Atlas Villas Memory Care.

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 facility neglected the resident when staff failed to provide infection control measures. The resident was hospitalized after contracting COVID-19 and Pneumonia. The resident passed away in the hospital weeks later. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was inconclusive. There was not a preponderance of evidence to support that the actions of the facility staff met the definition of neglect. Conflicting accounts of the incident were provided and it could not be determined if staff failed to use appropriate infectious disease precautions and available personal protective equipment (PPE) while caring for residents. The investigator conducted interviews with facility staff members, including nursing staff, and unlicensed staff. The investigation included review of the resident record, facility incident reports, personnel files, and related facility policy and procedures. The investigator toured the facility, as well as observed staff interactions and provision of care. The resident resided in an assisted living facility memory care unit. The resident’s diagnoses included Parkinson's disease and Alzheimer's disease. The resident’s service plan included safety checks, medication administration, laundry, housekeeping, and meal reminders. The resident’s assessment indicated she remained independent and staff were to provide reminders and cues when needed. Documentation indicated that one morning the resident began showing symptoms associated with a common cold, such as fatigue, body aches, congestion, and a runny nose. The resident also reported to facility staff that she was not hungry and didn’t want to eat breakfast. Nursing staff at the facility assessed the resident and she was found to not have a fever, although other vital signs were not within normal limits. A COVID-19 test was conducted at the facility which indicated the resident was COVID-19 positive. The facility contacted the resident’s family, and it was determined that the family would bring her to a local hospital for evaluation. At the hospital, the resident was prescribed an antibiotic related to a new diagnosis of pneumonia and returned to the facility. Days later, the facility again contacted the family when the resident showed signs of a change in condition and emergency medical services (EMS) were required to transport the resident back to the hospital. The resident admitted to the hospital and required intensive care until she passed away weeks later. During an interview, a nurse stated that after the resident tested positive for COVID-19 the facility began testing all staff and residents which identified other positive cases. Infection control procedures were implemented although not all precautions met state and federal COVID-19 guidelines. The nurse stated that due to the acuity and diagnosis of other resident, quarantine efforts were not successful at all times and also acknowledged that the facility allowed staff members who previously tested positive for COVID-19 to return to work at their own discretion. During an interview, an unlicensed staff member stated that although she was not present during the incident in question, she was aware of facility infection control policies and trained on infection control procedures as part of the facility onboarding process. During an interview, a family member stated that she was made aware of an outbreak of infectious disease at the facility by the nursing staff, as well as the change in conditions of the resident. The family member stated that during a visit the day before the resident was sent back to the hospital, she recalled staff persons exhibiting signs of illness and noticed that not all were wearing personal protective equipment (PPE) while performing resident care tasks. In conclusion, the Minnesota Department of Health determined neglect was inconclusive. Inconclusive: Minnesota Statutes, section 626.5572, Subdivision 11. "Inconclusive" means there is less than a preponderance of evidence to show that maltreatment did or 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: No, deceased Family/Responsible Party interviewed: Yes Alleged Perpetrator interviewed: N/A Action taken by facility: The facility contacted the resident’s family when a change in condition was observed and continued to monitor and advised the family when a higher level of care was needed. Action taken by the Minnesota Department of Health: The facility was found to be in noncompliance. 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. cc: The Office of Ombudsman for Long Term Care The Office of Ombudsman for Mental Health and Developmental Disabilities PRINTED: 06/10/2025 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 _____________________________ 39714 05/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1825 MAIN STREET ATLAS VILLAS MEMORY CARE CENTERVILLE, MN 55038 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 144G.08 to 144G.95, these correction orders are far-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. #HL397149963C/#HL397141001M PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On May 7, 2025, the Minnesota Department of STATES,"PROVIDER'S PLAN OF Health conducted a complaint investigation at the CORRECTION." THIS APPLIES TO above provider, and the following correction FEDERAL DEFICIENCIES ONLY. THIS orders are issued. At the time of the complaint WILL APPEAR ON EACH PAGE. investigation, there were 13 residents receiving services under the provider's Assisted Living with THERE IS NO REQUIREMENT TO Dementia Care license. SUBMIT A PLAN OF CORRECTION FOR VIOLATIONS OF MINNESOTA STATE The following correction order is issued/orders STATUTES. are issued for #HL397149963C/#HL397141001M, tag THE LETTER IN THE LEFT COLUMN IS identification 0510. USED FOR TRACKING PURPOSES AND REFLECTS THE SCOPE AND LEVEL ISSUED PURSUANT TO 144G.31 SUBDIVISION 1-3. 0 510 144G.41 Subd. 3 Infection control program 0 510 SS=F (a) All assisted living facilities must establish and LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 1LIG11 If continuation sheet 1 of 4 PRINTED: 06/10/2025 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.

correction orders and document the actions taken to comply in the facility's records. The Department reserves the right to return to the facility at any time should the Department receive a complaint or deem it necessary to ensure the health, safety, and welfare of residents in your care. This is your o fficial notice t hat you have been granted your assisted living facility license with dementia care. Your license effective and expiration dates remain the same as on your provisional license. Your updated status will be listed on the license certificate at renewal and this letter serves as proof i n the meantime. If you have not received a letter from us with information regarding renewing your license within 60 days prior to your expiration date, please contact us at (651) 201-5273 or by email at Health.assistedliving@state.mn.us. Furthermore, the follow-up survey determined your facility had not corrected all of the state correction orders issued pursuant to the February 29, 2024, initial survey. In accordance with Minn. Stat. § 144G.31, Subd. 4 (a), state correction orders issued pursuant to the last survey completed on February 29, 2024, found not corrected at the time of the follow-up survey follow-up survey and/or subject to a penalty assessment are as follows: 0650-Employee Records-144g.42 Subd. 8 The details of the violations noted at the time of this follow-up survey completed on July 2, 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. An equal opportunity employer. Letter ID: 292I_Revised 04/14/2023 Atlas Villas Memory Care July 25, 2024 Page 2 Also, at the time of this follow-up survey completed on July 2, 2024, we identified the following violation(s): 1360-Instructor And Competency Evaluation Requirem-144g.61 Subdivision 1 The details of the violation(s) noted at the time of this follow-up survey are delineated on the attached State Form. Only the ID Prefix Tag in the left hand column without brackets will identify these state correction orders. It is not necessary to develop a plan of correction. Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, no immediate fines are assessed. DOCUMENTATION OF ACTION TO COMPLY Per Minn. Stat. § 144G.30, Subd. 5(c), t he 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. The correction order documentation should include the following: Identify how the area(s) of noncompliance was corrected related to the resident(s)/employee(s) identified in the correction order. Identify how the area(s) of noncompliance was corrected for all of the provider’s resident(s)/employees that may be affected by the noncompliance. Identify what changes to your systems and practices were made to ensure compliance with the specific statute(s). 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 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, Rick Michals, J.D. Interim Assistant Division Director HHH PRINTED: 07/25/2024 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 _____________________________ 39714 07/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ATLAS VILLAS MEMORY CARE ATLAS VILLAS MEMORY CARE CENTERVILLE, MN 55038 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 SL39714015-1 requirement is not met as evidenced by." Following the evaluators ' findings is the On July 1, 2024, through July 2, 2024, the Time Period for Correction. 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 February 29, 2024. At the time of STATES,"PROVIDER'S PLAN OF the survey, there were 13 residents; 13 receiving CORRECTION." THIS APPLIES TO services under the provisional Assisted Living FEDERAL DEFICIENCIES ONLY. THIS with Dementia Care license. As a result of the WILL APPEAR ON EACH PAGE. follow-up survey, the following orders were issued/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. {0 650} 144G.42 Subd. 8 Employee records {0 650} SS=D (a) The facility must maintain current records of LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 4NMY12 If continuation sheet 1 of 10 PRINTED: 07/25/2024 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 _____________________________ 39714 07/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ATLAS VILLAS MEMORY CARE ATLAS VILLAS MEMORY CARE CENTERVILLE, MN 55038 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) {0 650} Continued From page 1 {0 650} each paid employee, each regularly scheduled volunteer providing services, and each individual contractor providing services. The records must include the following information: (1) evidence of current professional licensure, registration, or certification if licensure, registration, or certification is required by this chapter or rules; (2) records of orientation, required annual training and infection control training, and competency evaluations; (3) current job description, including qualifications, responsibilities, and identification of staff persons providing supervision; (4) documentation of annual performance reviews that identify areas of improvement needed and training needs; (5) for individuals providing assisted living services, verification that required health screenings under subdivision 9 have taken place and the dates of those screenings; and (6) documentation of the background study as required under section 144.057. This MN Requirement is not met as evidenced by: Based on interview and record review, the licensee failed to ensure the employee record contained the required content for one of five employees (unlicensed personnel (ULP)-M). 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 an isolated scope (when one or a limited number of residents are affected or one or a limited number of staff are involved or the situation has occurred only occasionally). STATE FORM 6899 4NMY12 If continuation sheet 2 of 10 PRINTED: 07/25/2024 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.