1, R2, R5, R6, R7). [...]”

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 implement all services included in the service plan for one of two residents (R1).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to implement all services included in the service plan for one of two residents (R1). 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 [...]”

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 registered nurse (RN) conducted a face-to-face medication management reassessment to include all required content for two of two residents (R1, R2) who received medication management services.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) conducted a face-to-face medication management reassessment to include all required content for two of two residents (R1, R2) who received medication management services. [...]”

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 [...]”

MDH’s finding, as written: “Based on observation, interview, and record review, licensee failed to ensure medications were administered according to policy and accepted standards of practice for one of one unlicensed personnel (ULP)-C with documenting medication administration. [...]”

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 administered as ordered for one of one of

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medications were administered as ordered for one of one of two residents (R1), failed to accurately document medication administration, failed to document administration of medications, and failed to document follow up for as needed medications. [...]”

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) trained and ensured competency for one of two employees (unlicensed personnel (ULP)-G) providing medications for residents with unplanned time away from home when the licensed nurse was not available.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) trained and ensured competency for one of two employees (unlicensed personnel (ULP)-G) providing medications for residents with unplanned time away from home when the licensed nurse was not available. [...]”

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 [...]”

Summary: MDH found the licensee failed to ensure medications were stored per manufacturer guidelines.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medications were stored per manufacturer guidelines. 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 limited number [...]”

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 medications were labeled with the date opened for the licensee's three residents (R1, R6, R8) with time sensitive medications and failed to ensure medications were maintained bearing the original prescription label.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medications were labeled with the date opened for the licensee's three residents (R1, R6, R8) with time sensitive medications and failed to ensure medications were maintained bearing the original prescription label. [...]”

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 prescription insulin pens were not being saved for use by anyone other than the resident prescribed the insulin.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure prescription insulin pens were not being saved for use by anyone other than the resident prescribed the insulin. This had the potential to affect one of one residents receiving insulin. [...]”

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 and implement a treatment or therapy management plan to include the required content for one of two residents (R2).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to develop and implement a treatment or therapy management plan to include the required content for one of two residents (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 provide a prescribed treatment for one of one resident (R1).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to provide a prescribed treatment for one of one resident (R1). This resulted in an immediate correction order issued on March 11, 2026. [...]”

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 ensure policies and procedures required for assisted living facilities with dementia care were provided to each resident and/or the resident's legal and designated representative at the time of move-in for four of four residents (R1, R2, R6, R7).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure policies and procedures required for assisted living facilities with dementia care were provided to each resident and/or the resident's legal and designated representative at the time of move-in for four of four residents (R1, R2, R6, R7). [...]”

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 the current Minnesota Bill of Rights for Assisted Living

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the current Minnesota Bill of Rights for Assisted Living Residents was provided and a written acknowledgement was received for four of four residents (R1, R2, R6, R7) prior to providing services. [...]”

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 written notice to the residents, legal representative, or designated representative of a change of ownership within seven calendar days.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide written notice to the residents, legal representative, or designated representative of a change of ownership within seven calendar days. [...]”

Rule cited: “(a) A facility must provide written notice to the resident, legal representative, or designated representative of a change of ownership within seven calendar days after the facility receives a new license. [...]”

Summary: MDH found the licensee failed to provide care and services according to acceptable health care, medical, or nursing standards for the licensee's one resident (R4) with a hospital bed rail and the licensee's one resident (R1) with consumer grab bars.

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 the licensee's one resident (R4) with a hospital bed rail and the licensee's one resident (R1) with consumer grab bars. This resulted in an immediate order issued on March 11, 2026. [...]”

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 ensure one of one resident (R1) received appropriate care and services related to diabetes care and medication administration.

MDH’s finding, as written: “Based on observation, interview, and document review, the licensee failed to ensure one of one resident (R1) received appropriate care and services related to diabetes care and medication administration. This resulted in an immediate correction order identified on March 11, 2026. [...]”

Rule cited: “(b) Residents have the right to receive health care and other assisted living services with continuity from people who are properly trained and competent to perform their duties and in sufficient numbers to adequately provide the services agreed to in the [...]”

Summary: MDH found the licensee failed to provide privacy for one of one resident (R7) during medication administration.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to provide privacy for one of one resident (R7) during medication administration. 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: “(a) Residents have the right to consideration of their privacy, individuality, and cultural identity as related to their social, religious, and psychological well-being. [...]”