Cherrywood Big Lake.

findings which are in violation of the state items, failure to comply with any of the items will requirement after the statement, "This be considered lack of compliance. Minnesota requirement is not met as evidenced by." Following the surveyors' INITIAL COMMENTS: findings is the Time Period for Correction. #HL281148345M/ #HL281145532C PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On November 8, 2023, 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 orders are issued. At the time WILL APPEAR ON EACH PAGE. of the complaint investigation, there were 16 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 order is issued for STATUTES. #HL281148345M/#HL281145532C, tag identification 0620, and 2360. 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. 0 620 144G.42 Subd. 6 (a) / 626.557, Subd. 3 0 620 SS=I Compliance with requirements for reporting ma (a) The assisted living facility must comply with LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 SISD11 If continuation sheet 1 of 16 PRINTED: 01/04/2024 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 28114 B. WING _____________________________ 11/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 171 HENRY ROAD CHERRYWOOD BIG LAKE BIG LAKE, MN 55309 (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) 0 620 Continued From page 1 0 620 the requirements for the reporting of maltreatment of vulnerable adults in section 626.557. The facility must establish and implement a written procedure to ensure that all cases of suspected maltreatment are reported. The requirement in Minnesota Statute section 626.557, Subd. 3 is: (a) A mandated reporter who has reason to believe that a vulnerable adult is being or has been maltreated, or who has knowledge that a vulnerable adult has sustained a physical injury which is not reasonably explained shall immediately report the information to the common entry point. If an individual is a vulnerable adult solely because the individual is admitted to a facility, a mandated reporter is not required to report suspected maltreatment of the individual that occurred prior to admission, unless: (1) the individual was admitted to the facility from another facility and the reporter has reason to believe the vulnerable adult was maltreated in the previous facility; or (2) the reporter knows or has reason to believe that the individual is a vulnerable adult as defined in section 626.5572, subdivision 21, paragraph (a), clause (4). (b) A person not required to report under the provisions of this section may voluntarily report as described above. (c) Nothing in this section requires a report of known or suspected maltreatment, if the reporter knows or has reason to know that a report has been made to the common entry point. (d) Nothing in this section shall preclude a reporter from also reporting to a law enforcement agency. (e) A mandated reporter who knows or has STATE FORM 6899 SISD11 If continuation sheet 2 of 16 PRINTED: 01/04/2024 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 28114 B. WING _____________________________ 11/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 171 HENRY ROAD CHERRYWOOD BIG LAKE BIG LAKE, MN 55309 (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) 0 620 Continued From page 2 0 620 reason to believe that an error under section 626.5572, subdivision 17, paragraph (c), clause (5), occurred must make a report under this subdivision. If the reporter or a facility, at any time believes that an investigation by a lead investigative agency will determine or should determine that the reported error was not neglect according to the criteria under section 626.5572, subdivision 17, paragraph (c), clause (5), the reporter or facility may provide to the common entry point or directly to the lead investigative agency information explaining how the event meets the criteria under section 626.5572, subdivision 17, paragraph (c), clause (5). The lead investigative agency shall consider this information when making an initial disposition of the report under subdivision 9c. This MN Requirement is not met as evidenced by: Based on interview and record review the licensee failed to immediately report observed abuse for 1 of 1 resident, R1, reviewed for allegations of staff mistreatment. Staff observed licensed practical nurse (LPN)-A shove a t-shirt into R1's mouth to make him be quiet. Staff failed to immediately report the abuse until the following day. After the incident was reported the licensee failed to thoroughly investigate the incident or take action to protect residents. The incident was not reported to the common entry point Minnesota Adult Abuse Reporting Center (MAARC) until five days later. The staff had prior concerns regarding LPN-A's mistreatment of residents, however, the facility failed to report or investigate the allegations. This had the potential to cause harm to all 16 residents residing in the facility when LPN-A continued to have access to residents after an incident of witnessed abuse occurred. STATE FORM 6899 SISD11 If continuation sheet 3 of 16 PRINTED: 01/04/2024 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 28114 B. WING _____________________________ 11/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 171 HENRY ROAD CHERRYWOOD BIG LAKE BIG LAKE, MN 55309 (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) 0 620 Continued From page 3 0 620 This practice resulted in a level three violation (a violation that harmed a client's health or safety, not including serious injury, impairment, or death, or a violation that has the potential to lead to serious injury, impairment, or death) and was issued at a widespread scope (when problems are pervasive or represent a systemic failure that has affected or has the potential to affect a large portion or all of the clients). Findings include: R1 was admitted to the assisted living with dementia care facility on March 21, 2022, with diagnoses including hereditary ataxia (a nervous system disease affecting the central nervous system), peripheral vascular disease (narrowing of the blood vessels), persistent asthma, and weakness. R1's service/care plan dated May 29, 2023, indicated R1 was totally dependent on two staff for assistance with bed mobility, eating, toileting, dressing, personal hygiene, and used a full body Hoyer mechanical lift for transfers due to limited mobility. The care/service plan identified R1 had difficult to understand speech and would yell if he became frustrated. The care plan instructed staff to mute the resident's television and ask the resident to speak slowly. R1's Braden scale assessment dated February 27, 2023, indicated R1 had very limited mobility and was only able to make slight movements of his extremities and could only sit for a short period of time. R1's significant change assessment dated August 28, 2023, indicated R1 was able to respond to STATE FORM 6899 SISD11 If continuation sheet 4 of 16 PRINTED: 01/04/2024 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 28114 B.