Arbor Lane.

Finding: 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 alleged perpetrator (AP), facility unlicensed personnel, neglected a resident when they administered as needed medications to a resident without obtaining permission from a registered nurse prior to the administration of Morphine (narcotic) and lorazepam (anti-anxiety medication.) Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was substantiated inconclusive. The AP was responsible for the maltreatment. The facility policy, staff education, and the resident’s medication administration record all directed unlicensed personnel to contact a facility nurse or on-call trigae nurse prior to administering any prn (as needed) medication. Instead of contacting the nurse, the AP dispensed Morphine (narcotic) and lorazepam to the resident. For An equal opportunity employer. the next three days following the administration of the medications, the resident experienced a decreased level of consciousness. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigation included review of resident records, hospice records, employee records, and facility policy and procedures. The resident resided in an assisted living memory care unit and received hospice nursing care. The resident’s diagnoses included Parkinson’s disease, dementia, heart disease, and heart failure. The resident’s service plan included assistance with activities of daily living and with medication management. The resident’s provider orders included Morphine 5mg (milligrams) 1 tablet every one hour as needed for pain or shortness of breath, and lorazepam 0.5mg, one tablet as needed every 1 hour for anxiety and agitation. The incident report indicated one day the resident’s family was concerned the resident was not responding appropriately to stimulation. The family questioned what medication the resident was given. After the director inquired with nursing it was determined the previous evening, the AP gave the resident as needed Morphine and lorazepam even though staff were previously instructed to provide the resident with Tylenol for agitation and pain. That evening dose of Morphine was the first time the resident received Morphine. The resident’s medication administration record indicated one day in the later afternoon the resident was given his scheduled lorazepam 0.5mg 1 tablet. The AP documented giving the resident as needed Morphine and lorazepam about four hours later. The resident’s medication administration record directed staff to contact the facility nurse or on-call triage nurse prior to the administration of any as needed medication including the Morphine and lorazepam and to first give the resident Tylenol. During an interview, the AP stated a couple of days before she administered the Morphine and the lorazepam, it was discussed in a staff meeting that the resident was increasingly agitated and had blood in his brief. The AP stated because of that conversation, the next time the resident appeared agitated, the AP decided the resident might be experiencing pain and administered the as needed Morphine and lorazepam. The AP stated she did not follow protocol which was to call the facility nurse or on-call triage nurse to get permission to give the Morphine and lorazepam prior to the administration to the resident. In addition, the AP stated she falsely documented she notified the nurse prior to the administration of the Morphine and lorazepam. During an interview the registered nurse stated during a staff meeting, there was a discussion about the resident’s increased use of the call pendant, agitation, and the possibility of pain. Staff were instructed to use non-medicine interventions or to give the resident Tylenol. The nurse stated staff are trained to notify a nurse to get permission prior to giving a resident any as needed medications. The nurse stated the AP did not contact the nurse for permission prior to giving the resident Morphine and lorazepam. In conclusion, the Minnesota Department of Health determined neglect was substantiated 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. (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, attempted resident unable to participate because of cognitive decline. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Yes. Action taken by facility: Facility staff provided the staff including the AP education on dispensing as needed medications. 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 Dakota County Attorney Burnsville City Attorney Burnsville Police Department PRINTED: 02/07/2025 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 30765 B. WING _____________________________ 06/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 13810 COMMUNITY DRIVE ARBOR LANE BURNSVILLE, MN 55337 (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 **REVISED DUE TO RECONSIDERATION Minnesota Department of Health is PROCESS** documenting the State Correction Orders using federal software. Tag numbers have been assigned to Minnesota State ******ATTENTION****** Statutes for Assisted Living Facilities. The assigned tag number appears in the far-left column entitled "ID Prefix Tag." The INITIAL COMMENTS: state Statute number and the corresponding text of the state Statute out #HL307651181C/#HL307652220M of compliance is listed in the "Summary Statement of Deficiencies" column. This On June 5, 2024, the Minnesota Department of column also includes the findings which Health conducted a complaint investigation at the are in violation of the state requirement above provider. At the time of the complaint after the statement, "This Minnesota investigation, there were 45 residents receiving requirement is not met as evidenced by." services under the provider's Assisted Living with Following the evaluators' findings is the Dementia Care license. No correction orders Time Period for Correction. were issued. PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH STATES,"PROVIDER'S PLAN OF CORRECTION." THIS APPLIES TO FEDERAL DEFICIENCIES ONLY. THIS 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 SUBDIVISION 1-3. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 UQL911 If continuation sheet 1 of 1

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 did not follow the resident’s service plan and provide scheduled safety checks or toilet the resident on the overnight shift. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was substantiated. The alleged perpetrator was responsible for the maltreatment. The alleged perpetrator documented the resident’s cares as completed but did not actually perform them on the overnight shift. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted the legal guardian. The investigation included review of resident’s service plan, assessments, services received, death record, facility internal investigation, personnel files, staff schedules, and related facility policy and procedures. Also, the investigator completed an onsite visit and reviewed video footage recording during the night of the incident. The resident resided in an assisted living memory care unit. The resident’s diagnoses included dementia, congestive heart failure, weakness, and history of falls. The resident’s service plan included assigned staff to be oriented to the plan of care for assigned residents, face to face safety checks every two hours, transfer assistance, and physical assist with toileting scheduled three times on the overnight shift. The resident was enrolled in hospice cares. The resident’s assessment indicated the resident does not know her own limitations regarding her safety and attempts to self-transfer herself. The facility incident report indicated the resident was found deceased in her apartment near the doorway by a staff member on the morning shift. The report indicated the resident was not checked on during the scheduled safety checks during the overnight shift nor was she toileted. The service delivery record indicated the alleged perpetrator, who was a unlicensed caregiver assigned to provide the resident’s cares that shift, signed off overnight tasks as completed to includes four “safety checks” at 12 a.m., 2 a.m., 4 a.m., and 6 a.m., three “toileting assist” tasks at 12 a.m., 3 a.m., and 6 a.m., along with “homemaker services” at 6 a.m. prior to ending her shift. The alleged perpetrator’s time punches indicated the alleged perpetrator punched in at 11 p.m. and punched out at 7:15 a.m. the next morning. During an interview, unlicensed caregiver #1 stated when she came on to the morning shift, she checked the resident’s service plan and went into the resident’s room to provide morning cares. Caregiver #1 stated she found the resident lying on the floor inside her apartment door, unresponsive with no pulse and not breathing. Caregiver #1 stated the pendant is usually worn as a necklace, but she found the resident’s pendant on a television stand. Caregiver #1 contacted hospice services and facility triage nurse to report incident. During an interview, a manager stated the alleged perpetrator was the primary caregiver scheduled on the unit. During an interview the alleged perpetrator, who was an unlicensed caregiver, stated she had not previously worked an overnight shift for the facility prior to this night. The alleged perpetrator stated her usual shift was the 3 p.m. to 11 p.m. where she did care for the resident on that shift. The alleged perpetrator stated care sheets were available electronically to determine cares to be rendered to the resident on a shift. The alleged perpetrator stated she relied on her co-worker, unlicensed caregiver #2, who was a medication administration floater aid on the shift who told her to not disturb the resident throughout the overnight and that the resident would use her call pendant is she needed assistance. The alleged perpetrator stated she did not toilet or check on the resident her entire shift but did sign off services that were scheduled during the overnight. During an interview, a facility nurse stated she completed the internal investigation. The nurse stated the alleged perpetrator indicated she followed directions other staff on the night shift had provided her and did not follow the service plan which was updated and what staff are taught to follow. During an interview, the resident’s guardian stated the resident slept in her electric lift recliner and not in her bed. The guardian stated the resident had recent declines in her abilities and more confused. The investigation included attempts to interview unlicensed caregiver #2 but without success. 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 provided the alleged perpetrator with verbal education ensuring they follow care plans and cannot falsify documents. Additionally, the facility reinforced this with caregivers during daily stand-up meeting by and reviewed with all staff the importance of following resident’s service plans at all times. 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 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 Dakota County Attorney Burnsville City Attorney Burnsville Police Department PRINTED: 10/11/2024 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 _____________________________ 30765 10/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 13810 COMMUNITY DRIVE ARBOR LANE BURNSVILLE, MN 55337 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 Onsite 10/1/24 Minnesota Department of Health is ******ATTENTION****** documenting the State Correction Orders using federal software. Tag numbers have ASSISTED LIVING PROVIDER CORRECTION been assigned to Minnesota State ORDER Statutes for Assisted Living Facilities. The assigned tag number appears in the far In accordance with Minnesota Statutes, section left column entitled "ID Prefix Tag." The 144G.08 to 144G.95, these correction orders are state Statute number and the issued pursuant to a complaint investigation. corresponding text of the state Statute out of compliance is listed in the "Summary Determination of whether a violation is corrected Statement of Deficiencies" column. This requires compliance with all requirements column also includes the findings which provided at the statute number indicated below. are in violation of the state requirement When a Minnesota Statute contains several after the statement, "This Minnesota items, failure to comply with any of the items will requirement is not met as evidenced by." be considered lack of compliance. Following the evaluators ' findings is the Time Period for Correction. INITIAL COMMENTS: PLEASE DISREGARD THE HEADING OF HL307657580C/#HL307655461M THE FOURTH COLUMN WHICH STATES,"PROVIDER'S PLAN OF On October 1, 2024, the Minnesota Department CORRECTION." THIS APPLIES TO of Health conducted a complaint investigation at FEDERAL DEFICIENCIES ONLY.