Woodcrest Assisted Living

Summary: MDH found the licensee failed to develop an individual abuse prevention plan with the required content for two of two residents (R1, R2) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to develop an individual abuse prevention plan with the required content for two of two residents (R1, R2) with records reviewed. [...]”

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 have a written emergency preparedness plan with all the required content and post an emergency preparedness plan prominently.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to have a written emergency preparedness plan with all the required content and post an emergency preparedness plan prominently. This had the potential to affect all seven residents receiving services under the assisted living with dementia care 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 provide smoke alarms in some of the resident's bedrooms.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to provide smoke alarms in some of the resident's bedrooms. In addition, the facility failed to provide smoke alarms that were interconnected in some resident's bedrooms and in a basement bedroom. 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 facility 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 physical environment in a continuous state of good repair and operation regarding the health, safety, and well-being of the residents. This deficient condition had the ability to affect a limited number of residents. [...]”

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 fire safety training and evacuation plans for residents and staff.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to provide the required fire safety training and evacuation plans for residents and staff. This has 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 ensure all facility physical elements, including, the minimum size egress windows on the second-floor resident room, do not create a distinct hazard to residents and staff.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to ensure all facility physical elements, including, the minimum size egress windows on the second-floor resident room, do not create a distinct hazard to residents and staff. This affected resident room #5. [...]”

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 ensure employees received orientation to 144G licensing requirements for two of two employees (unlicensed personnel (ULP)-C and clinical nurse supervisor (CNS)-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)-C and clinical nurse supervisor (CNS)-B) with employee records reviewed. This had potential to affect all seven residents. [...]”

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 develop and maintain current written medication management policies and procedures that were developed 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 that were developed 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 develop and maintain a current individualized medication management record for each resident to include all required content for two of two residents (R1, R2) 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 medication management record for each resident to include all required content for two of two residents (R1, R2) 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. [...]”

MDH’s finding, as written: “Based on observation, interview and record review, the license failed to ensure documentation of medication setup was completed at the time of setup and included all the required content for two of two residents (R1, R2) 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 develop, implement, and maintain up-to-date written treatment or therapy management policies and procedures that were developed under the supervision and direction of a registered nurse (RN) consistent with current practice standards and guidelines, with records reviewed.

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 that were developed under the supervision and direction of a registered nurse (RN) consistent with current practice standards and guidelines, with records reviewed. [...]”

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 develop an individual treatment management plan to include all required content for one of two residents (R1) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to develop an individual treatment management plan to include all required content for one of two residents (R1) 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 conduct a hazard vulnerability or safety risk assessment on or around the facility property.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to conduct a hazard vulnerability or safety risk assessment on or around the facility property. This had the potential to directly affect all residents, staff, and visitors. [...]”

Rule cited: “An assisted living facility with dementia care that has a secured dementia care unit must meet the requirements of section 144G.45 and the following additional requirements: (1) a hazard vulnerability assessment or safety risk must be performed on and around [...]”

Summary: MDH found the licensee failed to ensure policies and procedures required in the licensing of assisted living facilities with dementia care were developed and/or implemented.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure policies and procedures required in the licensing of assisted living facilities with dementia care were developed and/or implemented. [...]”

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 storage of 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 storage of oxygen. This had the potential to affect all seven residents and staff. [...]”

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 comply with the requirement of immediately reporting suspected maltreatment of a vulnerable adult to the Minnesota Adult Abuse Reporting Center (MAARC) for one of one resident (R2) reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to comply with the requirement of immediately reporting suspected maltreatment of a vulnerable adult to the Minnesota Adult Abuse Reporting Center (MAARC) for one of one resident (R2) reviewed. R2 left the facility and was returned by law enforcement. The licensee was aware of the incident but did not file a MAARC report. [...]”

Rule cited: “(a) A mandated reporter who has reason to believe that a vulnerable adult is being or has been maltreated, or who has knowledge that a vulnerable adult has sustained a physical injury which is not reasonably explained shall immediately report the information [...]”