April 20, 2022

Assisted Living Survey Data - First Quarter 2023

On April 20, 2023 by Bobbie Guidry

In assisted living and assisted living with dementia care licensing surveys completed in the first quarter of 2023 by the Minnesota Department of Health, the average number of survey citations is 13.85. Analyzing the survey data can help assisted living settings provide safe, quality care and avoid citations on future surveys.

Here are a few key stats:

• 95 surveys were initiated for licensed facilities, with an additional 43 initial surveys of provisional licenses and 16 change of ownership surveys conducted.
• 18 providers had “conditions” placed on their licenses based on the survey results, but no licenses were revoked.
• 30 received a level three citation with no level four citations issued.

Most common citations

The top ten cited areas, including common issues triggering the citations, are:

1. Tag 480: AL Minimum Requirements – Food Code

• Proper food storage, temping, cooling
• Equipment – not commercial grade, not holding temps
• No staff illness log
• No CFPM

2. Tag 810: Fire protection and physical environment – Evacuation drills

• No written fire and evacuation plan
• Lack of required drills
• Training records for staff and residents capable of participating
• Floor plans lacking information

3. Tag 800: Fire protection and physical environment – Environment in good repair and operation

• Annual fire alarm and detector tests
• Missing carbon monoxide alarms
• Keyed exit doors/padlocks on gates of the patio in the emergency exit area
• Snow blocking egress windows/Excess storage in egress path or near mechanical room equipment
• Unsecured chemicals

4. Tag 680: Disaster Planning and Emergency Preparedness

• Lack of emergency and disaster plan or plan missing required elements/plan not posted
• Quarterly review of the missing resident plan
• For a site with a generator – missing monthly load test

5. Tag 1620 Initial reviews, assessments, and monitoring

• Exceeding time for every 90-day requirement for assessments
• Missing the 14-day assessment after the initial
• Missing Change of Condition assessments

6. Tag 1760: Documentation of administration of medication

• Meds were given but not yet recorded on MAR
• Quantity of medication given not recorded

7. Tag 2040: Fire protection and physical environment – additional requirements for ALDC

• Missing Hazard Vulnerability Assessments or unmitigated identified hazards

8. Tag 660 Tuberculosis prevention and control

• No TB screening in accordance with requirements
• Risk assessment not current

9. Tag 2310: Appropriate care and services

• Incomplete evaluation and communication regarding siderail use or other assist devices
• Checking for correct installation according to manufacturer’s guidelines/checking for recalls

10. Tag 510: Infection Control Program

• Hand Hygiene – washing hands when changing gloves/changing gloves according to policy
• Cleanliness of medication storage areas
• Safety lid on sharps containers

Survey results can be reviewed on the MDH website with searches available by dates, facility, or location.