Cannon Falls Assisted 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) abused the resident when the AP placed an arm around the resident’s neck and a hand over the resident’s mouth. Investigative Findings and Conclusion: The Minnesota Department of Health determined abuse was substantiated. The AP was responsible for the maltreatment. The AP stated she placed her left arm across placed the resident’s chest and placed her right hand over the resident’s mouth two or three times to attempt to stop his yelling. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted the resident’s family members. The investigation included review of the resident record, death record, facility internal investigation, facility incident reports, personnel files, staff schedules, and related facility policy and procedures. Also, the investigation included an onsite visit where the investigator observed interactions between residents and facility staff. The resident resided in an assisted living memory care unit. The resident’s diagnoses included dementia, anxiety, and mood disturbance. The resident’s service plan included assistance of one with mobility and transfers. The resident’s assessment indicated the resident was forgetful and needed reorientation at times, was easily understood and was able to walk with assistance of one unlicensed caregiver using gait belt and walker. A facility internal investigation summary indicated the AP was witnessed by two unlicensed caregivers placing her arm around the resident to talk into his ear and then when the resident would not stop yelling, the AP placed her hand two times over the resident’s mouth. During an interview unlicensed caregiver #1 reported she was helping the AP provide cares to the resident, who was agitated and yelling out. The AP was attempting to talk into the resident’s ear to try to calm the resident and did place her hand over the resident’s mouth “a couple of times”. Unlicensed caregiver #1 stated she was unsure how long the AP’s hand was over the resident’s mouth but did not feel it was a long time as the resident was attempting to bite the AP’s hand. Unlicensed caregiver #1 stated she had worked with the AP for many years and had not witnessed the AP be abusive to residents, however she had noticed the AP had not been herself in the days prior to the incident and felt something may have been affecting her personally. During an interview, the nurse stated the resident had no physical injury when assessed. The nurse also stated the AP had not had any other reports of resident abuse in the past. The nurse stated during the internal investigation the AP was remorseful and stated she only wanted the resident to stop screaming. During an interview the AP stated she did place her hand over the residents mouth two to three times for approximately 5-10 seconds. She stated she was trying to get the resident’s attention by covering his mouth as he calmed after the first and second time she had placed her hand over his mouth, but the third time he did not. The AP also stated she was not thinking in the moment of the action being right or wrong, but knew it was wrong immediately after the incident. The AP stated she was experiencing health issues recently and the night had been a rough with a number of resident falls. The AP went on to state she and the resident did have a “nice conversation” after incident when the resident had calmed down. In conclusion, the Minnesota Department of Health determined abuse 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. Abuse: Minnesota Statutes section 626.5572, subdivision 2. "Abuse" means: (a) An act against a vulnerable adult that constitutes a violation of, an attempt to violate, or aiding and abetting a violation of: (1) assault in the first through fifth degrees as defined in sections 609.221 to 609.224; (2) the use of drugs to injure or facilitate crime as defined in section 609.235; (3) the solicitation, inducement, and promotion of prostitution as defined in section 609.322; and (4) criminal sexual conduct in the first through fifth degrees as defined in sections 609.342 to 609.3451. A violation includes any action that meets the elements of the crime, regardless of whether there is a criminal proceeding or conviction. (b) Conduct which is not an accident or therapeutic conduct as defined in this section, which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to, the following: (1) hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult; (2) use of repeated or malicious oral, written, or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening; Vulnerable Adult interviewed: no, resident is deceased. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Yes Action taken by facility: Facility suspended the AP, completed an internal investigation then terminated the AP. Retraining on vulnerable adult abuse completed with all facility caregivers. 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 Goodhue County Attorney Cannon Falls City Attorney Cannon Falls Police Department MN Department of Human Services PRINTED: 09/04/2024 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 B. WING _____________________________ 26730 08/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 900 MAIN STREET WEST CANNON FALLS ASSISTED LIVING CANNON FALLS, MN 55009 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****** ASSISTED LIVING PROVIDER CORRECTION ORDER In accordance with Minnesota Statutes, section 144G.08 to 144G.95, these correction orders are issued pursuant to a complaint investigation. Determination of whether a violation is corrected requires compliance with all requirements provided at the statute number indicated below. When a Minnesota Statute contains several items, failure to comply with any of the items will be considered lack of compliance. INITIAL COMMENTS: #HL267304043C/#HL267303603M On August 8, 2024, the Minnesota Department of Health conducted a complaint investigation at the above provider, and the following correction orders are issued. At the time of the complaint investigation, there were 92 residents receiving services under the provider's Assisted Living with Dementia Care license. The following correction order is issued for #HL267304043C/#HL267303603M, tag identification 2360. 02360 144G.91 Subd. 8 Freedom from maltreatment 02360 Residents have the right to be free from physical, sexual, and emotional abuse; neglect; financial exploitation; and all forms of maltreatment covered under the Vulnerable Adults Act. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 CH7911 If continuation sheet 1 of 2 PRINTED: 09/04/2024 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 B.

correction orders issued pursuant to the May 23, 2024 survey. In accordance with Minn. Stat. § 144G.31 Subd. 4 (a), state correction orders issued pursuant to the last survey, completed on May 23, 2024, found not corrected at the time of the August 15, 2024, follow-up survey and/or subject to penalty assessment are as follows: 1290 - Background Studies Required - 144g.60 Subdivision 1 - $3,000.00 The details of the violations noted at the time of this follow-up survey completed on August 15, 2024 (listed above), are on the attached State Form. Brackets around the ID Prefix Tag in the left hand column, e.g., {2 ----} will identify the uncorrected tags. Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, t he total amount you are assessed is $3,000.00. You will be invoiced approximately 30 days after receipt of this notice, subject to appeal. DOCUMENTATION OF ACTION TO COMPLY In accordance with Minn. Stat. § 144G.30, Subd. 5(c), the licensee must document actions taken to comply with the correction orders within the time period outlined on the state form; however, plans of correction are not required to be submitted for approval. IMPOSITION OF FINES: Level 1: no fines or enforcement. Level 2: a fine of $500 per violation, in addition to any enforcement mechanism authorized in §144G.20 for widespread violations; Level 3: a fine of $3,000 per violation per incident, in addition to any enforcement mechanism authorized in §144G.20. Level 4: a fine of $5,000 per incident, in addition to any enforcement mechanism authorized in An equal opportunity employer. Letter ID: 8GKP Revised 04/14/2023 Cannon Falls Assisted Living Septembe r13, 2024 Page 2 §144 G.20. CORRECTION ORDER RECONSIDERATION PROCESS In accordance with Minn. Stat. § 144G.32, Subd. 2, you may challenge the correction order(s) issued, including the level and scope, and any fine assessed through the correction order reconsideration process. The request for reconsideration must be in writing and received by MDH within 15 calendar days of the correction order receipt date. To submit a reconsideration request, please visit: https://forms.web.health.state.mn.us/form/HRDAppealsForm REQUESTING A HEARING Alternatively, in accordance with Minn. Stat. § 144G.31, Subd. 5(d), an assisted living provider that has been assessed a fine under this subdivision has a right to a reconsideration or a hearing under this section and chapter 14. Pursuant to Minn. Stat. § 144G.20, Subd. 14 and Subd. 18, a request for a hearing must be in writing and received by the Department of Health within 15 business days of the correction order receipt date. The request must contain a brief and plain statement describing each matter or issue contested and any new information you believe constitutes a defense or mitigating factor. to submit a hearing request, please visit: https://forms.web.health.state.mn.us/form/HRDAppealsForm To appeal fines via reconsideration, please follow the procedure outlined above. P lease note that you may request a reconsideration o r a hearing, but not both. If you wish to contest tags without fines in a reconsideration and tags with the fines at a hearing, please submit two separate appeals forms at the website listed above. We urge you to review these orders carefully. If you have questions, please contact Jodi Johnson at You are encouraged to retain this document for your records. It is your responsibility to share the information contained in the letter and/or state form with your organization’s Governing Body. Sincerely, Jodi Johnson, Supervisor State Evaluation Team Email: jodi.johnson@state.mn.us Telephone: 507-344-2730 Fax: 1 -866-890-9290 JMD PRINTED: 09/13/2024 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ R B. WING _____________________________ 26730 08/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 900 MAIN STREET WEST CANNON FALLS ASSISTED LIVING CANNON FALLS, MN 55009 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 ASSISTED LIVING PROVIDER LICENSING documenting the State Correction Orders CORRECTION ORDER using federal software. Tag numbers have In accordance with Minnesota Statutes, section been assigned to Minnesota State 144G.08 to 144G.95 this correction order(s) has Statutes for Assisted Living Facilities. The been issued pursuant to a survey. assigned tag number appears in the far Determination of whether a violation has been left column entitled "ID Prefix Tag." The corrected requires compliance with all state Statute number and the requirements provided at the Statute number corresponding text of the state Statute out indicated below. When Minnesota Statute of compliance is listed in the "Summary contains several items, failure to comply with any Statement of Deficiencies" column. This of the items will be considered lack of column also includes the findings which compliance. are in violation of the state requirement INITIAL COMMENTS: after the statement, "This Minnesota SL26730015-1 requirement is not met as evidenced by." Following the evaluators ' findings is the On August 12, 2024, through August 15, 2024, Time Period for Correction. the Minnesota Department of Health conducted a follow-up survey at the above provider to PLEASE DISREGARD THE HEADING OF follow-up on orders issued pursuant to a survey THE FOURTH COLUMN WHICH completed on May 23, 2024. At the time of the STATES,"PROVIDER'S PLAN OF survey, there were 92 residents; 63 receiving CORRECTION." THIS APPLIES TO services under the Assisted Living with Dementia FEDERAL DEFICIENCIES ONLY. THIS Care license. As a result of the follow-up survey, WILL APPEAR ON EACH PAGE. the following orders were reissued. 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. {01290} 144G.60 Subdivision 1 Background studies {01290} SS=I required LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 XD2112 If continuation sheet 1 of 4 PRINTED: 09/13/2024 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ R B. WING _____________________________ 26730 08/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 900 MAIN STREET WEST CANNON FALLS ASSISTED LIVING CANNON FALLS, MN 55009 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) {01290} Continued From page 1 {01290} (a) Employees, contractors, and regularly scheduled volunteers of the facility are subject to the background study required by section 144.057 and may be disqualified under chapter 245C. Nothing in this subdivision shall be construed to prohibit the facility from requiring self-disclosure of criminal conviction information. (b) Data collected under this subdivision shall be classified as private data on individuals under section 13.02, subdivision 12. (c) Termination of an employee in good faith reliance on information or records obtained under this section regarding a confirmed conviction does not subject the assisted living facility to civil liability or liability for unemployment benefits. This MN Requirement is not met as evidenced by: Based on interview and record review, the licensee failed to ensure management of NETStudy 2.0 (web-based system used to submit background study (BGS) requests to the Department of Human Services (DHS) affiliated with the licensee's health facility identification number (HFID) 26730 for one of 78 employees (clinical nurse specialist (CNS)-B). This has the potential to affect all residents residing within the facility. This practice resulted in a level three violation (a violation that harmed a resident'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 potential to affect a large portion or all of the residents). The findings include: STATE FORM 6899 XD2112 If continuation sheet 2 of 4 PRINTED: 09/13/2024 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ R B.

Finding: Not Substantiated 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 resident was neglected when the facility failed to ensure the resident received care, services, and supervision according to the resident’s plan of care. The resident fell and sustained multiple fractures, then laid on the floor for 6 hours before staff found her. The resident was transferred to the emergency department (ED) for evaluation and treatment. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. The resident had a fall and was not found for approximately 6 hours. Staff were following the resident individualized plan of care at the time of the incident. The resident received one safety check per shift and was seen earlier that day with no concerns. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted the resident’s family member. The investigation included review of the resident record(s), hospital records, facility internal investigation, facility incident reports, staff schedules, related facility policy and procedures. The investigator observed the resident at the facility. The resident resided in an assisted living facility with diagnoses including severe protein-calorie malnutrition, adult failure to thrive, and muscle weakness. The resident’s service plan and assessment at the time of the incident indicated the resident was cognitively intact, able to make her needs known, and had no history of falls prior to the incident. The service plan and assessment indicated the resident was independent with dressing, grooming, toileting, transfers, ambulation, and medication administration. The resident’s service plan included safety checks to be completed one time per shift on the day and evening shifts, with no specific time indicated. The service plan indicated the resident received meals 3 times daily. A facility incident report indicated one day the resident had an unwitnessed fall out of bed when her feet became tangled in the blankets with injuries to her hip and wrist. The facility investigation included a staff interview who seen and talked to the resident in the hallway just prior to the incident. The investigation indicated the resident was to have daily routine safety checks, and meal attendance documented. The investigation indicated staff documented the resident was unavailable for meals the day of the incident, which indicated they had not seen the resident. The resident’s services report documentation indicated staff frequently documented the resident was unavailable at mealtimes including breakfast and lunch. The documentation indicated the resident rarely attended meals in the dining room, as a result meal attendance was not an indicator of the resident’s safety or wellbeing. On the day of the incident staff also documented the resident was unavailable for meals during the day shift. The investigation indicated the resident picked up breakfast but had not picked up her noon meal, staff became concerned, went to check on the resident and found her on the floor. A progress note indicated unlicensed personnel (ULP) called for staff assistance in the resident’s room. The resident was found lying on her stomach next to the bed. Nursing staff noted distortion of the resident’s right forearm with bruising, and the resident had pain in the right hip. The note indicated 911 was called and the resident was transferred to the ED for evaluation and treatment of her injuries. Another progress note indicated after the incident occurred multiple staff were interviewed, and one staff reported seeing and talking to the resident in the hallway around 7:00 a.m. The note indicated the resident reported she fell around 7:30 a.m. but was unable to reach her pendant to call for help. When interviewed the staff who had saw and talked to the resident the morning of the incident indicated she did not document completing the safety check on the resident because she was not working the resident’s group that day. When interviewed multiple licensed and ULP staff indicated the resident rarely went to the dining room for breakfast, and indicated it was not unusual to not see the resident at breakfast time. Staff stated the resident’s safety check was not scheduled and could be completed at any time during their shift. When interviewed the resident stated she rarely ate or ordered breakfast. The resident stated she had no concerns that staff did not respond to her or check on her as they should have. When interviewed the resident’s family member stated at the time of the incident the resident’s day shift safety checks were not scheduled at a specific time. The family member stated she had no concerns staff were not providing safety checks or meals as indicated in the resident’s care/service plan, and indicated she had no concerns for the resident’s safety at the facility. In conclusion, the Minnesota Department of Health determined neglect was not substantiated. “Not Substantiated” means: An investigatory conclusion indicating the preponderance of evidence shows that an act meeting the definition of maltreatment did not occur. 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: Yes Family/Responsible Party interviewed: Yes Alleged Perpetrator interviewed: N/A the Action taken by facility: The facility staff checked on the resident, found her on the floor, and called 911 for the resident to be transported to the ED for evaluation and treatment of her injuries. Action taken by the Minnesota Department of Health: No further action taken at this time. cc: The Office of Ombudsman for Long Term Care The Office of Ombudsman for Mental Health and Developmental Disabilities PRINTED: 04/23/2024 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 _____________________________ 26730 03/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 900 MAIN STREET WEST CANNON FALLS ASSISTED LIVING CANNON FALLS, MN 55009 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 License In accordance with Minnesota Statutes, section Providers. The assigned tag number 144G.08 to 144G.95, these correction orders are appears in the far left column entitled "ID issued pursuant to a complaint investigation. Prefix Tag." The state Statute number and the corresponding text of the state Statute Determination of whether a violation is corrected out of compliance is listed in the requires compliance with all requirements "Summary Statement of Deficiencies" provided at the statute number indicated below. column. This column also includes the When a Minnesota Statute contains several 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. #HL267309045M/#HL267306632C #HL267308106M/#HL267305202C PLEASE DISREGARD THE HEADING OF #HL267307705M/#HL267304522C THE FOURTH COLUMN WHICH STATES,"PROVIDER'S PLAN OF On March 4, 2024, the Minnesota Department of CORRECTION." THIS APPLIES TO Health conducted a complaint investigation at the FEDERAL DEFICIENCIES ONLY. THIS above provider, and the following correction WILL APPEAR ON EACH PAGE. orders are issued. At the time of the complaint investigation, there were 105 residents receiving THERE IS NO REQUIREMENT TO services under the provider's Assisted Living with SUBMIT A PLAN OF CORRECTION FOR Dementia Care license. VIOLATIONS OF MINNESOTA STATE STATUTES.