Westwood Place

Summary: MDH found the licensee failed to ensure contracted staff met all requirements required for personnel employed by the facility for all temporary or contracted unlicensed personnel (ULP).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure contracted staff met all requirements required for personnel employed by the facility for all temporary or contracted unlicensed personnel (ULP). [...]”

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 annual training was provided and included all required topics for each 12 months of employment, for one of two unlicensed personnel (ULP)-L.

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

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 resident's service plans included all required content for three of three residents (R3, R5, and R11).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure resident's service plans included all required content for three of three residents (R3, R5, and R11). [...]”

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 develop an individualized medication management record with the required content for one of one resident (R5) who had a pen-based medication.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to develop an individualized medication management record with the required content for one of one resident (R5) who had a pen-based medication. [...]”

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 medication administration was documented accurately for one of one resident (R5) who had a pen-based medication.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medication administration was documented accurately for one of one resident (R5) who had a pen-based medication. [...]”

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) specified, in writing, specific treatment instructions for each resident and documented those instructions in the resident's record for one of one resident (R11).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the registered nurse (RN) specified, in writing, specific treatment instructions for each resident and documented those instructions in the resident's record for one of one resident (R11). [...]”

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 the registered nurse (RN) specified, in writing, specific instructions for each resident and documented those instructions in the resident's record for one of one resident (R11) who had an ordered treatment.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the registered nurse (RN) specified, in writing, specific instructions for each resident and documented those instructions in the resident's record for one of one resident (R11) who had an ordered treatment. [...]”

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

Rule cited: “An assisted living facility with dementia care must meet the requirements of section 144G.45 and the following additional requirements: (1) an assessment of safety risks must be performed on and around the property. [...]”

Summary: MDH found the licensee failed to post the required information related to its grievance procedure, with all required content.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to post the required information related to its grievance procedure, with all required content. This had the potential to affect all residents, staff, and visitors to the facility. [...]”

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 display its current assisted living license in the main entrance of the facility.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to display its current assisted living license in the main entrance of the facility. This had the potential to affect all residents, staff and visitors to the facility. [...]”

Rule cited: “The original current license must be displayed at the main entrance of each assisted living facility. The facility must provide a copy of the license to any person who requests it.”

Summary: MDH found the licensee failed to implement and maintain a quality management program (QMP) appropriate to the size of the facility and relevant to the type of services provided.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to implement and maintain a quality management program (QMP) appropriate to the size of the facility and relevant to the type of services provided. This had the potential to affect all residents, staff, and visitors. [...]”

Rule cited: “The facility shall engage in quality management appropriate to the size of the facility and relevant to the type of services provided. [...]”

Summary: MDH found the licensee 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 post the 911 emergency number in common areas and near telephones provided by the assisted living facility. This had the potential to affect all residents, 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 ensure employee records included all required content for three of three employees (unlicensed personnel (ULP)-A and ULP-B, and contracted maintenance engineer (CME)-E) with employee records reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure employee records included all required content for three of three employees (unlicensed personnel (ULP)-A and ULP-B, and contracted maintenance engineer (CME)-E) with employee records reviewed. [...]”

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) prevention program, based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC), which included a current facility TB risk assessment.

MDH’s finding, as written: “Based on 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), which included a current facility TB risk assessment. [...]”

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 [...]”

MDH’s finding, as written: “Based on interview and record review the licensee failed to have a written emergency preparedness (EP) plan with all the required content. This had the potential to affect all residents receiving services under the assisted living license. [...]”

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 resident record included a discharge summary with the required content for one of one discharged resident (R1).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the resident record included a discharge summary with the required content for one of one discharged resident (R1). [...]”

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 comply with the Minnesota State Fire Code (MSFC) in Minnesota Rules, chapter 7511.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to comply with the Minnesota State Fire Code (MSFC) in Minnesota Rules, chapter 7511. This had the potential to directly affect all residents, staff, and visitors. [...]”

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 provide smoke alarms that functioned and were interconnected so that the actuation of one alarm caused all alarms in the dwelling unit to actuate.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to provide smoke alarms that functioned and were interconnected so that the actuation of one alarm caused all alarms in the dwelling unit to actuate. This had the potential to directly affect all residents, staff, and visitors. [...]”

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 portable fire extinguishers.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to maintain the portable fire extinguishers. This had the potential to directly affect all residents, staff, and visitors. [...]”

Rule cited: “(2) install and maintain portable fire extinguishers in accordance with the State Fire Code; (3) install portable fire extinguishers having a minimum 2-A:10-B:C rating within Group R-3 occupancies, as defined by the State Fire Code, located so that the travel [...]”

Summary: MDH found the licensee failed to develop the fire safety and evacuation plan with the required content, to provide the required training, and to conduct evacuation 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 the required content, to provide the required training, and to conduct evacuation 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 a written notice with the required content for an emergency relocation to the resident, legal representative, or designated representative and failed to provide the notification to the Office of Ombudsman for Long-Term Care (OOLTC) of the emergency relocation greater than four days for one of one resident (R4).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide a written notice with the required content for an emergency relocation to the resident, legal representative, or designated representative and failed to provide the notification to the Office of Ombudsman for Long-Term Care (OOLTC) of the emergency relocation greater than four days for one of one resident (R4). [...]”

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 current and eligible on NETStudy 2.0 (web-based system for submitting background study requests to the Department of Human Services (DHS)) prior to staff providing services for four of thirty-four staff, unlicensed personnel ((ULP)-B, ULP-F), server (S)-G, and cotracted maintenance engineer (CME)-E.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure a background study was current and eligible on NETStudy 2.0 (web-based system for submitting background study requests to the Department of Human Services (DHS)) prior to staff providing services for four of thirty-four staff, unlicensed personnel ((ULP)-B, ULP-F), server (S)-G, and cotracted maintenance engineer (CME)-E. [...]”

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 required for personnel employed by the facility for one of one unlicensed personnel (ULP-I) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure contracted staff met all requirements required for personnel employed by the facility for one of one unlicensed personnel (ULP-I) with records reviewed. [...]”

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 the registered nurse (RN) documented instructions for a delegated task in the resident's record for one of one resident (R3) with catheter maintenance.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) documented instructions for a delegated task in the resident's record for one of one resident (R3) with catheter maintenance. [...]”

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 the registered nurse (RN) completed supervision of an unlicensed personnel within 30 calendar days of beginning to provide delegated tasks 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 the registered nurse (RN) completed supervision of an unlicensed personnel within 30 calendar days of beginning to provide delegated tasks for one of one unlicensed personnel ((ULP)-A). [...]”

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 received orientation to 144G licensing requirements for one of one employee (unlicensed personnel (ULP)-I) with employee records reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure employees received orientation to 144G licensing requirements for one of one employee (unlicensed personnel (ULP)-I) with employee records reviewed. [...]”

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 employees received orientation to 144G licensing requirements for two of two employees (unlicensed personnel (ULP)-A and ULP-B) with employee records reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure employees received orientation to 144G licensing requirements for two of two employees (unlicensed personnel (ULP)-A and ULP-B) with employee records reviewed. [...]”

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 two of three employees (unlicensed personnel (ULP)-A and ULP-I) received the required amount of mental illness and de-escalation training within the required time frame.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure two of three employees (unlicensed personnel (ULP)-A and ULP-I) received the required amount of mental illness and de-escalation training within 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) conducted ongoing resident monitoring and reassessment to include all areas required on the uniform assessment tool for one of one resident (R3).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the registered nurse (RN) conducted ongoing resident monitoring and reassessment to include all areas required on the uniform assessment tool for one of one resident (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 and maintain current written medication management policies and procedures under the supervision and direction of a registered nurse (RN).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop and maintain current written medication management policies and procedures under the supervision and direction of a registered nurse (RN). [...]”

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

Summary: MDH found the licensee failed to ensure prior to

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 unlicensed personnel (ULP) were trained in the proper methods to perform the task or procedure for each resident (R) and were able to demonstrate, to the registered nurse (RN), the ability to competently follow the procedure for two of two employees (ULP-A and ULP-B). [...]”

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 [...]”

MDH’s finding, as written: “Based on observation, interview, and record review the licensee failed to ensure all medications were securely locked in substantially constructed compartments and permitted only authorized personnel to have access for all residents. [...]”

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 provide documentation in the resident's record regarding the disposition of medication to including the medication's name, strength, prescription number as applicable, quantity, to whom the medications were given, date of disposition, and names of staff and other individuals involved in the disposition for one of one discharged resident (R1).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide documentation in the resident's record regarding the disposition of medication to including the medication's name, strength, prescription number as applicable, quantity, to whom the medications were given, date of disposition, and names of staff and other individuals involved in the disposition for one of one discharged resident (R1). [...]”

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, implement, and maintain up-to-date written treatment or therapy management policies and procedures.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop, implement, and maintain up-to-date written treatment or therapy management policies and procedures. [...]”

Rule cited: “(a) An assisted living facility that provides treatment and therapy management services must develop, implement, and maintain up-to-date written treatment or therapy management policies and procedures. [...]”

Summary: MDH found the licensee failed to conduct a hazard vulnerability assessment or safety risk assessment of the physical environment with mitigation factors on and around the property for the facility.

MDH’s finding, as written: “Based on record review and interview, the licensee failed to conduct a hazard vulnerability assessment or safety risk assessment of the physical environment with mitigation factors on and around the property for the facility. This deficient practice had the ability to affect all staff, residents, and visitors. [...]”

Rule cited: “An assisted living facility with dementia care must meet the requirements of section 144G.45 and the following additional requirements: (1) an assessment of safety risks must be performed on and around the property. [...]”

Summary: MDH found the licensee failed to provide care and services according to acceptable health care, medical or nursing standards for one of one residents (R4) with hospital-style bed rails.

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 residents (R4) with hospital-style bed rails. [...]”

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.”