Round Lake Senior Living.

Finding: Substantiated, individual 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 alleged perpetrator (AP) neglected the resident when the AP failed to supervise the resident per the resident’s care plan during a shower and the resident fell. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was substantiated. The AP was responsible for the maltreatment. The AP failed to provide stand by assistance during the resident’s shower per the resident’s service plan and the resident fell. The AP failed to report the incident to a nurse and failed to follow facility protocol after the resident fell. The resident complained of back pain for a few days after the fall. He was sent to the hospital and diagnosed with a spinal fracture. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted the resident’s family. The investigation included review of resident records, hospital records, facility internal investigation, facility incident reports, personnel files, staff schedules, and related facility policy and procedures. Also, the investigator toured the facility and observed staff members assisting with resident cares. The resident resided in an assisted living facility. The resident’s diagnoses included osteoporosis and frequent falls. The resident’s service plan included standby assist of one staff during bathing. The resident’s assessment indicated the resident had moderate cognitive impairment and was at risk for falls. The nursing assessment indicated the resident was at risk for falls and had a prior fall while at the facility resulting in an injury that caused bleeding in his brain. The resident’s service delivery record indicated the AP provide standby bathing assistance the evening of the incident. The internal investigation indicated while the AP assisted the resident with a shower, the AP stepped away to get more towels and the resident fell. The AP’s interview summary in the internal investigation indicated the resident fell when the AP stepped away to get towels. The AP reported he assisted the resident up. The AP failed to follow the proper procedure after a fall and failed to report the fall. Multiple family members were interviewed for the internal investigation, they reported the resident told them the AP stepped away while assisting him with a shower. The resident fell off the shower chair and landed on his bottom. The resident said the AP assisted him up and the family was not notified. The resident’s progress notes indicated the resident’s back was “hurting very badly from his fall. ” A member of management spoke with a family member who reported the resident told the family member he fell and had significant pain in his back. The family member made an appointment for the resident to be assessed by his primary care provider, but the resident refused the appointment. The following day the facility sent the resident to the hospital for continued pain and increased confusion. The resident went to a transitional care unit for two weeks following the injury. The resident’s hospital record indicated he was sent to the hospital two days after a fall while getting out of the shower. He was diagnosed with a fracture in his spine. During an interview, a member of management said the AP reported he left the resident alone in the shower to get towels and the resident fell. He assisted the resident off the floor and failed to report the fall to anyone. The resident’s family member reported the resident complained of pain and reported he fell in the shower. The resident identified the AP as the staff assisting him during the incident. The resident was sent to the hospital where he was diagnosed with a fracture in his back. He stayed at a transitional care unit for two weeks before returning to the facility. During an interview, the nurse said the AP left the resident unattended in the bathroom while removing towels and the resident fell. The resident reported the AP received a phone call and he left the area. The AP was trained to stay with the resident when a resident’s service plan indicated stand by assist. The AP failed to report the fall to a nurse and failed to follow the protocol after a resident fell. During an interview, a family member said the resident reported he fell in the shower. The resident was able to identify the AP who assisted him with his shower. The resident said the AP received a phone call and left the bathroom, then the resident fell. The resident complained of pain and was sent to the hospital a few days later. At the hospital, the resident was diagnosed with a spinal fracture. He was sent to a transitional care unit for a couple weeks and then returned to the facility. During an interview, the AP said he assisted the resident with a shower. While he was removing the wet towels, he heard the shower chair move. The AP turned around and the resident was standing up. He denied witnessing the resident fall. The AP said he was unable to remember details of the incident including what he reported to management about the incident during the internal investigation. The facility’s falls policy indicated after a resident fall; the staff member must notify a nurse before moving a resident. A post fall procedure with specific steps based on evaluation must be followed after a fall to ensure the resident’s health and safety. The daily schedule indicated a second staff member was assigned to the assisted living unit on the evening of the incident and available to the AP to call for assistance. The AP’s training record indicated the AP received training on resident falls multiple times before the incident. In conclusion, the Minnesota Department of Health determined neglect was substantiated. Substantiated: Minnesota Statutes, section 626.5572, Subdivision 19. “Substantiated” means a preponderance of evidence shows that an act that meets the definition of maltreatment occurred. Neglect: Minnesota Statutes, section 626.5572, subdivision 17 “Neglect” means neglect by a caregiver or self-neglect. (a) "Caregiver neglect" means the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to, food, clothing, shelter, health care, or supervision which is: (1) reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult; and (2) which is not the result of an accident or therapeutic conduct. Mitigating Factors considered, Minnesota Statutes, section 626.557, Subd. 9c(f): (1) The AP did not follow an erroneous order, direction or care plan with awareness and failure to take action. The facility did not direct an erroneous order, direction, or care plan. (2) The facility was in compliance with regulatory standards. The facility provided proper training and/or supervision of staff. The facility provided adequate staffing levels. The AP failed to follow the facility directive and/or policies and procedures. (3) The AP failed to follow professional standards and/or exercise professional judgement. The AP failed to act in good faith interest of the vulnerable adult. The maltreatment was not a sudden or foreseen event. Vulnerable Adult interviewed: Yes. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Yes. Action taken by facility: The facility completed an internal investigation and sent the resident to the hospital. Action taken by the Minnesota Department of Health: The facility was issued a correction order regarding the vulnerable adult’s right to be free from maltreatment. To view a copy of the Statement of Deficiencies and/or correction orders, please visit: https://www.health.state.mn.us/facilities/regulation/directory/provcompselect.html You may also call 651-201-4200 to receive a copy via mail or email. The responsible party will be notified of their right to appeal the maltreatment finding. If the maltreatment is substantiated against an identified employee, this report will be submitted to the nurse aide registry for possible inclusion of the finding on the abuse registry and/or to the Minnesota Department of Human Services for possible disqualification in accordance with the provisions of the background study requirements under Minnesota 245C.

Finding: Substantiated, facility responsibility, Individual responsibility changed to Inconclusive. 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 and the alleged perpetrator (AP), a facility nurse, neglected the resident when they failed to follow proper facility process and procedure and did not contact emergency medical services (EMS) after the resident was found unresponsive. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was substantiated. The facility and the AP was responsible for the maltreatment. Facility policies and procedures were not followed by licensed and unlicensed staff. Upon discovering the resident unresponsive, facility staff failed to immediately notify emergency medical services for assistance and failed to initiate cardiopulmonary resuscitation (CPR) on the resident who was a full code status. The investigator conducted interviews with facility staff members, including administrative staff and nursing staff. The investigation included review of the resident record, death record, facility internal investigation documentation, personnel files, staff schedules, and facility policies and procedures. The investigator also spoke with a law enforcement officer. The investigator toured the facility, observed staff interacting with residents and completing scheduled care activities at the time of the onsite visit. The resident resided in an assisted living facility. The resident’s diagnoses included heart failure, heart disease, and renal failure. The resident’s service plan included assistance with activities of daily living, housekeeping, meal reminders, transfer assistance, prosthetic care, and safety checks. The resident’s assessment indicated that the resident’s code status (type of emergent treatment a person would or would not receive if their heart or breathing were to stop) was indicated as full code (all resuscitative and aggressive curative treatments are provided). The resident’s assessment indicated the resident was cognitively intact and able to communicate his needs. During a scheduled nighttime check around 12:50 a.m., unlicensed person (ULP) found the resident unresponsive in his bed. ULP called the on-call registered nurse (RN) and the executive director for guidance, and the nurse instructed ULP to not contact emergency medical services (EMS). The ULPs and the RN did not review the resident’s code status at the time the resident was found unresponsive. Instead, the resident’s family was contacted and informed that the resident was found deceased. The family arrived at the facility approximately three hours later and when they asked staff about the process for after life care, they were told they needed to contact a funeral home to make arrangements. The family contacted the funeral home who directed them to contact EMS to report the resident’s death. EMS arrived at the facility a short time later and pronounced the resident deceased. During an interview, the facility administrator stated that all employees received training on proper procedures and protocols involved in response to a resident death and could access the policy and procedure database for reference at any time. The administrator confirmed staff did not follow procedures, as the resident was a full code status and emergency services should have been contacted after the resident was found unresponsive. During an interview, the alleged perpetrator (AP), a registered nurse (RN), who was on call the night of the incident, could not recall specifics of the incident. The AP/RN did not recall being given specific information relating to the resident’s condition, vital signs, or events leading up to the discovery of the resident. The AP/RN verified she failed to follow facility protocol relating to an unexpected death at the facility when she instructed ULP to not immediately call 911. During an interview, the ULP who first found the resident stated she entered the room approximately four hours after the resident’s last service was recorded. She immediately called the nurse for direction and was told to not notify 911. Later, a second ULP called the nurse for clarification and was told not to notify 911 but to contact the family. During an interview, the second ULP who assisted when the resident was found unresponsive, stated she initially called the facility administrator for direction on how to proceed and was told to call 911. However, upon hearing the information given to the first ULP by the on-call nurse, she contacted the nurse for clarification and was informed to notify the family and not to call 911. During an interview with a family member, they stated they were informed by staff that the resident was found deceased. After the family arrived at the facility, staff told them to contact the funeral home to report the resident’s death. The funeral home told the family to call 911. Facility staff told the family they could not make the call to 911, so the family had to contact 911 to report the resident’s death. In conclusion, the Minnesota Department of Health determined neglect was substantiated. Substantiated: Minnesota Statutes, section 626.5572, Subdivision 19. “Substantiated” means a preponderance of evidence shows that an act that meets the definition of maltreatment occurred. Neglect: Minnesota Statutes, section 626.5572, subdivision 17 “Neglect” means neglect by a caregiver or self-neglect. (a) "Caregiver neglect" means the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to, food, clothing, shelter, health care, or supervision which is: (1) reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult; and (2) which is not the result of an accident or therapeutic conduct. Vulnerable Adult interviewed: No Family/Responsible Party interviewed: Yes Alleged Perpetrator interviewed: Yes the Action taken by facility: The facility conducted an internal investigation. Facility staff members received additional training on emergency process and procedures. Action taken by the Minnesota Department of Health: The facility was found to be in noncompliance. To view a copy of the Statement of Deficiencies and/or correction orders, please visit: https://www.health.state.mn.us/facilities/regulation/directory/provcompselect.html If you are viewing this report on the MDH website, please see the attached Statement of Deficiencies. You may also call 651-201-4200 to receive a copy via mail or email The responsible party will be notified of their right to appeal the maltreatment finding. If the maltreatment is substantiated against an identified employee, this report will be submitted to the nurse aide registry for possible inclusion of the finding on the abuse registry and/or to the Minnesota Department of Human Services for possible disqualification in accordance with the provisions of the background study requirements under Minnesota 245C. cc: The Office of Ombudsman for Long Term Care The Office of Ombudsman for Mental Health and Developmental Disabilities Ramsey County Attorney Arden Hills City Attorney Ramsey County Sherriff Department Arden Hills Police Department Minnesota Board of Nursing Medical Examiner PRINTED: 11/04/2024 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ C 39081 B. WING _____________________________ 08/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1740 PARKSHORE DRIVE ROUND LAKE SENIOR LIVING ARDEN HILLS, MN 55112 (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 ******ATTENTION****** Assisted Living Provider 144G. ASSISTED LIVING PROVIDER CORRECTION Minnesota Department of Health is ORDER documenting the State Correction Orders using federal software. Tag numbers have In accordance with Minnesota Statutes, section been assigned to Minnesota State 144G.08 to 144G.95, these correction orders are Statutes for Assisted Living Facilities. The issued pursuant to a complaint investigation. assigned tag number appears in the far-left column entitled "ID Prefix Tag." The Determination of whether a violation is corrected state Statute number and the requires compliance with all requirements corresponding text of the state Statute out provided at the statute number indicated below. of compliance is listed in the "Summary When a Minnesota Statute contains several Statement of Deficiencies" column. This items, failure to comply with any of the items will column also includes the findings which be considered lack of compliance. are in violation of the state requirement after the statement, "This Minnesota INITIAL COMMENTS: requirement is not met as evidenced by.

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 resident fell and laid on the apartment floor for multiple days before being found by staff. The resident sustained multiple injuries and required hospitalization. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was substantiated. The facility was responsible for the maltreatment. The facility failed to complete safety checks when the resident did not push a button indicating he was okay each day. The resident laid on the floor of his apartment for multiple days before being found. Due to prolonged time laying in the same position, the resident endured multiple permanent debilitating injuries. The investigator conducted interviews with facility staff members, including administrative staff and unlicensed staff. The investigator contacted law enforcement and the resident’s family. The investigation included review of the resident’s medical record and contract, policies including An equal opportunity employer. vulnerable adult, as well as fall risk and prevention. The investigation also included review of the resident’s hospital record and the law enforcement report. Also, the investigator observed staff interactions with residents, cares, and transfers. The resident resided in an assisted living facility. The resident’s diagnoses included Parkinson’s disease. The resident was a housing only resident and had an assisted living contract. The resident’s individual abuse prevention plan (IAPP) indicated the resident walked safely. The resident’s assisted living contract for independent (housing only) residents included a description of the daily safety check program and the resident’s decision to opt in. The daily safety check program description indicated participating residents were expected to push a button in their bathroom between the hours of 6:00 a.m. and 10:00 a.m. every morning. After 10:00 a.m., a staff member would call residents who did not push the button. The staff member would contact the resident’s responsible party if the resident did not answer the phone. The staff member would also go to the resident’s apartment if needed to make sure they were okay. The daily safety check reports were sent each day to the licensed assisted living director (LALD), the assistant LALD, the front desk staff and the director of nursing (DON). The daily safety check document indicated the resident pressed the button to complete the daily safety check on morning. The next two days, the resident did not respond to the safety check by pressing the button. No staff completed a safety check on the resident over those two days. The third day, the resident again failed to respond to the safety check by pressing the button. A facility internal investigation indicated on the third day with no response from the resident, two management staff noticed a collection of newspapers at the front desk that belonged to the resident. At 12:00 p.m., the two managers went to the resident’s apartment to check on him. They found the resident laying on his bedroom floor and called 911. A law enforcement report indicated two facility staff members found the resident laying on the floor at the foot of his bed, on his right side. The resident appeared to have vomit or drool pooled around his mouth. The resident also defecated and urinated on himself. The resident appeared to have a swollen right eye and various bruises on his arms and legs. Emergency medical services (EMS) transported the resident to the hospital. The resident’s hospital record indicated the resident remained in the hospital for 33 days. The resident presented with several pressure wounds to both knees, abdomen, right elbow, right shoulder, right cheek, and right hip. In the emergency department (ED), the resident noted numbness in his right hand. The fourth and fifth fingers on the right hand showed evidence of reduced blood flow which physicians suspected was from prolonged pressure from laying on it. The resident’s admitting diagnoses included a fall with rhabdomyolysis (a serious medical condition that can be fatal or result in permanent disability which occurs when damaged muscle tissue releases its proteins and electrolytes into the blood). During the hospitalization, the resident could not walk and required total assistance for bed mobility and transfers. The resident also aspirated (accidentally inhaling food or liquid into the airway) and choked, leading to a transfer to the intensive care unit (ICU) and a feeding tube was placed. Hospital staff also treated the resident for sepsis (an infection in the blood stream), acute respiratory failure, thrombocytopenia (blood clotting), and acute kidney injury (when the kidneys suddenly become unable to filter waste products from the blood). These records indicated a very low likelihood the resident would return to his prior baseline. The resident discharged from the hospital to a skilled nursing facility’s transitional care unit with various orders including a dietary order of nothing by mouth (NPO) with continuous tube feeding, wound care, and physical, occupational, and speech therapy to evaluate and treat. During an interview, management staff-1 stated at noon every day, a report would be sent to a couple of management staff and the front desk. The front desk staff were responsible for following up, including calling, or going to the apartment to check on the resident. After this incident, the facility changed the daily safety check program process. The change included ensuring all management received the daily report, the facility switched systems and management staff-1 said she personally completed a daily audit of the report. During an interview, management staff-2 stated at the time of this incident, the LALD, assistant LALD, and the DON were responsible for following up on the daily safety check report. Management staff-2 stated she noticed the resident had not come down for dinner for a couple of days, and his newspapers had been piling up. After asking other staff if they had seen the resident and being told no, management staff-2 gathered the newspapers and walked to the resident’s apartment with another management staff member. Management staff-2 found the resident on the floor, laying on his right side. The resident looked pale and had vomit, urine and feces on him. Management staff-2 notified the DON and provided a capful of ginger ale per the resident’s request while waiting for EMS to arrive. During an interview, a family member stated prior to the fall, the resident had tremors on his left side but could do things for himself including driving to the grocery store. Since the fall, the resident had mostly been bedridden, and he had needed help getting into and propelling a wheelchair. The resident developed nerve damage on his right side and could no longer use his right hand and foot from laying on the right side of his body after the fall. The resident also could no longer swallow, and the hospital placed a feeding tube for nutrition. The family member also stated the resident has been to the hospital about five times since the initial hospitalization due to continued issues from the fall like swallowing problems causing pneumonia and multiple urinary tract infections. The family member stated they thought the resident’s inability to recover from the fall was due to being left on the floor for multiple days without food, water, or his medications. During the investigation, the family member sent an email informing the investigator the resident passed away. In conclusion, the Minnesota Department of Health determined neglect was substantiated. Substantiated: Minnesota Statutes, section 626.5572, Subdivision 19. “Substantiated” means a preponderance of evidence shows that an act that meets the definition of maltreatment occurred. Neglect: Minnesota Statutes, section 626.5572, subdivision 17 “Neglect” means neglect by a caregiver or self-neglect. (a) "Caregiver neglect" means the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to, food, clothing, shelter, health care, or supervision which is: (1) reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult; and (2) which is not the result of an accident or therapeutic conduct. Vulnerable Adult interviewed: No; deceased. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Not Applicable.