Plaza Gardens.
Plaza Gardens is Grade D, ranked in the bottom 35% of Minnesota memory care with 2 MDH citations on record; last inspected Mar 2025.
A large home, reviewed on public record.
Ranked against 142 Minnesota facilities.
ALF memory care · 36-month window. Higher percentile = better. Source: Minnesota Dept. of Health · Health Regulation Division.
FACILITY WATCH · BETA
Plaza Gardens has 2 citations on record. Know the moment anything changes.
New findings, complaint investigations, or status changes — emailed to you free.
Citation history, plotted month by month.
2 deficiencies on record. Each bar is a month with a citation.
Finding distribution
2 total · 36 monthsScope × Severity (CMS A–L)
Questions to ask before you visit.
A short pre-tour checklist tailored to Plaza Gardens's record and state requirements.
The most recent MDH inspection on March 19, 2025 found zero deficiencies — can you walk us through the written policies and staff training protocols that support your dementia care program under Minnesota Statutes chapter 144G?
Ask the operator on tour. Take notes and compare answers across facilities you visit.
Two complaints were filed with the Minnesota Department of Health during the inspection period on file — were either of those complaints substantiated, and what documentation can you share about how the facility responded?
Ask the operator on tour. Take notes and compare answers across facilities you visit.
With 80 licensed beds and an Assisted Living Facility with Dementia Care designation, how does Plaza Gardens document that residents' care plans address the specific needs of individuals with dementia, and can families review examples of those care plan sections on a tour?
Ask the operator on tour. Take notes and compare answers across facilities you visit.
Every MDH visit, verbatim.
3 inspections in the public record, most recent first. Click any row to expand — cited rows open automatically.
2025-03-31Complaint Investigation1 · Substantiated Finding
Plain-language summary
A Minnesota Department of Health complaint investigation substantiated that the facility neglected a resident with dementia, fall history, and mobility limitations by failing to supervise or educate family members about safe care practices. Staff allowed the resident to be transported out of the secure memory care area by a family member and left unsupervised in another resident's room, where the resident fell into a hospital bed and died from head trauma. The facility knew the resident required mechanical lift assistance for mobility, had a documented fall history, and was supposed to receive scheduled safety checks and service interventions throughout the day.
“MDH substantiated maltreatment or licensing violation finding”
Full inspector notes
Finding: Substantiated, facility responsibility Nature of Investigation: The Minnesota Department of Health investigated an allegation of maltreatment, in accordance with the Minnesota Reporting of Maltreatment of Vulnerable Adults Act, Minn. Stat. 626.557, and to evaluate compliance with applicable licensing standards for the provider type. Initial Investigation Allegation(s): The facility neglected the resident when the facility failed to provide supervision, interventions or education to prevent the resident’s fall that resulted in death. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was substantiated. The facility was responsible for the maltreatment. The facility had knowledge of the resident’s fall history. The resident’s spouse had diagnoses of dementia, falls and required a Hoyer (mechanical lift) for mobility. The resident’s spouse was unable to provide any type of assistance to the resident. The facility staff would often see family transport the resident from a specialized care area to another area of the facility where significantly less staff supervision was present. The facility failed to provide education or interventions to prevent the resident from being left unsupervised. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted law enforcement. The investigation included review of the resident record(s), death record, hospital records, pharmacy records, facility internal investigation, facility incident reports, personnel files, staff schedules, law enforcement report, 911 transcripts, related facility policy and procedures. Also, the investigator observed facility staff provide direct cares. The resident resided in an assisted living facility. The resident’s diagnoses included dementia, tremors and muscle weakness. The resident’s service plan included medication management, assistance with meal escorts, dressing, toileting, safety checks, ambulation and transfers with a mechanical lift (device used to transfer residents unable to stand or transfer themselves). The resident’s assessment indicated the resident had cognitive impairment, was impulsive, chair bound, required staff assistance for mobility and was unable to use a call pendant to alert staff of needs. The residents record indicated the resident received blood thinning medication daily and had a history of falls. The resident moved from the facility’s secured memory care to a smaller specialized care area due to impulsiveness and the resident’s fall history. The specialized area was separated from the rest of the facility by a closed door and located on the third floor of the building. The specialized area included five apartments grouped close together with common living and dining space to ensure closer observation of residents by facility staff. The residents scheduled services record indicated the resident had services scheduled nearly every hour throughout the day and every two-hour safety checks at night. A completed service record indicated a meal escort back to the resident’s room and a toileting assist scheduled for 6:00 p.m. and 6:30 p.m. respectively, were signed off by unlicensed staff at 6:20 p.m. the evening of the incident. The resident was not present in the specialized care area at the time unlicensed staff signed off evening tasks. A time stamped video indicated a family member signed in to the facility at 5:25 p.m. and signed out of the facility at 6:10 p.m. While at the facility, the family member transferred the resident out of the specialized care area and to a spouse’s room located in another area of the facility on the third floor. The resident was left unsupervised when the family member left the facility. The resident’s progress notes indicated it was routine for family members to take the resident out of the specialized area to visit a spouse. Progress notes indicated the family member left the facility a short time after arrival and left the resident in the spouse’s room. Progress notes indicated unlicensed staff were scheduled to administer the resident’s evening medications and were unable to locate the resident. Several unlicensed staff searched the building, opened the spouse’s room door, saw a dark room but did not see the resident, and continued searching the rest of the building. Unlicensed staff phoned a family member and were informed the resident was left in the spouse’s room next to the spouse’s bed in her wheelchair. Unlicensed staff returned to the spouse’s room, turned on lights and located the resident face down in the springs of a hospital bed with severe injuries. Unlicensed staff notified on-call triage for a medical emergency. The residents progress notes indicated an unlicensed staff had called triage on-call, reported the resident was found in a spouse’s apartment and had fallen face first into a hospital bed. The unlicensed staff reported head trauma and bleeding and were instructed to call 911. Progress notes indicated 911 was called. Law enforcement and emergency medical services arrived at the facility and life-saving measures were started until the resident’s resuscitation status was verified. The progress notes indicated unlicensed staff called triage back and reported the resident had died. The law enforcement report indicated law enforcement was notified of a resident found unconscious and breathing. The report indicated when officers arrived the resident was not breathing, and cardiopulmonary resuscitation (CPR) was started. The report indicated a short time after arrival resuscitation status was verified and CPR was stopped. The resident was declared deceased. The facility’s internal investigation indicated unlicensed staff had observed a family member wheel the resident out of the specialized area and this was not unusual. Several hours later, unlicensed staff looked for the resident to administer evening medications and were unable to locate the resident. The internal investigation indicated several staff searched the building and at one point opened the door to the spouse’s room, however, did not see the resident in the dark room. The internal investigation indicated the resident’s family had been called and were told the resident was left in the spouse’s room next to the bed. Unlicensed staff returned to the spouse’s room, turned on lights and found the resident face down on the spouse’s hospital bed with head and facial injuries. The internal investigation indicated on-call triage and emergency medical services were called to the facility and emergency care was provided, however, the resident’s code status indicated no resuscitation, and the resident passed away. During interview, unlicensed personnel stated a coworker had come to her area on the second floor and asked if she had seen the third-floor resident because it was the resident’s medication time. The unlicensed personnel told the coworker she had not seen the resident and both unlicensed personnel started looking for the resident. The unlicensed personnel asked the coworker if she had looked in the spouse’s room because it was typical for family to come in the evening and transport the resident to the spouse’s room for a visit. The coworker stated she had checked the spouse’s room and did not find the resident; however, two other unlicensed personnel made the decision to recheck the spouse’s room while other unlicensed personnel continued the building search. The unlicensed personnel stated the two staff that went to the spouse’s room found the resident on the floor with her face in the bed and bleeding. The unlicensed personnel stated on-call was notified and unlicensed personnel were directed to call 911 and 911 transferred the call to paramedics. The paramedics directed unlicensed personnel to roll the resident over on her back and start chest compressions, which she did until emergency services arrived on site and directed no resuscitation. The unlicensed personnel stated she had worked at the facility for a year and did not recall any communication or direction on the plan of care directing unlicensed personnel to check on the resident while the resident was out of the specialized care area or changes to the resident’s services related to supervision of the resident. During interview, another unlicensed personnel stated the resident resided in the specialty unit because she was a high fall risk and specialty unit residents were closely monitored. Unlicensed personnel stated the resident was dependent on staff for total care and did not have the cognitive ability to utilize a call pendant. Unlicensed personnel stated staff communicated with most other families if a resident was taken out of the specialty unit, however, communication with the resident’s family had not occurred. Unlicensed personnel stated she was assisting another resident when she saw the resident’s family member transport the resident out of the specialty unit, but did not approach them because it was the resident’s family and wasn’t concerned.
2025-03-19Annual Compliance VisitNo findings
Plain-language summary
A routine licensing inspection was conducted March 17-19, 2025 at Walker Methodist Plaza Gardens, which identified violations of Minnesota food service requirements under state statute 144G.41. The facility received state correction orders requiring documented compliance actions within a specified timeframe, and no immediate fines were assessed for this survey.
Full inspector notes
correction orders and document the actions taken to comply in the facility's records. The Department reserves the right to return to the facility at any time should the Department receive a complaint or deem it necessary to ensure the health, safety, and welfare of residents in your care. STATE CORRECTION ORDERS The enclosed State Form documents the state correction orders. MDH documents state licensing correction orders using federal software. Tag numbers are assigned to Minnesota state statutes for Assisted Living Facilities. The assigned tag number appears in the far left column entitled "ID Prefix Tag." The state statute number and the corresponding text of the state statute out of compliance are listed in the "Summary Statement of Deficiencies" column. This column also includes the findings that are in violation of the state statute after the statement, "This MN Requirement is not met as evidenced by . . ." In accordance with Minn. Stat. § 144G.31 Subd. 4, MDH may assess fines based on the level and scope of the violations; h owever, no immediate fines are assessed for this survey of your facility. DOCUMENTATION OF ACTION TO COMPLY In accordance with Minn. Stat. § 144G.30, Subd. 5(c), the licensee must document actions taken to comply with the correction orders within the time period outlined on the state form; however, plans of correction are not required to be submitted for approval. The correction order documentation should include the following: Identify how the area(s) of noncompliance was corrected related to the An equal opportunity employer. Letter ID: IS7N REVISED 09/13/2021 Walker Methodist Plaza Gardens April 15, 2025 Page 2 resident(s)/employee(s) identified in the correction order. Identify how the area(s) of noncompliance was corrected for all of the provider’s resident(s)/employees that may be affected by the noncompliance. Identify what changes to your systems and practices were made to ensure compliance with the specific statute(s). CORRECTION ORDER RECONSIDERATION PROCESS In accordance with Minn. Stat. § 144G.32, Subd. 2, you may challenge the correction order(s) issued, including the level and scope, and any fine assessed through the correction order reconsideration process. The request for reconsideration must be in writing and received by MDH within 15 calendar days of the correction order receipt date. To submit a reconsideration request, please visit: https://forms.web.health.state.mn.us/form/HRDAppealsForm The MDH Health Regulation Division (HRD) values your feedback about your experience during the survey and/or investigation process. Please fill out this anonymous provider feedback questionnaire at your convenience at this link: h ttps://forms.office.com/g/Bm5uQEpHVa. Your input is important to us and will enable MDH to improve its processes and communication with providers. If you have any questions regarding the questionnaire, please contact Susan Winkelmann at susan.winkelmann@state.mn.us or call 651-201-5952. You are encouraged to retain this document for your records. It is your responsibility to share the information contained in the letter and state form with your organization’s Governing Body. If you have any questions, please contact me. Sincerely, Kelly Thorson, Supervisor State Evaluation Team Email: Kelly.Thorson@state.mn.us Telephone: 320-223-7336 Fax: 1-866-890-9290 HHH PRINTED: 04/15/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 32216 03/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 100 MONROE STREET WALKER METHODIST PLAZA GARDENS ANOKA, MN 55303 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 000 Initial Comments 0 000 ASSISTED LIVING PROVIDER LICENSING Minnesota Department of Health is CORRECTION ORDER(S) documenting the State Licensing Correction Orders using federal software. In accordance with Minnesota Statutes, section Tag numbers have been assigned to 144G.08 to 144G.95, these correction orders are Minnesota State Statutes for Assisted issued pursuant to a survey. Living License Providers. The assigned tag number appears in the far left column Determination of whether violations are corrected entitled "ID Prefix Tag." The state Statute requires compliance with all requirements number and the corresponding text of the provided at the Statute number indicated below. state Statute out of compliance is listed in When Minnesota Statute contains several items, the "Summary Statement of Deficiencies" failure to comply with any of the items will be column. This column also includes the considered lack of compliance. findings which are in violation of the state requirement after the statement, "This INITIAL COMMENTS: Minnesota requirement is not met as evidenced by." Following the surveyors' SL32216016 findings is the Time Period for Correction. On March 17, 2025, through March 19, 2025, the PLEASE DISREGARD THE HEADING OF survey at the above provider. At the time of the STATES,"PROVIDER'S PLAN OF survey, there were 66 resident(s); 61 receiving CORRECTION." THIS APPLIES TO services under the Assisted Living Facility with FEDERAL DEFICIENCIES ONLY. THIS Dementia Care license. WILL APPEAR ON EACH PAGE. THERE IS NO REQUIREMENT TO SUBMIT A PLAN OF CORRECTION FOR VIOLATIONS OF MINNESOTA STATE STATUTES. The letter in the left column is used for tracking purposes and reflects the scope and level issued pursuant to 144G.31 subd. 1, 2, and 3. 0 480 144G.41 Subdivision 1 Subd. 1a (a-b) Minimum 0 480 SS=F requirements; required food services (a) Except as provided in paragraph (b), food LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 A9P211 If continuation sheet 1 of 10 PRINTED: 04/15/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 32216 03/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 100 MONROE STREET WALKER METHODIST PLAZA GARDENS ANOKA, MN 55303 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 480 Continued From page 1 0 480 must be prepared and served according to the Minnesota Food Code, Minnesota Rules, chapter 4626. (b) For an assisted living facility with a licensed capacity of ten or fewer residents: (1) notwithstanding Minnesota Rules, part 4626.0033, item A, the facility may share a certified food protection manager (CFPM) with one other facility located within a 60-mile radius and under common management provided the CFPM is present at each facility frequently enough to effectively administer, manage, and supervise each facility's food service operation; (2) notwithstanding Minnesota Rules, part 4626.0545, item A, kick plates that are not removable or cannot be rotated open are allowed unless the facility has been issued repeated correction orders for violations of Minnesota Rules, part 4626.1565 or 4626.1570; (3) notwithstanding Minnesota Rules, part 4626.0685, item A, the facility is not required to provide integral drainboards, utensil racks, or tables large enough to accommodate soiled and clean items that may accumulate during hours of operation provided soiled items do not contaminate clean items, surfaces, or food, and clean equipment and dishes are air dried in a manner that prevents contamination before storage; (4) notwithstanding Minnesota Rules, part 4626.1070, item A, the facility is not required to install a dedicated handwashing sink in its existing kitchen provided it designates one well of a two-compartment sink for use only as a handwashing sink; (5) notwithstanding Minnesota Rules, parts 4626.1325, 4626.1335, and 4626.1360, item A, existing floor, wall, and ceiling finishes are allowed provided the facility keeps them clean STATE FORM 6899 A9P211 If continuation sheet 2 of 10 PRINTED: 04/15/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 32216 03/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 100 MONROE STREET WALKER METHODIST PLAZA GARDENS ANOKA, MN 55303 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 480 Continued From page 2 0 480 and in good condition; (6) notwithstanding Minnesota Rules, part 4626.
2024-11-27Complaint Investigation1 · Substantiated Finding
Plain-language summary
A complaint investigation found that the facility failed to administer a blood thinner medication (Eliquis) as prescribed to a resident, with the resident missing at least ten doses due to medication supply issues and delays in reordering. Approximately two weeks after the medication lapses began, the resident developed throat pain and coughing up blood, and died at the facility; the death record indicated the cause was pulmonary embolism. The Minnesota Department of Health substantiated neglect and determined the facility was responsible for the maltreatment.
“MDH substantiated maltreatment or licensing violation finding”
Full inspector notes
Finding:(cid:3)Substantiated,(cid:3)facility(cid:3)responsibility(cid:3) (cid:3) (cid:3) Nature(cid:3)of(cid:3)Investigation:(cid:3) The(cid:3)Minnesota(cid:3)Department(cid:3)of(cid:3)Health(cid:3)investigated(cid:3)an(cid:3)allegation(cid:3)of(cid:3)maltreatment,(cid:3)in(cid:3)accordance(cid:3) with(cid:3)the(cid:3)Minnesota(cid:3)Reporting(cid:3)of(cid:3)Maltreatment(cid:3)of(cid:3)Vulnerable(cid:3)Adults(cid:3)Act,(cid:3)Minn.(cid:3)Stat.(cid:3)626.557,(cid:3) and(cid:3)to(cid:3)evaluate(cid:3)compliance(cid:3)with(cid:3)applicable(cid:3)licensing(cid:3)standards(cid:3)for(cid:3)the(cid:3)provider(cid:3)type.(cid:3) (cid:3) Initial(cid:3)Investigation(cid:3)Allegation(s):(cid:3) The(cid:3)facility(cid:3)neglected(cid:3)the(cid:3)resident(cid:3)when(cid:3)the(cid:3)facility(cid:3)failed(cid:3)to(cid:3)administer(cid:3)blood(cid:3)thinner(cid:3) medication(cid:3)as(cid:3)prescribed.(cid:3)Approximately(cid:3)two(cid:3)weeks(cid:3)later(cid:3)the(cid:3)resident(cid:3)experienced(cid:3)a(cid:3)medical(cid:3) emergency(cid:3)and(cid:3)died.(cid:3)(cid:3) (cid:3) Investigative(cid:3)Findings(cid:3)and(cid:3)Conclusion:(cid:3) The(cid:3)Minnesota(cid:3)Department(cid:3)of(cid:3)Health(cid:3)determined(cid:3)neglect(cid:3)was(cid:3)substantiated.(cid:3)The(cid:3)facility(cid:3)was(cid:3) responsible(cid:3)for(cid:3)the(cid:3)maltreatment.(cid:3)The(cid:3)facility(cid:3)failed(cid:3)to(cid:3)ensure(cid:3)the(cid:3)residents(cid:3)Eliquis(cid:3)(blood(cid:3) thinner(cid:3)used(cid:3)to(cid:3)prevent(cid:3)blood(cid:3)clots)(cid:3)was(cid:3)administered(cid:3)as(cid:3)ordered.(cid:3)The(cid:3)resident(cid:3)was(cid:3) experiencing(cid:3)throat(cid:3)pain(cid:3)and(cid:3)coughing(cid:3)up(cid:3)blood(cid:3)for(cid:3)approximately(cid:3)seven(cid:3)days(cid:3)prior(cid:3)to(cid:3)the(cid:3) resident’s(cid:3)death(cid:3)at(cid:3)the(cid:3)facility.(cid:3)The(cid:3)resident’s(cid:3)death(cid:3)record(cid:3)indicated(cid:3)the(cid:3)cause(cid:3)of(cid:3)death(cid:3)was(cid:3) pulmonary(cid:3)embolism.(cid:3)(cid:3)(cid:3) (cid:3) The(cid:3)investigator(cid:3)conducted(cid:3)interviews(cid:3)with(cid:3)facility(cid:3)staff(cid:3)members,(cid:3)including(cid:3)administrative(cid:3) staff,(cid:3)nursing(cid:3)staff,(cid:3)and(cid:3)unlicensed(cid:3)staff.(cid:3)The(cid:3)investigator(cid:3)contacted(cid:3)a(cid:3)provider(cid:3)that(cid:3)cared(cid:3)for(cid:3) (cid:3) Page(cid:3)2(cid:3)of(cid:3)4(cid:3) the(cid:3)resident.(cid:3)The(cid:3)investigation(cid:3)included(cid:3)review(cid:3)of(cid:3)the(cid:3)resident’s(cid:3)medical(cid:3)records,(cid:3)death(cid:3)record,(cid:3) facility(cid:3)internal(cid:3)investigation,(cid:3)facility(cid:3)incident(cid:3)reports,(cid:3)personnel(cid:3)files,(cid:3)staff(cid:3)schedules,(cid:3)and(cid:3) related(cid:3)facility(cid:3)policy(cid:3)and(cid:3)procedures.(cid:3)Also,(cid:3)the(cid:3)investigator(cid:3)observed(cid:3)staff(cid:3)administering(cid:3) resident(cid:3)medications.(cid:3)(cid:3) (cid:3) The(cid:3)resident(cid:3)resided(cid:3)in(cid:3)an(cid:3)assisted(cid:3)living(cid:3)facility.(cid:3)The(cid:3)resident’s(cid:3)diagnoses(cid:3)included(cid:3)blood(cid:3)clots(cid:3) of(cid:3)the(cid:3)lungs,(cid:3)chronic(cid:3)nerve(cid:3)cell(cid:3)break(cid:3)down(cid:3)disorder,(cid:3)and(cid:3)falls.(cid:3)The(cid:3)resident’s(cid:3)service(cid:3)plan(cid:3) included(cid:3)assistance(cid:3)with(cid:3)medication(cid:3)management(cid:3)and(cid:3)safety(cid:3)checks.(cid:3)The(cid:3)resident’s(cid:3)assessment(cid:3) indicated(cid:3)the(cid:3)resident(cid:3)had(cid:3)difficulty(cid:3)with(cid:3)communication(cid:3)and(cid:3)required(cid:3)patience(cid:3)with(cid:3)staff(cid:3)to(cid:3) allow(cid:3)slow,(cid:3)clear(cid:3)conversation(cid:3)and(cid:3)make(cid:3)needs(cid:3)known.(cid:3)(cid:3) (cid:3) Review(cid:3)of(cid:3)the(cid:3)medication(cid:3)administration(cid:3)record(cid:3)indicated(cid:3)the(cid:3)resident(cid:3)was(cid:3)prescribed(cid:3)Eliquis(cid:3) twice(cid:3)per(cid:3)day.(cid:3)Per(cid:3)documentation(cid:3)during(cid:3)the(cid:3)time(cid:3)in(cid:3)question,(cid:3)the(cid:3)resident(cid:3)missed(cid:3)ten(cid:3)doses(cid:3)of(cid:3) blood(cid:3)thinner(cid:3)medication(cid:3)due(cid:3)to(cid:3)the(cid:3)medication(cid:3)not(cid:3)being(cid:3)available(cid:3)and(cid:3)awaiting(cid:3)medication(cid:3) delivery.(cid:3) (cid:3) Written(cid:3)correspondence(cid:3)with(cid:3)facility(cid:3)leadership(cid:3)indicated(cid:3)four(cid:3)doses(cid:3)of(cid:3)blood(cid:3)thinner(cid:3)were(cid:3) documented(cid:3)in(cid:3)the(cid:3)resident’s(cid:3)medication(cid:3)administration(cid:3)record(cid:3)as(cid:3)given(cid:3)after(cid:3)staff(cid:3)documented(cid:3) the(cid:3)resident(cid:3)had(cid:3)no(cid:3)Eliquis(cid:3)to(cid:3)administer(cid:3)and(cid:3)prior(cid:3)to(cid:3)when(cid:3)a(cid:3)new(cid:3)supply(cid:3)of(cid:3)Eliquis(cid:3)was(cid:3) available(cid:3)at(cid:3)the(cid:3)facility.(cid:3)Facility(cid:3)leadership(cid:3)could(cid:3)not(cid:3)confirm(cid:3)or(cid:3)deny(cid:3)if(cid:3)the(cid:3)four(cid:3)doses(cid:3)of(cid:3)Eliquis(cid:3) were(cid:3)administered(cid:3)or(cid:3)documented(cid:3)incorrectly.(cid:3)(cid:3) (cid:3) Review(cid:3)of(cid:3)progress(cid:3)notes(cid:3)indicated(cid:3)a(cid:3)nurse(cid:3)attempted(cid:3)to(cid:3)reorder(cid:3)the(cid:3)residents(cid:3)Eliquis(cid:3)from(cid:3)the(cid:3) pharmacy(cid:3)five(cid:3)days(cid:3)after(cid:3)the(cid:3)Eliquis(cid:3)was(cid:3)first(cid:3)noted(cid:3)as(cid:3)not(cid:3)available.(cid:3)(cid:3) (cid:3) Additional(cid:3)progress(cid:3)notes(cid:3)indicated(cid:3)eleven(cid:3)days(cid:3)later(cid:3)the(cid:3)resident(cid:3)began(cid:3)to(cid:3)experience(cid:3)throat(cid:3) pain(cid:3)and(cid:3)coughing(cid:3)up(cid:3)blood.(cid:3)Two(cid:3)additional(cid:3)days(cid:3)later,(cid:3)the(cid:3)resident(cid:3)had(cid:3)a(cid:3)medical(cid:3)event(cid:3)and(cid:3) died(cid:3)at(cid:3)the(cid:3)facility.(cid:3) (cid:3) Review(cid:3)of(cid:3)emergency(cid:3)room(cid:3)records(cid:3)indicated(cid:3)seven(cid:3)days(cid:3)before(cid:3)the(cid:3)resident(cid:3)died,(cid:3)she(cid:3)went(cid:3)to(cid:3) the(cid:3)hospital(cid:3)due(cid:3)to(cid:3)chest(cid:3)pain(cid:3)and(cid:3)was(cid:3)checked(cid:3)for(cid:3)heart(cid:3)related(cid:3)issues.(cid:3)Emergency(cid:3)room(cid:3)notes(cid:3) also(cid:3)indicated(cid:3)the(cid:3)resident(cid:3)had(cid:3)a(cid:3)sore(cid:3)throat,(cid:3)difficulty(cid:3)swallowing,(cid:3)and(cid:3)fatigue.(cid:3)Notes(cid:3)indicated(cid:3) due(cid:3)to(cid:3)Huntington’s(cid:3)disease;(cid:3)the(cid:3)resident’s(cid:3)speech(cid:3)was(cid:3)somewhat(cid:3)difficult(cid:3)to(cid:3)interpret.(cid:3)Chest(cid:3)X(cid:882) rays,(cid:3)lab(cid:3)tests,(cid:3)and(cid:3)heart(cid:3)rhythm(cid:3)check(cid:3)were(cid:3)completed,(cid:3)and(cid:3)the(cid:3)resident(cid:3)was(cid:3)discharged(cid:3)back(cid:3) to(cid:3)the(cid:3)facility(cid:3)later(cid:3)that(cid:3)day.(cid:3)(cid:3) (cid:3) The(cid:3)Emergency(cid:3)room(cid:3)records(cid:3)contained(cid:3)no(cid:3)information(cid:3)related(cid:3)to(cid:3)the(cid:3)residents(cid:3)missed(cid:3)Eliquis.(cid:3)(cid:3) (cid:3) The(cid:3)resident’s(cid:3)facility(cid:3)medical(cid:3)record(cid:3)contained(cid:3)no(cid:3)information(cid:3)regarding(cid:3)the(cid:3)resident(cid:3)being(cid:3) sent(cid:3)to(cid:3)the(cid:3)emergency(cid:3)room.(cid:3) (cid:3) (cid:3) Page(cid:3)3(cid:3)of(cid:3)4(cid:3) During(cid:3)interview,(cid:3)a(cid:3)nurse(cid:3)stated(cid:3)she(cid:3)was(cid:3)on(cid:3)vacation(cid:3)when(cid:3)the(cid:3)facility(cid:3)transitioned(cid:3)pharmacy(cid:3) providers.(cid:3)The(cid:3)nurse(cid:3)stated(cid:3)when(cid:3)she(cid:3)returned(cid:3)to(cid:3)work(cid:3)and(cid:3)reviewed(cid:3)medication(cid:3) administration(cid:3)reports,(cid:3)many(cid:3)residents’(cid:3)medications(cid:3)were(cid:3)missed(cid:3)due(cid:3)to(cid:3)medication(cid:3)supply(cid:3)not(cid:3) being(cid:3)available.(cid:3)The(cid:3)nurse(cid:3)stated(cid:3)the(cid:3)resident(cid:3)missed(cid:3)ten(cid:3)doses(cid:3)of(cid:3)Eliquis(cid:3)over(cid:3)a(cid:3)five(cid:882)day(cid:3)period.(cid:3) The(cid:3)nurse(cid:3)reordered(cid:3)the(cid:3)resident’s(cid:3)medications(cid:3)and(cid:3)communicated(cid:3)the(cid:3)issue(cid:3)to(cid:3)leadership.(cid:3) (cid:3) During(cid:3)interview,(cid:3)a(cid:3)leadership(cid:3)member(cid:3)stated(cid:3)while(cid:3)on(cid:3)the(cid:3)elevator,(cid:3)a(cid:3)nurse(cid:3)informed(cid:3)her(cid:3)a(cid:3) staff(cid:3)member(cid:3)called(cid:3)for(cid:3)assistance(cid:3)because(cid:3)the(cid:3)resident(cid:3)reported(cid:3)throat(cid:3)pain(cid:3)and(cid:3)blood(cid:3)was(cid:3) coming(cid:3)out(cid:3)of(cid:3)the(cid:3)resident’s(cid:3)mouth.(cid:3)The(cid:3)leadership(cid:3)member(cid:3)stated(cid:3)she(cid:3)and(cid:3)the(cid:3)nurse(cid:3)went(cid:3)to(cid:3) the(cid:3)resident.(cid:3)The(cid:3)resident(cid:3)was(cid:3)slumped(cid:3)forward(cid:3)in(cid:3)her(cid:3)wheelchair(cid:3)and(cid:3)a(cid:3)pool(cid:3)of(cid:3)blood(cid:3)was(cid:3)on(cid:3) the(cid:3)floor.(cid:3)The(cid:3)resident(cid:3)was(cid:3)transferred(cid:3)to(cid:3)her(cid:3)bed,(cid:3)and(cid:3)911(cid:3)was(cid:3)called.(cid:3)(cid:3)The(cid:3)resident(cid:3)was(cid:3) deceased(cid:3)when(cid:3)paramedics(cid:3)arrived.(cid:3)(cid:3) (cid:3) During(cid:3)interview,(cid:3)another(cid:3)nurse(cid:3)stated(cid:3)the(cid:3)day(cid:3)of(cid:3)the(cid:3)resident’s(cid:3)medical(cid:3)event(cid:3)the(cid:3)resident(cid:3) could(cid:3)not(cid:3)stop(cid:3)vomiting(cid:3)brown(cid:3)colored(cid:3)liquid.(cid:3)The(cid:3)resident(cid:3)lost(cid:3)consciousness(cid:3)and(cid:3)died.(cid:3)(cid:3) (cid:3) During(cid:3)interview,(cid:3)a(cid:3)medical(cid:3)provider(cid:3)indicated(cid:3)the(cid:3)resident(cid:3)was(cid:3)prescribed(cid:3)Eliquis(cid:3)due(cid:3)to(cid:3)a(cid:3) history(cid:3)of(cid:3)blood(cid:3)clots(cid:3)to(cid:3)the(cid:3)lungs.(cid:3) (cid:3) In(cid:3)conclusion,(cid:3)the(cid:3)Minnesota(cid:3)Department(cid:3)of(cid:3)Health(cid:3)determined(cid:3)neglect(cid:3)was(cid:3)substantiated.(cid:3)(cid:3) (cid:3) Substantiated:(cid:3)(cid:3)Minnesota(cid:3)Statutes,(cid:3)section(cid:3)626.5572,(cid:3)Subdivision(cid:3)19.(cid:3)(cid:3)(cid:3) “Substantiated”(cid:3)means(cid:3)a(cid:3)preponderance(cid:3)of(cid:3)evidence(cid:3)shows(cid:3)that(cid:3)an(cid:3)act(cid:3)that(cid:3)meets(cid:3)the(cid:3) definition(cid:3)of(cid:3)maltreatment(cid:3)occurred.(cid:3)(cid:3)(cid:3) (cid:3) (cid:3) Neglect:(cid:3)Minnesota(cid:3)Statutes,(cid:3)section(cid:3)626.5572,(cid:3)subdivision(cid:3)17(cid:3)(cid:3) “Neglect”(cid:3)means(cid:3)neglect(cid:3)by(cid:3)a(cid:3)caregiver(cid:3)or(cid:3)self(cid:882)neglect.(cid:3) (a)(cid:3)"Caregiver(cid:3)neglect"(cid:3)means(cid:3)the(cid:3)failure(cid:3)or(cid:3)omission(cid:3)by(cid:3)a(cid:3)caregiver(cid:3)to(cid:3)supply(cid:3)a(cid:3)vulnerable(cid:3)adult(cid:3) with(cid:3)care(cid:3)or(cid:3)services,(cid:3)including(cid:3)but(cid:3)not(cid:3)limited(cid:3)to,(cid:3)food,(cid:3)clothing,(cid:3)shelter,(cid:3)health(cid:3)care,(cid:3)or(cid:3) supervision(cid:3)which(cid:3)is:(cid:3) (1)(cid:3)reasonable(cid:3)and(cid:3)necessary(cid:3)to(cid:3)obtain(cid:3)or(cid:3)maintain(cid:3)the(cid:3)vulnerable(cid:3)adult's(cid:3)physical(cid:3)or(cid:3)mental(cid:3) health(cid:3)or(cid:3)safety,(cid:3)considering(cid:3)the(cid:3)physical(cid:3)and(cid:3)mental(cid:3)capacity(cid:3)or(cid:3)dysfunction(cid:3)of(cid:3)the(cid:3)vulnerable(cid:3) adult;(cid:3)and(cid:3) (2)(cid:3)which(cid:3)is(cid:3)not(cid:3)the(cid:3)result(cid:3)of(cid:3)an(cid:3)accident(cid:3)or(cid:3)therapeutic(cid:3)conduct.(cid:3) (cid:3) Vulnerable(cid:3)Adult(cid:3)interviewed:(cid:3)No,(cid:3)resident(cid:3)is(cid:3)deceased.(cid:3) Family/Responsible(cid:3)Party(cid:3)interviewed:(cid:3)Yes.(cid:3) Alleged(cid:3)Perpetrator(cid:3)interviewed:(cid:3)Not(cid:3)Applicable.(cid:3) (cid:3) Action(cid:3)taken(cid:3)by(cid:3)facility:(cid:3)(cid:3) Facility(cid:3)conducted(cid:3)an(cid:3)internal(cid:3)investigation(cid:3)of(cid:3)the(cid:3)incident(cid:3)and(cid:3)updated(cid:3)policies(cid:3)and(cid:3) procedures.(cid:3) Page(cid:3)4(cid:3)of(cid:3)4(cid:3) (cid:3) Action(cid:3)taken(cid:3)by(cid:3)the(cid:3)Minnesota(cid:3)Department(cid:3)of(cid:3)Health:(cid:3)(cid:3) The(cid:3)facility(cid:3)was(cid:3)found(cid:3)to(cid:3)be(cid:3)in(cid:3)noncompliance.(cid:3)To(cid:3)view(cid:3)a(cid:3)copy(cid:3)of(cid:3)the(cid:3)Statement(cid:3)of(cid:3)Deficiencies(cid:3) and/or(cid:3)correction(cid:3)orders,(cid:3)please(cid:3)visit:(cid:3)(cid:3) (cid:3)(cid:3) https://www.health.state.mn.us/facilities/regulation/directory/provcompselect.html (cid:3)(cid:3) If(cid:3)you(cid:3)are(cid:3)viewing(cid:3)this(cid:3)report(cid:3)on(cid:3)the(cid:3)MDH(cid:3)website,(cid:3)please(cid:3)see(cid:3)the(cid:3)attached(cid:3)Statement(cid:3)of(cid:3) Deficiencies.(cid:3)(cid:3) (cid:3)(cid:3) You(cid:3)may(cid:3)also(cid:3)call(cid:3)651(cid:882)201(cid:882)4200(cid:3)to(cid:3)receive(cid:3)a(cid:3)copy(cid:3)via(cid:3)mail(cid:3)or(cid:3)email(cid:3) (cid:3) The(cid:3)responsible(cid:3)party(cid:3)will(cid:3)be(cid:3)notified(cid:3)of(cid:3)their(cid:3)right(cid:3)to(cid:3)appeal(cid:3)the(cid:3)maltreatment(cid:3)finding.(cid:3)If(cid:3)the(cid:3) maltreatment(cid:3)is(cid:3)substantiated(cid:3)against(cid:3)an(cid:3)identified(cid:3)employee,(cid:3)this(cid:3)report(cid:3)will(cid:3)be(cid:3)submitted(cid:3)to(cid:3) the(cid:3)nurse(cid:3)aide(cid:3)registry(cid:3)for(cid:3)possible(cid:3)inclusion(cid:3)of(cid:3)the(cid:3)finding(cid:3)on(cid:3)the(cid:3)abuse(cid:3)registry(cid:3)and/or(cid:3)to(cid:3)the(cid:3) Minnesota(cid:3)Department(cid:3)of(cid:3)Human(cid:3)Services(cid:3)for(cid:3)possible(cid:3)disqualification(cid:3)in(cid:3)accordance(cid:3)with(cid:3)the(cid:3) provisions(cid:3)of(cid:3)the(cid:3)background(cid:3)study(cid:3)requirements(cid:3)under(cid:3)Minnesota(cid:3)245C.(cid:3) (cid:3) (cid:3) (cid:3) cc:(cid:3) (cid:3) (cid:3)(cid:3)(cid:3)The(cid:3)Office(cid:3)of(cid:3)Ombudsman(cid:3)for(cid:3)Long(cid:3)Term(cid:3)Care(cid:3) (cid:3) (cid:3)(cid:3)(cid:3)The(cid:3)Office(cid:3)of(cid:3)Ombudsman(cid:3)for(cid:3)Mental(cid:3)Health(cid:3)and(cid:3)Developmental(cid:3)Disabilities(cid:3) (cid:3) (cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)Anoka(cid:3)County(cid:3)Attorney(cid:3)(cid:3) (cid:3) Anoka(cid:3)City(cid:3)Attorney(cid:3) (cid:3) Anoka(cid:3)Police(cid:3)Department(cid:3) (cid:3) (cid:3) PRINTED: 06/06/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ R-C 32216 B. WING _____________________________ 02/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 100 MONROE STREET WALKER METHODIST PLAZA GARDENS ANOKA, MN 55303 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) {0 000} Initial Comments {0 000} On February 6, 2025, the Minnesota Department No further action required. of Health conducted a licensing order follow-up related to correction orders issued for complaint #HL322166291C/#HL322164821M and #HL322167391C. Walker Methodist Plaza Gardens was found to be in compliance with state regulations. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 9CIX12 If continuation sheet 1 of 1
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