Windsong at Woodsedge

Summary: MDH found the licensee failed to ensure orientation to assisted living facility statutes included all the required content for two of two employees, (RN-C and ULP-D) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure orientation to assisted living facility statutes included all the required content for two of two employees, (RN-C and ULP-D) with 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 [...]”

MDH’s finding, as written: “Based on observation, interview, and record review the licensee failed to ensure the registered nurse (RN) completed a comprehensive reassessment using the uniform assessment tool on day 14 for one of one resident (R5) and on day 90 for one of three residents (R1) as required with records reviewed. [...]”

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 service plans were revised to reflect the current services provided for one of four residents (R4), with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure service plans were revised to reflect the current services provided for one of four residents (R4), with records reviewed. [...]”

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 the required content for four of four residents (R1, R3, R4, and R5) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure the service plan included the required content for four of four residents (R1, R3, R4, and R5) with records reviewed. This had the potential to affect all 21 residents who received assisted living services from the licensee. [...]”

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 [...]”

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the security and accountability of controlled substances was maintained for one of one resident (R1) with records reviewed. [...]”

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

Summary: MDH found the licensee failed to ensure the registered nurse (RN) conducted a face-to-face medication management assessment to include all required content for one of one resident (R5), prior to providing medication management services, with records reviewed.

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 assessment to include all required content for one of one resident (R5), prior to providing medication management services, with records reviewed. [...]”

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) conducted a face-to-face medication management reassessment to include all required content for three of three residents (R1, R3, and R4) with records reviewed.

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 three of three residents (R1, R3, and R4) with records reviewed. [...]”

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 plan for each resident to include all

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to develop and maintain a current individualized medication management plan for each resident to include all required content for four for four residents (R1, R3, R4 and R5) with records reviewed. [...]”

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 medications were administered according to manufacturer's instructions for one of one resident (R3) with records reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medications were administered according to manufacturer's instructions for one of one resident (R3) with records reviewed. [...]”

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 documentation of medication setup included all the required content for two of two residents (R1 and R4) with records reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure documentation of medication setup included all the required content for two of two residents (R1 and R4) with records reviewed. [...]”

Rule cited: “Documentation of dates of medication setup, name of medication, quantity of dose, times to be administered, route of administration, and name of person completing medication setup must be done at the time of setup.”

Summary: MDH found the licensee failed to ensure one of one unlicensed personnel (ULP-D) was trained and had demonstrated competency to prepare and give medications for residents having unplanned time away.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure one of one unlicensed personnel (ULP-D) was trained and had demonstrated competency to prepare and give medications for residents having unplanned time away. [...]”

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 residents were assessed for self-administration of medications for one of one resident (R5) who self-administered medications.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure residents were assessed for self-administration of medications for one of one resident (R5) who self-administered medications. [...]”

Rule cited: “When the assisted living facility is aware of any medications or dietary supplements that are being used by the resident and are not included in the assessment for medication management services, the staff must advise the registered nurse and document that in [...]”

Summary: MDH found the licensee failed to ensure the resident's record contained documentation of the disposition of medications to include the medications's name, strength, prescription number as applicable, quantity, to whom the medications were given,

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the resident's record contained documentation of the disposition of medications to include the medications's name, strength, prescription number as applicable, quantity, to whom the medications were given, date of disposition, and names of staff and other individuals in the disposition for one of one discharged resident (R6), with records reviewed. [...]”

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 and maintain a current individualized treatment and therapy management plan for each resident to include all required content for two of three residents (R4 and R5) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to develop and maintain a current individualized treatment and therapy management plan for each resident to include all required content for two of three residents (R4 and R5) with records reviewed. [...]”

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

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure prior to delegating nursing tasks, the registered nurse (RN) trained unlicensed personnel (ULP) in the proper methods to perform the task or procedure for each resident, and to ensure the ULP was able to demonstrate the ability to competently follow the procedure to perform the tasks for one of one (ULP-G), who completed wound care for R4 with records reviewed. [...]”

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 document treatment administration for one of three residents (R3) reviewed, who received treatments.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to document treatment administration for one of three residents (R3) reviewed, who received treatments. [...]”

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 the care and services were provided according to a suitable and up-to-date plan, and subject to acceptable health care and medical, or nursing standards for one of one resident with falls (R4) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the care and services were provided according to a suitable and up-to-date plan, and subject to acceptable health care and medical, or nursing standards for one of one resident with falls (R4) with records reviewed. [...]”

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.”