Hayden Grove Senior Living.

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." Following the evaluators' findings is the #HL369135022C Time Period for Correction. On March 12, 2024, the Minnesota Department of PLEASE DISREGARD THE HEADING OF Health conducted a complaint investigation at the THE FOURTH COLUMN WHICH above provider, and the following correction order STATES,"PROVIDER'S PLAN OF is issued. At the time of the complaint CORRECTION." THIS APPLIES TO investigation, there were 123 residents receiving FEDERAL DEFICIENCIES ONLY. THIS services under the provider's Assisted Living with WILL APPEAR ON EACH PAGE. Dementia Care license. THERE IS NO REQUIREMENT TO The following correction order is issued for SUBMIT A PLAN OF CORRECTION FOR #HL369135022C, tag identification 470. 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 SUBDIVISION 1-3. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 7OM211 If continuation sheet 1 of 9 PRINTED: 04/02/2024 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 B. WING _____________________________ 36913 03/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 8715 PORTLAND AVENUE SOUTH HAYDEN GROVE SENIOR LIVING BLOOMINGTON, MN 55420 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) 0 470 Continued From page 1 0 470 0 470 144G.41 Subdivision 1 Minimum requirements 0 470 SS=F (11) develop and implement a staffing plan for determining its staffing level that: (i) includes an evaluation, to be conducted at least twice a year, of the appropriateness of staffing levels in the facility; (ii) ensures sufficient staffing at all times to meet the scheduled and reasonably foreseeable unscheduled needs of each resident as required by the residents' assessments and service plans on a 24-hour per day basis; and (iii) ensures that the facility can respond promptly and effectively to individual resident emergencies and to emergency, life safety, and disaster situations affecting staff or residents in the facility; (12) ensure that one or more persons are available 24 hours per day, seven days per week, who are responsible for responding to the requests of residents for assistance with health or safety needs. Such persons must be: (i) awake; (ii) located in the same building, in an attached building, or on a contiguous campus with the facility in order to respond within a reasonable amount of time; (iii) capable of communicating with residents; (iv) capable of providing or summoning the appropriate assistance; and (v) capable of following directions; This MN Requirement is not met as evidenced by: Based on observation, interview and record review, the licensee failed to ensure they had sufficient staff to meet the scheduled needs of all residents who resided in the licensee's facility. During the overnight (NOC) shift from 10:00 p.m. until 6:00 a.m., the facility was routinely short-staffed and staffed unlicensed personnel STATE FORM 6899 7OM211 If continuation sheet 2 of 9 PRINTED: 04/02/2024 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 B. WING _____________________________ 36913 03/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 8715 PORTLAND AVENUE SOUTH HAYDEN GROVE SENIOR LIVING BLOOMINGTON, MN 55420 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) 0 470 Continued From page 2 0 470 (ULP) who were assigned light duty and unable to assist with transfers. The licensee utilized the local fire department to provide lift assistance for residents who had falls during the overnight shift. This had the potential to affect all 123 residents. This practice resulted in a level two violation (a violation that did not harm a resident's health or safety but had the potential to have harmed a resident's health or safety, but was not likely to cause 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 residents). The findings include: Minnesota Rule 4659.0180, Subpart 5, indicates a minimum of two direct-care staff must be scheduled and available to assist at all times whenever a resident requires the assistance of two direct-care staff for scheduled and reasonably foreseeable and unscheduled needs, as reflected in the resident's assessments and service plans. The licensee's Uniform Disclosure of Assisted Living Services & Amenities (UDALSA) indicated the licensee staffed four unlicensed personnel (ULP) during the overnight shift. In an email dated August 25, 2023, at 11:53 a.m., from a local fire department's assistant fire chief (AFC)-H to the Minnesota Department of Health (MDH), AFC-H indicated the fire department saw an increase in lift assists from the facility. AFC-H indicated, "it appears there is either not adequate staffing, not the proper lifting equipment, or it is easier to call us." STATE FORM 6899 7OM211 If continuation sheet 3 of 9 PRINTED: 04/02/2024 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 B. WING _____________________________ 36913 03/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 8715 PORTLAND AVENUE SOUTH HAYDEN GROVE SENIOR LIVING BLOOMINGTON, MN 55420 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) 0 470 Continued From page 3 0 470 Review of the local fire department's call lift assist report indicated between February 18, 2023, and March 11, 2024, the fire department responded to 29 calls from the facility requesting lift assistance for residents who fell. Review of a Minnesota Department of Health document dated January 25, 2024, at 11:39 a.m., indicated on January 1, 2024, three ULP called off during the day shifts, which left one resident (R1)'s call light unanswered for 83 minutes. On March 12, 2024, at 10:24 a.m., the state investigators entered the licensee's facility. The facility had four floors and was licensed for 166 beds. During the entrance conference on March 12, 2024, at 10:43 a.m., interim director of nursing (IDON)-A stated 123 residents resided in the facility, 18 residents in memory care and 105 residents in assisted living. IDON-A stated there were eight ULPs who worked the morning and evening shifts (6:00 a.m.-2:00 p.m., 2:00 p.m.-10:00 p.m.), in the memory care and assisted living area. IDON-A stated there was one ULP scheduled in memory care and assisted living during the overnight (NOC) shift (10:00 p.m.-6:00 a.m.), and one ULP who floated between the two areas. IDON-A stated there were 12 care suites in assisted living that housed five residents who required total cares. IDON-A stated all five residents required a mechanical sling lift with the assistance of two staff for transfers. IDON-A stated all residents in assisted living had a call pendant they pushed when they needed assistance. IDON-A stated staff monitored resident alerts from their mobile phones. IDON-A stated weekly audits were performed on response STATE FORM 6899 7OM211 If continuation sheet 4 of 9 PRINTED: 04/02/2024 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 B.

Finding: Substantiated, facility responsibility Inconclusive Nature of Visit: 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 Perpetrators (APs), facility staff, neglected Resident 1 and Resident 2 when they failed to answer call lights in a timely manner and refused to toilet Resident 1 and Resident 2. It is alleged the APs neglected Resident 1 when they refused to wear personal protective equipment (masks and gloves) when caring for the resident and moved Resident 1's call light and phone, preventing the resident access to call for staff assistance. It is also alleged the APs abused Resident 1 when they caused bruises during transfers. Investigative Findings and Conclusion: An equal opportunity employer. The Minnesota Department of Health determined neglect was substantiated for Resident 1 and Resident 2. The facility was responsible for the maltreatment of Resident 1. The facility failed to ensure staff responded to the residents call light and request with toileting assistance. Resident 1 acquired bladder infections related to the lack of staff assistance. The facility was responsible for the maltreatment of Resident 2. The facility failed to ensure staff responded to the residents call light and assist the resident with cares. Resident 2 did not receive assistance with toileting and urinated in cups related to lack of staff assistance. The facility was aware the staff did not answer call lights in a timely manner and made no system changes to ensure Resident 1 and Resident 2 were receiving the necessary care and services. The facility was aware several staff (identified as APs by first name only, seen on residents’ apartment videos) would not provide residents assistance with services that were not in the resident’s service plan (such as unscheduled toileting). The facility was aware staff told residents the facility would charge them more money for extra services. In addition, the facility would not require staff to wear personal protective equipment in Resident 1’s room, which was ordered by a physician. The Minnesota Department of Health determined abuse was inconclusive. Resident 1 had fragile skin due to advanced age. Although Resident 1 had bruising, it could not be determined who caused the bruising or when the bruises occurred. The investigators conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted family members and reviewed video evidence. The investigation included review of incidents, personnel files, medical records, personnel files, policies, and procedures related to assessments, complaints, infection control, service plans, job responsibilities, staffing, and maltreatment of vulnerable adults. Also, the investigator observed Resident 1 and Resident 2’s rooms, as well as resident/staff interactions. Resident 1’s medical record indicated the resident had diagnoses including heart disease, osteoarthritis, advanced age-related decline in functional status, and recurrent urinary tract infections. The resident’s service plan included assistance with toileting every two hours. Resident 1 was independent with using her call light and phone, was alert and oriented, and able to make her needs known. During an interview Resident 1’s family member stated a camera placed in the resident’s apartment captured multiple staff (including AP1) denying Resident 1’s request to use the toilet, often telling the resident, “It’s not time”. The family member stated Resident 1 had several urinary tract infections, and she observed on video many times the resident activating her call light to request staff assistance and staff would not respond to the residents call light for hours. The family member stated she notified the administrator and nurse she observed on video staff moving Resident 1’s call light and phone out of her reach. During an interview, a nurse stated there had been a change in management and the facility was aware of the long call light response times. The nurse stated she felt the facility staffing was adequate. During investigative interviews, multiple staff members stated they went out of their way to not work with Resident 1 (switching assignments or changing shifts) because they did not want to interact with the family. Several staff stated if they were busy, they would acknowledge resident 1’s call light on their phone so the call light would stop beeping, but they did not go to Resident 1’s room to provide the resident with assistance. Staff stated the call light system alerted all staff working. Two staff stated they did not wear masks in Resident 1’s apartment because they were tired of masking since the pandemic and thought it was not needed. A review of four months of Resident 1’s call light logs indicated there were 82 instances of staff response times of greater than one hour. Resident 2’s medical record indicated the resident moved into the facility due to limited mobility. The resident was non ambulatory and a high fall risk. Resident 2 required assistance with toileting every two to three hours, and as needed. Resident 2 required assistance from 1 to 2 staff with transfers, toileting, dressing, and getting to and from meals and activities. Resident 2 was independent with using her the call light, telephone, and was able to communicate and make her needs known. During an observation the investigator observed multiple plastic cups stacked in Resident 2’s apartment. Two of the cups were full of urine, and the linen was soiled. Resident 2’s apartment smelled of urine. During interview, Resident 2 stated she used the cups to urinate in when the staff did not respond to the call light. Resident 2 stated she had waited up to six hours for staff to respond to a call light. Resident 2 stated her skin got sore from sitting in soiled briefs and sometimes she pinched her skin when using the plastic cup between her legs to urinate. Resident 2 stated earlier that day, staff did not come until 9:00 a.m. so she missed breakfast with peers which made her feel lonely. Resident 2 stated she was also late to a morning activity. Resident 2 stated “I’m scared, I want to run away but I don’t know where to go.” During interview, Resident 2’s family member stated they placed four cameras in the resident’s apartment and captured the lack of staff response. The family member stated the video confirmed the resident missed meals and activities when staff did not arrive for scheduled service. The video showed slow to no response when Resident 2 pushed her call light. The family member observed video of a staff who told Resident 2 she would not help her to the toilet because the last time she did not go. The family heard Resident 2 on the video state “I really have to go”. Family stated Resident 2 called 911 twice for help when staff did not respond. Once when staff left Resident 2 on the toilet and did not return to assist the resident when she was finished. Another time the resident called 911 was when no staff came to assist Resident 2 with her scheduled morning care. The family member stated Resident 2 missed breakfast and lunch while she laid in a wet bed and called 911 for assistance. The family member stated Resident 2 did not want to go on, she had lost hope, and did not trust the facility would provide needed services. During an interview, a nurse acknowledged the excessive call light wait times and stated it’s been a long term and repetitive problem. The nurse stated the facility was working on incentives with staff to improve the wait time and the customer service. During investigative interviews, multiple staff members stated Resident 2’s call light frequently went unanswered for long periods of time. Staff members acknowledged silencing the call light alerts and allowing Resident 2 to urinate in cups rather than provide the services agreed upon. A review of five months of Resident 2’s call light logs confirmed there were 42 instances of response times greater than one hour. In conclusion neglect is substantiated and abuse is inconclusive. 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.