Heritage of Edina Inc.

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 was observed on video swearing and yelling at the resident and hit the resident with an unknown object. Investigative Findings and Conclusion: The Minnesota Department of Health determined abuse was substantiated. The AP was responsible for the maltreatment. The video showed the AP hit the resident with a bag of garbage. The audio from the video heard the AP tell the resident he was a “worthless honkey” and told him he could not “even stand” on his own feet to clean his own “nasty ass.” The AP called the resident a “mother fucker.” The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator also contacted a family member. The investigation included review of the resident’s records, facility internal investigation, facility incident reports, personnel files, and facility policies. The investigator requested the police report. Also, the investigator toured the facility and observed facility staff providing hygiene cares to residents. The resident resided in an assisted living facility. The resident’s diagnoses included senile degeneration of brain, multiple sclerosis, depression, and anxiety. The resident’s service plan included assistance with dressing, bathing, grooming, incontinence cares, medication administration, mobility, and housekeeping. The resident’s assessment indicated he was confused, anxious and easily agitated. Interventions to help the resident remain safe included talking calmly and offer reassurance. A recording of the incident showed the resident laying on the bed naked, covered only with a brief. The video showed the AP hit the resident with a bag of garbage. The audio from the video heard the AP tell the resident he was a “worthless honkey” and told him he could not “even stand” on his own feet to clean his own “nasty ass.” The AP called the resident a “mother fucker.” The internal investigation indicated an email with an attached video was sent to the facility’s human resources department. Upon video review, the AP was identified as a staffing agency employee who had not worked at the facility for over one month. The facility spoke to unlicensed personnel (ULP)-1 and ULP-2, who were witness to the incident and the video. The investigation indicated ULP-2 recoded the video while her phone was in her pocket facing outward, so the camera was pointed at the AP. ULP-1 said ULP-2 sent her the video to report the incident as ULP-2 was afraid of the AP. When the facility met with ULP-2, she denied she recorded the video and said she did not know who sent it to her. ULP-2 said she sent it to ULP-1 because she wanted to discuss the video and what to do with it. During an interview, ULP-1 said a video of the incident was sent to her by ULP-2. She identified the AP in the video and said the AP called the resident names and hit him with a garbage bag filled with a dirty brief. She said she was trained on vulnerable adult maltreatment. She said ULP-2 sent her the video to report as ULP-2 was fearful of the AP. The AP has threatened ULP-2 in the past. During an interview, a member of management, who is also a nurse, said she conducted the internal investigation. She said ULP-1 reported ULP-2 sent her the video and she sent the video to the facility’s human resources department. When management questioned ULP-2, she denied she recorded the incident. After investigating the incident and speaking with all staff members who worked with the AP, management said the only person who could have recorded the incident was ULP-2. She watched the video and described the AP’s actions as disgusting and said the AP should not be allowed to work with vulnerable adults. The resident was assessed, and no injuries were noted. She reported the incident to the staffing agency and the AP was removed from the schedule. Facility staff receive training on maltreatment of vulnerable adults from staff development upon hire and annually. The resident’s family member declined interview as they had no further information to add. The family member said the facility reported the incident to them. The AP declined the interview but provided a written statement via email that indicated the video was edited and falsified. the 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: (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; or (3) use of any aversive or deprivation procedure, unreasonable confinement, or involuntary seclusion, including the forced separation of the vulnerable adult from other persons against the will of the vulnerable adult or the legal representative of the vulnerable adult unless authorized under applicable licensing requirements or Minnesota Rules, chapter 9544. Mitigating Factors considered, Minnesota Statutes, section 626.557, Subd. 9c(f): (1) The AP did not follow an erroneous order, direction or care plan with awareness and failure to take action. The facility did not direct an erroneous order, direction, or care plan. (2) The facility was in compliance with regulatory standards. The facility provided proper training and/or supervision of staff. The facility provided adequate staffing levels. The AP failed to follow the facility directive and/or policies and procedures. (3) The AP failed to follow professional standards and/or exercise professional judgement. The AP failed to act in good faith interest of the vulnerable adult. The maltreatment was not a sudden or foreseen event. Vulnerable Adult interviewed: No, due to cognitive deficit. Family/Responsible Party interviewed: No, family member declined interview. Alleged Perpetrator interviewed: No, the AP declined. Action taken by facility: The facility reported the incident and completed a thorough internal investigation. The facility assessed the resident and spoke to all staff and residents who worked with the AP. The facility recently provided education on vulnerable adult maltreatment to all staff members. 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 Hennepin County Attorney Edina City Attorney Edina Police Department PRINTED: 12/17/2024 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 _____________________________ 35017 11/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3450 HERITAGE DRIVE HERITAGE OF EDINA INC EDINA, MN 55435 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 ASSISTED LIVING PROVIDER CORRECTION Minnesota Department of Health is ORDER documenting the State Correction Orders using federal software. Tag numbers have In accordance with Minnesota Statutes, section been assigned to Minnesota State 144G.08 to 144G.95, these correction orders are Statutes for Assisted Living Facilities. The issued pursuant to a complaint investigation.

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): It is alleged the alleged perpetrator (AP) neglected a resident when the resident did not receive medication according to physician orders. The resident experienced a hypertensive crisis that required hospitalization. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was substantiated. The facility was responsible for the maltreatment. The resident ran out of olanzapine (a psychotropic medication) and the medication nurse failed to notify the AP to follow up and order more medication, nor did the nurse attempt to order more of the residents Olanzapine. Although the resident had no Olanzapine, the medication nurse continued to document in the resident’s medication administration record the resident was receiving the olanzapine. The resident did not receive Olanzapine for 12 days. The resident had a hypertensive crisis and was hospitalized. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted family members, providers, and caregivers. The investigation included review of the resident records, hospital records, pharmacy records, clinic records, the facility internal investigation, facility incident reports, personnel files, staff schedules, and related facility policy and procedures. Also, the investigator observed medication administration and resident interactions with staff. The resident resided in an assisted living facility The resident’s diagnoses included schizophrenia, anxiety, and high blood pressure. The resident’s service plan included assistance with morning and evening cares, bathing, meals, housekeeping, laundry, and medication management. The resident’s assessment indicated the resident required orientation and redirection as needed by staff due to cognitive impairment. The facility’s internal investigation indicated the resident went without her olanzapine for a total of 12 days. The medication nurse sent a refill request to the pharmacy, and the pharmacy contacted the prescriber multiple times to request a new prescription. The prescriber denied the refill requests, but the facility did not receive this information. The medication nurse contacted the pharmacy but did not notify the AP for further follow up, per protocol. The nurse continued to sign off the olanzapine when setting up the resident’s weekly medication set up. However, the olanzapine was out of stock and not in the resident’s weekly medication setup. The resident’s progress notes indicated she then experienced a blood pressure spike and was sent to the hospital for further evaluation. The resident’s care sheets indicated unlicensed personnel (ULP) staff were instructed to administer the resident’s medications in the morning and evening. The care sheets provided no further direction to staff regarding the resident’s medications, such as the names, dosages, methods, and routes of administration. The ULP staff initialed and signed the care sheets, but there was no indication ULP staff knew what medications they were signing off as having administered. The resident’s hospital records indicated a diagnosis of hypertensive urgency with a history of hypertension, and delirium, hypoactive type. The resident’s family expressed concerns they discovered the resident had not been receiving olanzapine for 12 days. Upon receiving olanzapine in the hospital, the resident improved. Psychiatry recommended continuing the resident’s current medication management without any changes. At discharge, the resident’s diagnoses were altered mental status, unclear cause, and hypertensive emergency, improved. The resident’s condition at discharge was documented as stable. After hospitalization, the resident’s psychiatric clinic visit note indicated the resident experienced withdrawn behavior, psychosis, and cognitive changes. The resident was at a higher risk of falls and had not returned to baseline. When interviewed, the AP stated the medication nurse had not notified her that the resident was out of olanzapine. The AP was unaware she needed to follow up about the olanzapine with the pharmacy and provider. The AP was unaware of why the med nurse continued to document that she set up the resident’s olanzapine when it was out of stock, and the AP did not discover the missing olanzapine until after the resident returned from the hospital. The AP said ULP staff who administered medications to the residents would have had no way to double-check the med set up because the sign off sheets only note the medication times, and not what medications are being administered. When interviewed, leadership staff stated she discovered the medication nurse continued to sign off that the resident’s olanzapine had been included in her medication set up, although the medication had been out of stock for 12 days. The medication nurse contacted the pharmacy with a refill request; however, the AP was unaware and did not follow up on the prescription refill. The pharmacy contacted the prescriber multiple times with refill requests, and the prescriber denied the requests. The prescriber wanted the resident’s mental health provider to start prescribing the olanzapine. The facility did not receive this information. When interviewed, the med set up nurse said when the resident’s olanzapine was running low, she sent a refill request to the pharmacy. She said she also notified the AP, although there was no documentation of that until the resident had been out of olanzapine for six days. There was no indication of follow-up to that notification. The medication nurse stated she continued to document she was setting up olanzapine for the resident, which was “a mistake.” When interviewed, the resident’s mental health provider said the resident had pre-existing health issues the pre-disposed her to developing a hypertensive crisis in response to the abrupt discontinuation of olanzapine. In addition to the increased blood pressure, the resident developed a worsening of her psychosis. The mental health provider said the resident experienced significant clinical changes after she missed the olanzapine and did not return to her baseline status. When interviewed, family members said they were concerned the resident was not getting some of her medications. In response, family members contacted the dispensing pharmacy. The family discovered the resident had been without her olanzapine for almost two weeks, as the prescription had not been refilled. The family notified the facility and coordinated with the resident’s mental health provider to obtain an updated prescription. Family members said the resident never returned to a baseline level of functioning. 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, due to cognitive limitations. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Yes. the Action taken by facility: The facility identified the error, took corrective action, and implemented new measures designed to reduce the risk of further occurrence of this or similar errors. The facility trained staff in the new procedure for medication administration. 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 Hennepin County Attorney Edina City Attorney Edina Police Department PRINTED: 05/30/2024 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.

Finding: Substantiated, facility responsibility Nature of Visit: 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 alleged perpetrator (AP) neglected the resident when the resident was found lying on the ground in the patio located next to his apartment window. The resident was admitted to the hospital and passed away two days later due to head injury. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was substantiated. The facility was responsible for the maltreatment. While the AP did not provide safety checks the time the resident left the building and fell outside is unknown and the impact of the missed safety checks cannot be determined. Additionally, the facility failed to ensure its fire exit door from the secured building would alarm and alert staff members if a resident left the building. When the next shift found the resident outside with a head injury from a fall, he was sent to the hospital where he died two days later from his injuries. An equal opportunity employer. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigation included review of resident's records, the AP’s personnel record, facility's policies and procedures, incident reports, and the resident's external medical record. The investigation included an onsite visit, observations, and interactions between residents and facility staff. The resident resided in an assisted living secured memory care building. The resident’s diagnoses include dementia. The resident’s service plan included assistance with all activities of daily living which included hygiene, dressing, toileting, medications, meals, and housekeeping. The service plan also included hourly safety check and wander guard check every shift. The resident’s assessment indicated he was independent with transfer and mobility. The resident’s medical record indicated he had enrolled in hospice about a month prior to the events described in this report. The resident’s incident report and medical records indicated the resident was found at approximately 8:00 a.m. outside of the building on the ground with a possible head injury. The same documents indicated the resident was last seen around 2:00 a.m. The facility contacted 911 and transferred him to the hospital. The facility conducted an internal investigation which included review of security camera footage indicated the resident had been walking in the hallway over the night shift but was escorted back to his room multiple times over the night. The same document indicated unlicensed caregivers were recorded entering and exiting the resident’s room while providing cares for him around 2:00 a.m. No further recorded events were indicated until after 7:00 a.m. when a dayshift unlicensed caregiver entered and exited the resident’s room twice. The same document indicated the resident was not recorded leaving his room possibly due to the dimly lit hallway and/or the motion sensor on the camera was not activated. The resident was found outside on the patio at 8:00 a.m. after exiting a fire exit door which was not in view of the camera. The resident’s death record indicated he died two days later due to a fall resulting in a head injury and intracranial (head) bleeding. During the interview, registered nurse (RN) #1 stated the resident was found fallen outside and had gone out through the fire exit door, which should have been locked at all times. She said the door's battery was malfunctioning, and it did not trigger an alarm when he opened it. Furthermore, she mentioned the door did not have a wander guard system, so the resident's wander guard bracelet did not work on that door. The resident was on hourly safety checks for 24-hours a day, and a camera in the hallway showed the last time staff member leaving the resident’s room was at 2:00 a.m. According to the registered nurse, the resident walked independently without any assistive devices and probably tripped on a garden hose, causing him to fall outside. During an interview, RN #2 stated the resident was wearing a wander guard bracelet and had never attempted to leave the building before. She confirmed that she was working on the day of the incident. When a staff member reported the resident missing, everyone began searching and eventually found him lying outside. 911 was immediately called. The resident had been receiving hourly safety checks, but RN #2 was unsure of when he had last been checked. She also mentioned the door was malfunctioning, which allowed him to exit without triggering an alarm. During an interview, the AP, who is an unlicensed caregiver, stated he worked on the night of the incident. He reported seeing the resident walking along the hallway and noticed the resident needed to be cleaned up, so he and another caregiver brought the resident to his room and provided cares. The AP stated he did not perform hour safety check on the resident because he was not aware that the resident was assigned to him. He also stated that the night of the incident was not his first time working in that building as he works through a staffing agency and had worked there for two weeks prior to this occurrence. During an interview, the director stated the resident was found outside the facility in the garden area. Although the hallway had a camera, it was dark, and the resident was not recorded leaving the building. It was unknown how long the resident had been outside. While the resident had a functional wander guard, it did not work on the malfunctioned fire exit door, so the maintenance team had since changed the battery. The director did not know when the fire door had last been checked prior to this incident. She stated the resident was on hourly safety checks, but the caregiver assigned to him this shift said he did not know he was responsible for him. She said unlicensed caregivers are provided two books to review with the necessary cares and the caregiver may have not reviewed his assignment for the shift. During an interview, the director of maintenance stated he checked the fire exit door after the incident and discovered a dead battery had caused the door not to sound the alarm. He also stated the door was supposed to alarm if the door was opened but he did not know the battery needed to be replaced. He stated he checked the batteries monthly although he did not have any documentation of his checks. After the incident, he began checking all the fire exit doors weekly to ensure that they were functioning correctly and documented each check on paper. 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, the resident is deceased. Family/Responsible Party interviewed: No, attempts to interview unsuccessful Alleged Perpetrator interviewed: Yes Action taken by facility: The facility initiated an internal investigation. The facility chose to no longer use the AP as a caregiver at the facility. The facility provided education to all its caregivers regarding safety checks and notifying the nurse if a resident cannot be located. Furthermore, the facility began checking all fire exit doors weekly and documenting the checks to ensure they were functioning correctly. 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.