Woodlake Residences

Summary: MDH found the licensee failed to provide documentation in the resident's record regarding the disposition of medication to include the medication strength, prescription number, quantity, date of disposition, and names of staff and other individuals involved in the disposition for one of two discharged residents (R16) with records reviewed.

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 include the medication strength, prescription number, quantity, date of disposition, and names of staff and other individuals involved in the disposition for one of two discharged residents (R16) 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 an individual treatment management plan to include

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 one resident (R18) with record 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 treatments or therapies were documented accurately in the medical record for one of one resident (R18) with record reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure treatments or therapies were documented accurately in the medical record for one of one resident (R18) with record reviewed. [...]”

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 an individual abuse prevention plan (IAPP) was developed to include the required content for six of six residents (R1, R2, R3, R5, R6, R7) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure an individual abuse prevention plan (IAPP) was developed to include the required content for six of six residents (R1, R2, R3, R5, R6, R7) 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 maintain a tuberculosis (TB) prevention and control program based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to maintain a tuberculosis (TB) prevention and control program based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC). The licensee failed to provide TB training for two of three employees (registered nurse (RN)-A and unlicensed personnel (ULP)-B) with employee records reviewed. [...]”

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 develop a written plan of action to facilitate the management of the resident's care and services in response to a natural disaster, such as storms or other emergencies that may disrupt the licensee's ability to provide care and services.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop a written plan of action to facilitate the management of the resident's care and services in response to a natural disaster, such as storms or other emergencies that may disrupt the licensee's ability to provide care and services. In addition, the licensee failed to develop an all-hazards emergency preparedness program and plan to include Appendix Z required elements. [...]”

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 [...]”

MDH’s finding, as written: “Based on interview and record review the licensee failed to complete a discharge summary for one of one discharged resident (R4) with record reviewed. 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 [...]”

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 in all the bedrooms of apartments and ensure smoke alarms are interconnected so that the actuation of one alarm causes all alarms in the dwelling to actuate as required.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to provide smoke alarms in all the bedrooms of apartments and ensure smoke alarms are interconnected so that the actuation of one alarm causes all alarms in the dwelling to actuate as required. 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'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 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 the assisted living contract did not include language waiving the facility's liability for health, safety, or personal property of a resident for six of six residents (R1, R2, R3, R5, R6, R7) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the assisted living contract did not include language waiving the facility's liability for health, safety, or personal property of a resident for six of six residents (R1, R2, R3, R5, R6, R7) with records reviewed. [...]”

Rule cited: “The contract must not include a waiver of facility liability for the health and safety or personal property of a resident. [...]”

Summary: MDH found the licensee failed to ensure training was completed in all required areas for one of two employees (unlicensed personnel (ULP)-B) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure training was completed in all required areas for one of two employees (unlicensed personnel (ULP)-B) with records reviewed. [...]”

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 was completed for one of two employees (unlicensed personnel (ULP)-B) to include all required content with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure training and competency was completed for one of two employees (unlicensed personnel (ULP)-B) to include all required content with records reviewed. [...]”

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 employees received orientation to 144G licensing requirements for three of three employees (registered nurse (RN)-A, unlicensed personnel (ULP)-B and ULP-F) 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 three of three employees (registered nurse (RN)-A, unlicensed personnel (ULP)-B and ULP-F) with employee records reviewed. This had the potential to affect all fifty-four (54) residents receiving services. [...]”

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 three of three employees (registered nurse (RN)-A, unlicensed personnel (ULP)-B and ULP-F) received the required amount of dementia care

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure three of three employees (registered nurse (RN)-A, unlicensed personnel (ULP)-B and ULP-F) received the required amount of dementia care training in the required time frame with records reviewed. This had the potential to affect all residents. [...]”

Rule cited: “(a) All assisted living facilities must meet the following training requirements: (1) supervisors of direct-care staff must have at least eight hours of initial training on topics specified under paragraph (b) within 120 working hours of the employment start [...]”

Summary: MDH found the licensee failed to ensure the registered nurse (RN) completed a 14-day reassessment for one of three residents (R2) and ongoing resident reassessments did not exceed 90 days for three of three residents (R1, R2, R3) as required with records reviewed.

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 reassessment for one of three residents (R2) and ongoing resident reassessments did not exceed 90 days for three of three residents (R1, R2, R3) 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 the memory care was always secured per memory care service plan and agreement for two of three residents (R3, R9) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure the memory care was always secured per memory care service plan and agreement for two of three residents (R3, R9) with records reviewed. [...]”

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 ensure the registered nurse (RN) conducted a face-to-face medication management assessment, prior to providing medication management services, to include all required content for one of four residents (R9) 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, prior to providing medication management services, to include all required content for one of four residents (R9) 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 develop and maintain a current individualized medication management record for each resident to include all required content for two of two residents (R2, R3) 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 (R2, R3) 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 transcribe provider orders timely, ensure medications were administered per providers orders, and follow the process of medication administration for two of three residents (R2, R8) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to transcribe provider orders timely, ensure medications were administered per providers orders, and follow the process of medication administration for two of three residents (R2, R8) 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 prescription medications were stored according to the manufacturer's directions.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure prescription medications were stored according to the manufacturer's directions. 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 [...]”

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 time sensitive medication were labeled with the date opened or to dispose of expired medications.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to ensure time sensitive medication were labeled with the date opened or to dispose of expired medications. In addition. the licensee failed to ensure medications were maintained bearing the original prescription label with legible information for two of four residents (R2, R8) with records reviewed. [...]”

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 provide documentation in the resident's record regarding the disposition of medication to include the medication strength, prescription number, quantity, date of disposition, and names of staff and other individuals involved in the disposition for one of one discharged resident (R4) with record reviewed.

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 include the medication strength, prescription number, quantity, date of disposition, and names of staff and other individuals involved in the disposition for one of one discharged resident (R4) with record 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 an individual treatment management plan to include all required content for one of one resident (R2) 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 one resident (R2) 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 treatments or therapies were administered as prescribed, or to document the reason they were not provided to meet the resident's needs for one of one resident (R2) with supplemental oxygen monitoring managed by the provider.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure treatments or therapies were administered as prescribed, or to document the reason they were not provided to meet the resident's needs for one of one resident (R2) with supplemental oxygen monitoring managed by the provider. [...]”

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 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 the care and services were provided according to a suitable and up-to-date plan, and subject to accepted health care and medical, or nursing standards for two of three residents (R1, R2) with records

MDH’s finding, as written: “Based on observation, 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 accepted health care and medical, or nursing standards for two of three residents (R1, R2) 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.”

Summary: MDH found the licensee failed to ensure a required notice was posted at the main entry way of the facility to display statutory language to disclose electronic monitoring activity.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to ensure a required notice was posted at the main entry way of the facility to display statutory language to disclose electronic monitoring activity. This had the potential to affect all current residents, staff, and visitors to the facility. [...]”

Rule cited: “Subd. 8.Notice to visitors. (a) A facility must post a sign at each facility entrance accessible to visitors that states: "Electronic monitoring devices, including security cameras and audio devices, may be present to record persons and activities." (b) The [...]”