The Legacy of Delano.

Finding: Substantiated, facility 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 resident was neglected when she was observed walking unassisted, fell backwards, and sustained a head strike. The resident died. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was substantiated. The facility was responsible for the maltreatment. The facility failed to ensure staff were aware of the residents assessed needs. The resident had reoccurring falls and the facility failed to implement interventions to prevent further falls. The resident fell while walking without staff assistance and sustained a head strike. The resident’s death record indicated the resident died from complications of a subdural and subarachnoid hemorrhage as a result of the fall. 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), death record, outside medical records, facility internal investigation, facility incident reports, personnel files, staff schedules, and related facility policy and procedures. Also, the investigator toured the facility and observed resident’s and staff. The resident resided in an assisted living facility memory care unit with diagnoses including atrial fibrillation, congestive heart failure, coronary artery disease, type 2 diabetes mellitus, and stroke. The resident’s admission assessment indicated the resident was severely cognitively impaired and required staff assistance with dressing and grooming twice daily. The assessment indicated the resident was incontinent of bowel and bladder and needed 1 assist with transfers, ambulation, and toileting using a wheelchair and 4 wheeled walker for mobility. The assessment indicated the resident needed staff assistance to get to and from meals and activities. An assessment dated 14 days after admission, indicated the resident had 1-2 falls since admission related to balance problems, but was ambulatory and continent of bowel and bladder. The assessment indicated the resident was independent with ambulation dressing, transfers, toileting, and personal hygiene but required stand by assistance (SBA) with ambulation and indicated staff would escort the resident to and from activities and meals using her walker. The assessment did not align with the initial assessment. The resident’s service plan and service delivery of care record from the time of admission indicated the resident was independent and received escort mobility assistance using a 4 wheeled walker to and from all destinations and meals, scheduled 3 times daily. The service plan failed to include any assistance with transfers, ambulation, toileting, dressing, or grooming as assessed on admission and prior to the resident’s 14-day assessment. A review of the resident record indicated although the resident’s admission orders included orders for physical therapy (PT) and occupational therapy (OT), the resident record failed to indicate the orders were implemented until 19 days after admission, and after the resident had fallen 3 times. A review of the resident’s progress notes and facility communication to the resident’s provider failed to indicate why the orders were not implemented timely. A fall incident report and progress note (the day after the resident was admitted to the facility) indicated at 11:35 a.m. the resident had an unwitnessed fall in her room about 1 hour after staff documented the resident had an episode of explosive diarrhea. The incident report identified the resident had impaired balance, and impaired vision. The incident report identified the resident was not wearing her glasses, had no shoes on, and her walker was out of reach at the time the fall occurred. The incident report indicated the resident’s service plan and services were reviewed with scheduled services for safety checks, and indicated the resident was independent with transfers using her walker which did not align with the resident’s assessed needs at the time the incident occurred. The incident report indicated interventions to reduce recurring falls were to continue safety checks, ensure items were within reach, proper footwear was donned, and the resident was wearing her glasses. The facility failed to identify the resident’s services at the time the fall occurred failed to include assistance with transfers, toileting, ambulation, and dressing/grooming as assessed. The resident record failed to indicate safety checks were ever implemented or provided and failed to indicate PT/OT services were implemented as ordered at the time the fall occurred. Another fall incident report 2 days later identified the resident was cognitively impaired, had a balance disorder, impaired mobility, unsteady gait, and poor safety judgement. The incident report failed to identify the resident had previously fallen, and indicated there was no history of falls. The incident report indicated the resident was walking back from the bathroom unassisted with no shoes on and tripped on a blanket and fell. The report indicated the resident was found during safety checks. The incident report indicated staff were educated to tuck blankets in and family provided a nonslip rug for the floor. The incident report interventions to reduce recurring falls indicated they would continue PT/OT, and ensure the resident was wearing her glasses. The facility failed to identify the resident’s services at the time the fall occurred failed to include assistance with transfers, toileting, ambulation, dressing and grooming as assessed. The resident record failed to indicate safety checks were ever implemented or provided and failed to indicate PT/OT services were implemented as indicated and ordered at the time the fall occurred. Another fall incident report 18 days later indicated the resident had another unwitnessed fall while ambulating independently in the common area when she went to her room unassisted after breakfast, lost her balance, and fell. The resident’s plan of care to provide escort stand by assistance was not followed at the time the fall occurred. The incident report identified contributing factors in the resident’s fall included generalized weakness, confusion, decline in status, neuropathy, history of falls, and need to use the bathroom (with bowel/bladder incontinence at the time of the fall) but failed to identify the resident’s plan of care to provide stand by assist with ambulation was not followed at the time the fall occurred. The resident’s vital signs at the time of the fall indicated the resident’s blood pressure was 87/73 (abnormally low, which could increase dizziness and risk for falls). There was no indication in the resident record the resident’s fall or low blood pressure were reported to the resident’s provider. The incident report interventions to reduce recurring falls indicated the facility would offer toileting, and a PT/OT evaluation. There was no indication the facility implemented the resident’s admission order for PT/OT services prior to this fall incident. The incident report indicated safety checks were performed by staff, however there was no indication safety checks were provided to the resident according to her services provided. Although the facility identified the resident needed assistance with toileting, and indicated toileting services would be offered, there was no indication assistance with toileting was ever added to the resident’s services for staff to implement. The next day another fall incident report indicated the resident was observed ambulating independently in the common area, lost her balance, and fell over backwards onto the ground striking the back of her head. The resident’s plan of care to provide escort SBA was not followed at the time the fall occurred. The incident report identified contributing factors included fall history, cognitive impairment, generalized weakness, bowel/bladder incontinence, needing to use the bathroom, and indicated the resident was incontinent of stool at the time the incident occurred. The incident report indicated the resident was unresponsive after sustaining a head strike when falling, 911 was called and the resident was transferred to the emergency department via ambulance. There was no indication toileting assistance was provided as indicated for falls prevention noted on the fall incident report the previous day. The resident’s progress notes after the fall with head strike occurred indicated the resident was observed walking independently, stopped, then fell over backwards striking the back of her head. The resident had pale pallor, was not responsive or able to follow commands, and had a fixed blank stare. The resident was transferred to the hospital where she was diagnosed with a brain bleed and died.

Finding: Substantiated, facility 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 facility neglected Resident #1(R1) and Resident #2 (R2) when they failed to provide the appropriate level of supervision when R1 and R2 had sexual contact. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was substantiated. The facility was responsible for the maltreatment. The facility discovered R1 and R2 had sexual contact and assessed R1 was unable to consent to a sexual relationship related to R1’s cognitive ability. R1's family requested R1 and R2 have no further sexual contact. The facility failed to ensure R1 and R2 were supervised, and interventions were implemented to prevent further sexual contact between R1 and R2. Approximately one month later, R1 and R2 were found in R1’s apartment having another sexual encounter. An equal opportunity employer. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator coordinated with law enforcement. The investigation included review of resident’s medical records, facility investigations, video monitoring, family and facility coordination’s and facility policy and procedures. Also, the investigator observed staff and resident interactions at the facility during meals, activities, and personal cares. Resident #1’s medical record indicated R1 resided in an assisted living apartment with diagnoses including a cognitive impairment, short term memory loss, and impaired safety and judgment. R1’s service plan included assistance with medication, meals, and laundry. Resident #2 resided in an assisted living apartment with degenerative neurological diseases and experienced “brain fog” and other vulnerabilities. R2’s service plan included assistance with meals, medication, and personal care. R1 and R2’s nursing notes indicated early one morning staff observed R2 leaving R1’s apartment. Nursing staff investigated further, R1 stated no knowledge of a relationship or any sexual encounters. Nursing notes indicate R2 stated R1 and R2 had a sexual relationship when R2 was in R1’s room. The facility investigation indicated R1’s family was concerned with R1’s ability to consent to a sexual relationship and inquired what the facility could do to ensure R1 and R2 had no further sexual contact. The facility told R1’s family they would implement two safety checks for R1 during the night. In addition, the facility made recommendations to R1’s family for additional monitoring devices. The facility investigation indicated management staff spoke with R2 and implemented a verbal agreement that the relationship could not continue and R2 was told not to enter R1 apartment or call R1. R1’s progress note indicated approximately ten days later the resident’s family placed a camera in R1’s apartment and the facility discontinued R1’s two safety checks. A facility investigation indicated, approximately two weeks after the camera was installed the facility staff were contacted by R1’s family who reported R2 was in R1’s apartment and requested staff immediately go to R1’s apartment and ask R2 to leave. The recorded incident was reviewed and R1 was observed opening the apartment door and allowed R2 into the apartment. R1 and R2 were observed talking [inaudible], laughing, hugging, and kissing. After a couple minutes R1 and R2 walked into R1’s bedroom and closed the door. Approximately five minutes later two staff were observed entering R1’s apartment and proceeded to knock on R1’s bedroom door. During an interview a facility nurse stated R1 and R2 were both vulnerable, and a safety plan was intended to protect both residents. During an interview a member of facility leadership stated R1 and R2 lived in close proximity, however the residents were not moved until after the second sexual encounter occurred. During an interview a manager stated the facility did not do enough to prevent the incident from occurring a second time. The manager stated the facility had unrealistic expectations of R1 and R2’s ability to follow through on the expectations of facility and family. During an interview R2’s family members stated they notified facility management of concerns and lack of boundaries regarding R1 and R2. 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: R1 yes, R2 yes Family/Responsible Party interviewed: R1 yes, R2 yes. Alleged Perpetrator interviewed: Not Applicable. Action taken by facility: The facility moved R2 to another area until R1 could move to a higher level of care/supervision. Action taken by the Minnesota Department of Health: The responsible party will be notified of their right to appeal the maltreatment finding. 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 Wright County Attorney Delano City Attorney Delano Police Department PRINTED: 02/16/2024 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 _____________________________ 29189 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1350 ST. PETER AVENUE EAST THE LEGACY OF DELANO DELANO, MN 55328 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: #HL291897483C/ #HL291899565M On November 29, 2023, 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 52 residents receiving services under the provider's Assisted Living with Dementia Care license. The following correction order is issued for #HL291897483C/#HL291899565M, 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 PTRI11 If continuation sheet 1 of 2 PRINTED: 02/16/2024 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 _____________________________ 29189 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1350 ST. PETER AVENUE EAST THE LEGACY OF DELANO DELANO, MN 55328 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) 02360 Continued From page 1 02360 This MN Requirement is not met as evidenced by: The facility failed to ensure two of two residents reviewed (R1, R2) was free from maltreatment. Findings include: The Minnesota Department of Health (MDH) issued a determination maltreatment occurred, and the facility was responsible for the maltreatment, in connection with incidents which occurred at the facility.