Edgewood Egf Senior Living.

Finding: Substantiated, facility and 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 facility and the alleged perpetrators (AP), both registered nurses (RN) at the facility, neglected the resident when they failed to have a system in place to ensure availability of medication refills. The resident’s medications were not delivered immediately after new orders were received. AP/RN1 and AP/RN2 failed to notify the resident’s provider that medications were not available. The resident was hospitalized after missing ten days of prescribed medications. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was substantiated. The facility and AP/RN1 and AP/RN2 were responsible for the maltreatment. The resident had been hospitalized and treated for congestive heart failure and was started on nine new medications. After returning to the facility, the new medications did not immediately arrive. AP/RN1 and AP/RN2 were aware of this but failed to contact the pharmacy to follow up and failed to notify the primary care provider (PCP) that new medications to treat heart failure had not been started. The facility did not have a process in place to ensure the family and primary care provider were updated or a process to ensure new orders were followed up on to ensure the medications arrived. The resident missed ten days of essential medications. The resident was re-hospitalized with exacerbation of congestive heart failure. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted the primary care provider. The investigation included review of the resident record, hospital records, pharmacy records, facility incident reports, personnel files, staff schedules, and related facility policy and procedures. Also, the investigator observed the medication procedures and storage for residents using outside pharmacies at the facility. The resident resided in an assisted living memory care unit. The resident’s diagnoses included vascular dementia, Alzheimer’s disease, and congestive heart failure. The resident’s service plan included assistance with medication administration. The resident’s assessment indicated the resident's medications were ordered by facility staff through an outside pharmacy. Progress notes in the resident’s record indicated the resident returned to the facility with orders for nine new medications after he was treated for heart failure. New medications included treatment for fluid retention, high blood pressure, heart failure, and other heart problems. The resident’s medication administration record (MAR) indicated over a ten-day period, the medications were marked as not given. Progress notes documented by AP/RN2 indicated she was aware the orders were being sent to an outside pharmacy and would be mailed to the facility. AP/RN1 and AP/RN2 failed to notify the PCP that medications would not arrive for 7 to 10 days and failed to offer alternatives to the resident’s family to obtain medications in a more timely manner. The facility failed to follow up and ensure the outside pharmacy received the new orders and progress notes later indicated the outside pharmacy never received the orders and were not processing them as they were not sent. The facility failed to document a change in condition for the resident or why he was sent to the hospital again. Hospital records indicated the resident came to the emergency room after having shortness of breath for two days, as well as chest pain. The resident’s oxygen in the emergency room was noted to be 88% (normal is above 95%). The resident was admitted for congestive heart failure exacerbation and spent four days in the hospital. During an interview, a facility nurse stated she was responsible for passing the resident’s medications and when she noticed the resident did not have the new medications he needed to treat his heart failure, she told both AP/RN1 and AP/RN2 that he didn't have any medications and they needed to do something as he should not be missing so many doses. The nurse stated she was told they were looking into it and that the medication was being sent. The nurse stated she voiced concerns about not giving the medications was neglect because the medications were for heart failure, but nursing management kept telling her the medications were ordered. The nurse stated she got into an argument with AP/RN2 because she didn't feel like they were doing any follow up to see if the resident's medications were coming. During an interview, the resident’s son stated the facility did not call to tell him his dad wasn't getting medications. The resident’s son stated he only found out about it after the resident was hospitalized and the hospital told him the resident hadn't received his medications which caused fluid buildup. The resident’s son stated he spoke with both AP/RN1 and AP/RN2 after he was re-hospitalized and they said the hospital screwed up and didn't send the prescriptions and was under the impression his dad had only missed a few medications. The resident’s son stated if he would have been made aware of the medications never arriving, he would have called the pharmacy himself or found a way to get the medications for his dad. During an interview, the resident’s daughter stated she wasn't aware the resident missed any medications until a nurse at the hospital told her the facility had reported he didn't get his new medications filled. The resident’s daughter stated she spoke with AP/RN1 after the resident was hospitalized and asked why someone didn’t call somebody to see if they could get medications filled elsewhere while they were waiting on the outside pharmacy instead of just marking it down as not available the whole time. The resident’s daughter stated if the facility had notified her that the medications never arrived, she would have taken action to get them filled immediately. The resident’s daughter stated she was not told about the outstanding bill at the local pharmacy that prevented them from being able to fill there but as soon as she was aware of it, she paid it and was able to get the medications filled until the outside pharmacy could send the medications. During an interview, AP/RN1 stated he was not sure why there was no documentation leading up to the resident's rehospitalization or when nursing was notified of concerns. AP/RN1 confirmed the facility did not reach out to the primary care provider about the new medications not being able to be started and the resident's family was not notified about the issues with obtaining the new prescriptions that had been started to treat the resident's congestive heart failure. AP/RN1 stated the hospital should have sent the new orders to the outside pharmacy but they never followed up or called the outside pharmacy in the days after he returned to the facility. AP/RN1 stated this was the first time he had worked with the outside pharmacy before and confirmed they did not have a process in place for when a new order was initiated but the outside pharmacy wasn't able to deliver for 7 to 10 days. During an interview, AP/RN2 stated the son was "well aware" the resident was not receiving the new medications to treat his heart failure because the son chose to use an outside pharmacy that took a while to deliver. AP/RN2 confirmed the PCP was not notified the medications would not be able to be started immediately and she was not aware they could ask to get a hold order and thought they were to just mark it as medication not available. AP/RN2 stated the resident's son would have been educated in the hospital about the risks of not starting the medications and that he was aware they did not have the medications. AP/RN2 stated she never followed up to see if the pharmacy got the new orders because the hospital said they sent it, and the outside pharmacy would take a few days to send it. During an interview, a registered nurse (RN) with the resident's primary care provider's office stated they had reviewed the resident's clinic record and visited with the PCP and did not see any evidence they were notified the resident's new medications could not be started immediately. The RN stated they would expect the facility to contact them to either hold the medication or find alternatives until the medications could be delivered.

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 perpetrators (AP), unlicensed personnel (ULP) at the facility, emotionally abused the resident when they treated him in a harassing and humiliating manner. Camera footage showed AP1 and AP2 being chased down the hallway by the resident and the two APs closed themselves behind a door. AP1 and AP2 could be seen watching a recording of the incident on AP1’s phone and laughing. Investigative Findings and Conclusion: The Minnesota Department of Health determined abuse was inconclusive. While AP1 and AP2 may have treated the resident in a discourteous manner, there was insufficient evidence to demonstrate abuse occurred. Conflicting reports were provided, and the facility did not retain camera footage of the incident. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigation included review of the resident record, facility internal investigation documentation, facility incident reports, personnel files, staff schedules, and related facility policies and procedures. Also, the investigator observed the resident’s room. The resident resided in an assisted living memory care unit. The resident’s diagnoses included cognitive decline and Parkinson's disease. The resident’s service plan included assistance with all activities of daily living and behavior management services. The resident’s assessment indicated the resident had dementia, memory loss, and cognitive impairment. The resident was at risk for aggression both to and from others during periods of high stress. The resident had a history of being physically aggressive, hallucinating, breaking property, hitting, slapping, and kicking his wife and staff, and become verbally aggressive. No interventions besides redirecting the resident were identified. The facility’s internal investigation indicated management was notified of an incident that occurred on an overnight shift where two unlicensed personnel, alleged perpetrator (AP1) and AP2 were laughing at the resident. The incident report indicated the resident was agitated, throwing objects, and chasing staff. Surveillance camera footage was reviewed. It appeared that staff were repeatedly antagonizing the resident and running away from him. At one point, he chased them down the hallway and they closed themselves behind the magnetic door. The camera in the hallway showed that they were laughing and viewing something on AP1’s phone. AP1 was interviewed by facility staff and reported she and AP2 entered the resident's room to help the resident’s wife when the resident became upset, began throwing objects and chasing them. AP1 denied intentionally aggravating the resident and stated she wanted to record the incident because the surveillance cameras don't always record everything. AP2 was interviewed by facility staff and stated AP1 mocked the resident which angered him, and he attempted to hit her with an object. AP1 and AP2 left the room and returned when they heard the resident’s wife screaming. The resident did not want AP1 or AP2 back in the room and became upset again. AP2 reported that AP1 taunted the resident, and he threw a hairbrush and a plastic bowling pin at them before chasing them down the hallway. AP2 acknowledged AP1 recorded the incident on her phone, taunting the resident and using profanity. AP2 denied recording or possessing any recording of the incident. AP2 acknowledged that they were laughing during the incident and laughed when reviewing AP1’s recording of the incident. Facility staff interviewed the resident who recounted two girls were taunting him and that one gave him the finger and they were laughing. He stated he chased them down the hallway and shut the door so they couldn't come back. The resident was interviewed by the investigator, but he was unable to recall any details from the incident. During an interview, AP1 stated they were not trying to play around but they ended up laughing because they didn't know why the resident was throwing things at them. AP1 stated she was trying to help the resident's wife when he became upset with them and was throwing items like a hairbrush and a bowling pin. AP1 denied recording the incident and stated that AP2 recorded a video, texted it to her and asked her to delete the video after AP2 was fired. AP1 stated she did have her phone out during the incident because AP2 told her to but she did not record anything. AP1 stated she took accountability for her actions that night and acknowledged laughing at the resident was not appropriate. AP1 stated they had not been trained on any interventions for dealing with the resident's behaviors so they were doing the best they could in a difficult situation. During an interview, AP2 stated the resident got very angry after they tried to help his wife and he chased her and AP1 down the hallway with a hairbrush and a bowling pin. AP2 stated they tried to run away from the resident and AP1 was trying to mimic the resident and was repeating things he said. AP2 stated she did not have her phone out and denied recording anything. AP2 stated AP1 showed her AP1's phone and that she had recorded the incident. AP2 stated they were laughing at the resident because they didn't know what else to do. AP2 stated she had not been trained on any interventions for dealing with the resident's behaviors. During an interview, facility management stated it seemed like AP1 and AP2 were intentionally antagonizing the resident and when they watched the surveillance footage, they could see them going in the room and coming back out a few times. Management stated that it was difficult to hear anything on the video, but the resident could be seen coming further and further out of his room until he chased the two staff members down the hallway. Facility management confirmed surveillance footage of the incident was not saved and not available for review. In conclusion, the Minnesota Department of Health determined abuse 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. 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: Yes Family/Responsible Party interviewed: Yes Alleged Perpetrator interviewed: Yes, AP1 and AP2 Action taken by facility: The facility investigated the incident and filed a MAARC report. AP1 was terminated. AP2 was placed on administrative leave and later terminated. 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: 11/19/2024 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 The enclosed State Form documents the state correction orders. The MDH documents state licensing correction orders using federal software. Tag numbers are assigned to Minnesota state statutes for Assisted Living Facilities. The assigned tag number appears in the far left column entitled "ID Prefix Tag." The state statute number and the corresponding text of the state statute out of compliance are listed in the "Summary Statement of Deficiencies" column. This column also includes the findings that are in violation of the state statute after the statement, "This MN Requirement is not met as evidenced by . . ." In accordance with Minn. Stat. § 144G.31 Subd. 4, MDH may assess fines and enforcement actions based on the level and scope of the violations; however, no immediate fines are assessed for this survey of your facility. 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. 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). An equal opportunity employer. Letter ID: IS7N REVISED 09/13/2021 Edgewood EGF Senior Living June 8, 2023 Page 2 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 the MDH within 15 calendar days of the correction order receipt date. A state correction order under Minn. Stat. § 144G.91, Subd. 8, Free from Maltreatment is associated with a maltreatment determination by the Office of Health Facility Complaints. If maltreatment is substantiated, you will receive a separate letter with the reconsideration process under Minn. Stat. § 626.557. Please email reconsideration requests to: Health.HRD.Appeals@state.mn.us. Please attach this letter as part of your reconsideration request. Please clearly indicate which tag(s) you are contesting and submit information supporting your position(s). Please address your cover letter for reconsideration requests to: Reconsideration Unit 85 East Seventh Place St. Paul, MN 55164‐0970 You are encouraged to retain this document for your records. It is your responsibility to share the information contained in the letter and state form with your organization’s Governing Body. If you have any questions, please contact me. Sincerely, Jessie Chenze, Supervisor State Evaluation Team Email: jessica.chenze@state.mn.us Telephone: 218‐332‐5175 Fax: 651‐281‐9796 JMD PRINTED: 06/08/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ 30631 B. WING _____________________________ 05/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 608 5TH AVENUE NW EDGEWOOD EGF SENIOR LIVING EAST GRAND FORKS, MN 56721 (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 ******ATTENTION****** Minnesota Department of Health is documenting the State Correction Orders ASSISTED LIVING PROVIDER LICENSING using federal software. Tag numbers have CORRECTION ORDER(S) 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 survey. Prefix Tag." The state Statute number and the corresponding text of the state Statute Determination of whether violations are 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 Minnesota Statute contains several items, findings which are in violation of the state failure to comply with any of the items will be requirement after the statement, "This considered lack of compliance. Minnesota requirement is not met as evidenced by." Following the surveyors' INITIAL COMMENTS: findings is the Time Period for Correction. SL#30631015 PLEASE DISREGARD THE HEADING OF On May 22, 2023, through May 24, 2023, the THE FOURTH COLUMN WHICH survey at the above provider, and the following CORRECTION." THIS APPLIES TO correction orders are issued. At the time of the FEDERAL DEFICIENCIES ONLY. THIS survey, there were 36 active residents receiving WILL APPEAR ON EACH PAGE. services under the Assisted Living with Dementia Care license. 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 subd. 1, 2, and 3. 0 480 144G.41 Subd 1 (13) (i) (B) Minimum 0 480 SS=F requirements (13) offer to provide or make available at least the LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 X3ZE11 If continuation sheet 1 of 50 PRINTED: 06/08/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ 30631 B. WING _____________________________ 05/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 608 5TH AVENUE NW EDGEWOOD EGF SENIOR LIVING EAST GRAND FORKS, MN 56721 (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) 0 480 Continued From page 1 0 480 following services to residents: (B) food must be prepared and served according to the Minnesota Food Code, Minnesota Rules, chapter 4626; and This MN Requirement is not met as evidenced by: Based on observation, interview and record review, the licensee failed to ensure food was prepared and served according to the Minnesota Food Code. 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) 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 the residents). The findings include: Please refer to the included document titled, Food and Beverage Establishment Inspection Report dated May 22, 2023, for the specific Minnesota Food Code deficiencies. TIME PERIOD FOR CORRECTION: Twenty-one (21) days 0 485 144G.41 Subd 1. (13) (i) (A) and (C) Minimum 0 485 SS=C Requirements (13) offer to provide or make available at least the following services to residents: (i) at least three nutritious meals daily with snacks available seven days per week, according to the recommended dietary allowances in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables. The following apply: (A) menus must be prepared at least one week in STATE FORM 6899 X3ZE11 If continuation sheet 2 of 50 PRINTED: 06/08/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ 30631 B. WING _____________________________ 05/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 608 5TH AVENUE NW EDGEWOOD EGF SENIOR LIVING EAST GRAND FORKS, MN 56721 (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) 0 485 Continued From page 2 0 485 advance and made available to all residents. The facility must encourage residents' involvement in menu planning. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served.