Cornerstone Residence Senior C.

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), an unlicensed personnel (ULP), financially exploited a resident when she took the resident’s Tramadol (a narcotic pain medication) for her own use. The AP was seen on camera footage removing Tramadol from the resident’s medication box and replacing it with Tylenol. Investigative Findings and Conclusion: The Minnesota Department of Health determined financial exploitation was substantiated. The AP was responsible for the maltreatment. After being seen on camera removing Tramadol, the AP admitted to facility management that she removed the resident’s Tramadol and replaced it with Tylenol and that she had been doing so for some time. 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, facility internal investigation documentation, personnel files, staff schedules, and related facility policies and procedures. Also, the investigator observed services provided at the facility, including medication management and medication storage practices. The resident resided in an assisted living memory care unit. The resident’s diagnoses included dementia, osteoarthritis, and back pain. The resident’s service plan included assistance with medication administration. The resident’s assessment indicated she had a history of pain and required daily pain management. The facility’s internal investigation indicated that during an audit of medication boxes, a nurse noticed the resident’s Tramadol pill looked different. The nurse compared the pill to other medications and identified it was Tylenol and not Tramadol. Facility management reviewed security camera footage and observed the AP remove pills from the medication box and replace the pills with another medication taken from the stock medication drawer. The AP was observed putting the pills she removed from the medication box into her pocket. Management interviewed the AP about the security footage and the AP said, “I have a problem, it’s been going on since she started getting them, about a month later, I cannot control myself.” The AP was asked by management if she had switched out the Tramadol for Tylenol each time she worked, and the AP stated that she had. Security camera footage reviewed by the investigator showed a staff member matching the description of the AP, removing, and replacing pills from the medication cart and the narcotic medication drawer. During an interview, facility management stated they were monitoring narcotic medication storage and use in the facility and had started completing audits, when a nurse randomly checked a medication box and noticed the Tramadol didn’t look like Tramadol. After the nurse compared some medications, they realized it was a round Tylenol pill, so they began to investigate and interview people who would have had access to the medication cart. Facility management stated the AP had been a good employee and they didn’t have any previous concerns with her work or that she may have been stealing narcotics. Facility management stated when they interviewed the AP, she admitted to taking the Tramadol and switching it out with Tylenol, so they terminated her employment. During an interview, the AP admitted she had been taking the resident’s Tramadol and replacing it with Tylenol, but she was unable to put a number on how many times she had done it, saying “it was a lot.” The AP stated she had a history of substance abuse, and the Tramadol was “too easy” for her to access and she had “really bad self-control” and since it was just right there, she took the resident’s Tramadol. The AP stated she would ingest the Tramadol while working as it helped her work better and feel like she had more energy. In conclusion, the Minnesota Department of Health determined financial exploitation 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. Financial exploitation: Minnesota Statutes, section 626.5572, subdivision 9 "Financial exploitation" means: (b) In the absence of legal authority a person: (1) willfully uses, withholds, or disposes of funds or property of a vulnerable adult; (2) obtains for the actor or another the performance of services by a third person for the wrongful profit or advantage of the actor or another to the detriment of the vulnerable adult; (3) acquires possession or control of, or an interest in, funds or property of a vulnerable adult through the use of undue influence, harassment, duress, deception, or fraud; or (4) forces, compels, coerces, or entices a vulnerable adult against the vulnerable adult's will to perform services for the profit or advantage of another. Vulnerable Adult interviewed: Unable due to cognition Family/Responsible Party interviewed: Yes Alleged Perpetrator interviewed: Yes Action taken by facility: The facility identified the issue after conducting a routine audit of medication set up procedures. The facility investigated the discrespency and identified an alleged perpetrator. The facility contacted law enforcement and made a MAARC report. After conclusion of their investigation, the AP was terminated. 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. 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 Clearwater County Attorney Bagley City Attorney Bagley Police Department PRINTED: 01/30/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ C B. WING _____________________________ 30775 11/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 421 6TH STREET NE CORNERSTONE RESIDENCE SNR CARE BAGLEY, MN 56621 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 ******ATTENTION****** Minnesota Department of Health is documenting the State Correction Orders ASSISTED LIVING PROVIDER CORRECTION using federal software. Tag numbers have ORDER been assigned to Minnesota State Statutes for Assisted Living Facilities. The In accordance with Minnesota Statutes, section assigned tag number appears in the far 144G.08 to 144G.95, these correction orders are left column entitled "ID Prefix Tag." The issued pursuant to a complaint investigation. state Statute number and the corresponding text of the state Statute out Determination of whether a violation is corrected of compliance is listed in the "Summary requires compliance with all requirements Statement of Deficiencies" column. This provided at the statute number indicated below. column also includes the findings which When a Minnesota Statute contains several are in violation of the state requirement items, failure to comply with any of the items will after the statement, "This Minnesota be considered lack of compliance. requirement is not met as evidenced by." Following the evaluators ' findings is the INITIAL COMMENTS: Time Period for Correction. HL307756762M/ HL307751288C PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On November 27, 2024, the Minnesota STATES,"PROVIDER'S PLAN OF Department of Health conducted a complaint CORRECTION." THIS APPLIES TO investigation at the above provider, and the FEDERAL DEFICIENCIES ONLY. THIS following correction order is issued. At the time of WILL APPEAR ON EACH PAGE. the complaint investigation, there were 26 residents receiving services under the provider's THERE IS NO REQUIREMENT TO Assisted Living with Dementia Care license. SUBMIT A PLAN OF CORRECTION FOR VIOLATIONS OF MINNESOTA STATE The following correction order is issued for STATUTES. HL307756762M/ HL307751288C, tag identification 2360. THE LETTER IN THE LEFT COLUMN IS USED FOR TRACKING PURPOSES AND REFLECTS THE SCOPE AND LEVEL ISSUED PURSUANT TO 144G.31 SUBDIVISION 1-3. 02360 144G.91 Subd.