Elk River Senior Living.

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 alleged perpetrator (AP) abused a resident when the AP attempted to force medications into the resident’s mouth. Investigative Findings and Conclusion: The Minnesota Department of Health determined abuse was not substantiated. Although the AP’s actions were unprofessional and not therapeutic, the AP did not force the medications into the resident’s mouth. Unlicensed personnel (ULP) witnessed the AP place her left hand on the resident’s chin with her thumb on one side of his cheek and fingers on the other cheek. During the AP’s action, the resident was able to and continued to move his head from side to side to avoid the spoon. The spoon did not enter the resident’s mouth. There was no visible facial skin marks observed. The facility retrained staff on conduct with residents. The investigator conducted interviews with facility staff members, including nursing staff, and unlicensed staff. The AP declined to interview. The investigation included review of the resident records, facility internal investigation, facility incident reports, a personnel file, and related facility policy and procedures. Also, the investigator observed the resident and staff interactions with the resident. The resident resided in an assisted living memory care unit. The resident’s diagnoses included Alzheimer’s disease. The resident’s service plan included assistance with medication administration. The resident’s assessment indicated the resident was disoriented, had aphasia (loss of the ability to produce or comprehend language,) and took medications crushed in soft food. The facility’s internal investigation indicated a ULP witness stated the resident had moved his head side to side and pressed his lips together during medication administration. The AP held the resident’s chin and tried to force medication into the resident’s mouth. The ULP indicated in a written statement the resident was refusing his medications and moved his face side to side. The ULP stated the AP grabbed the resident’s face and forced medication into his mouth. The facility’s internal investigation indicated the AP denied grabbing the resident’s face or attempt to force medication into his mouth. The AP said she touched the resident’s cheek to see if he would take the medication. During an interview, the ULP stated herself and the AP were both in the resident’s room. The AP was administering medication, the ULP was in the room at the same time to empty the resident’s catheter bag. The resident was nonverbal. The resident was awake and seated in a chair. The resident’s medication was crushed in soft food and on a spoon. The ULP stated herself and the AP told the resident prior to administration, they were going to give him his medication. When the AP brought the spoon up to the resident’s mouth, the resident moved his head side to side, his mouth was closed. During the second attempt, the ULP said she tried to administer the spoonful of medication but still refused. The ULP said the resident was not shaking his head as if saying no, he moved his head to avoid and dodge the spoon when brought up to his mouth. The AP attempted again. During the third attempt the AP brought the spoon up to the resident’s mouth, the resident continued to move his head from side to side with his mouth closed. The ULP said at that point, the AP “grabbed” the resident’s face to hold his head still. When asked what she meant by grab, the ULP said the AP’s left hand was on the resident’s chin with her thumb on one side of his cheek and her fingers on the other cheek. The ULP stated the resident continued to move his head from side to side during the AP’s actions and there was no physical skin marks observed after the incident. The ULP stated the spoon did not enter the resident’s mouth nor was the medication administered. The resident did not take his medication. When asked what the resident did after these medication administration attempts, the ULP stated the resident appeared “fine” and said nothing abnormal was observed. Both staff members left the resident’s room. The resident’s medication administration record indicated the resident did not receive the medication the day and time in question. During an interview, nurse 1 stated the resident was nonverbal. Nurse 1 said the resident’s dementia was advanced, participation in medication administration varied, and had been challenging for staff. The resident had an order to crush medication and put in soft food. The facility used food items such as pudding or yogurt. The facility used various techniques to encourage compliance. Techniques included unlicensed staff attempting administration three times, to come back later, or a different staff member trying. The nurse said the resident took medications sometimes at other times he did not. Nurse 1 said when she seen the resident, the resident did not have any visible marks on his face. Nurse 1 also said the resident did not display any body language of fear or act in a way where he did not want anyone to approach him. Nurse 1 said there had been no similar allegations against the AP involving attempts to force residents to take medications. Nurse 1 also said there were no cameras in the resident’s room. During an interview, nurse 2 stated she had seen the AP interact with the resident and other residents. Nurse 2 said she had not seen or heard of any resident appearing fearful or scared around the AP. Nurse 2 said the resident had since admitted to hospice services, most of the resident’s crushable medications had since discontinued, and there was a medication administered in liquid form. The AP declined to interview. In conclusion, the Minnesota Department of Health determined abuse 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. 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; 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. (c) Any sexual contact or penetration as defined in section 609.341, between a facility staff person or a person providing services in the facility and a resident, patient, or client of that facility. (d) The act of forcing, compelling, coercing, or enticing a vulnerable adult against the vulnerable adult's will to perform services for the advantage of another. Vulnerable Adult interviewed: Yes. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: No. Declined an interview. the Action taken by facility: The facility conducted an internal investigation, provided staff reeducation on the facility’s code of conduct and vulnerable adult reporting. The AP is no longer employed by the facility. Action taken by the Minnesota Department of Health: No further action taken at this time.

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. STATE CORRECTION ORDERS The enclosed State Form documents the state correction orders. 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 based on the level and scope of the violations; h owever, 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 An equal opportunity employer. Letter ID: IS7N REVISED 09/13/2021 Elk River Senior Living April 10, 2025 Page 2 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 The MDH Health Regulation Division (HRD) values your feedback about your experience during the survey and/or investigation process. Please fill out this anonymous provider feedback questionnaire at your convenience at this link: h ttps://forms.office.com/g/Bm5uQEpHVa. Your input is important to us and will enable MDH to improve its processes and communication with providers. If you have any questions regarding the questionnaire, please contact Susan Winkelmann at susan.winkelmann@state.mn.us or call 651-201-5952. 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, Kelly Thorson, Supervisor State Evaluation Team Email: kelly.thorson@state.mn.us Telephone: 320-223-7336 Fax: 1 -866-890-9290 JMD PRINTED: 04/10/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 34079 03/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 11124 183RD CIRCLE NW ELK RIVER SENIOR LIVING ELK RIVER, MN 55330 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 LICENSING Minnesota Department of Health is CORRECTION ORDER(S) 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 survey. assigned tag number appears in the far-left column entitled "ID Prefix Tag." The Determination of whether violations are corrected state Statute number and the requires compliance with all requirements corresponding text of the state Statute out provided at the Statute number indicated below. of compliance is listed in the "Summary When Minnesota Statute contains several items, Statement of Deficiencies" column. This failure to comply with any of the items will be column also includes the findings which considered lack of compliance. are in violation of the state requirement after the statement, "This Minnesota INITIAL COMMENTS: requirement is not met as evidenced by." Following the evaluators ' findings is the SL34079016-0 Time Period for Correction. On March 10, 2025, through March 12, 2025, the PLEASE DISREGARD THE HEADING OF survey at the above provider. At the time of the STATES,"PROVIDER'S PLAN OF survey, there were 94 residents; 58 receiving CORRECTION." THIS APPLIES TO services under the Assisted Living Facility with FEDERAL DEFICIENCIES ONLY. THIS Dementia Care license. WILL APPEAR ON EACH PAGE. 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. 0 480 144G.41 Subdivision 1 Subd. 1a (a-b) Minimum 0 480 SS=F requirements; required food services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 YPC111 If continuation sheet 1 of 23 PRINTED: 04/10/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 34079 03/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 11124 183RD CIRCLE NW ELK RIVER SENIOR LIVING ELK RIVER, MN 55330 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) 0 480 Continued From page 1 0 480 (a) Except as provided in paragraph (b), food must be prepared and served according to the Minnesota Food Code, Minnesota Rules, chapter 4626. (b) For an assisted living facility with a licensed capacity of ten or fewer residents: (1) notwithstanding Minnesota Rules, part 4626.0033, item A, the facility may share a certified food protection manager (CFPM) with one other facility located within a 60-mile radius and under common management provided the CFPM is present at each facility frequently enough to effectively administer, manage, and supervise each facility's food service operation; (2) notwithstanding Minnesota Rules, part 4626.0545, item A, kick plates that are not removable or cannot be rotated open are allowed unless the facility has been issued repeated correction orders for violations of Minnesota Rules, part 4626.1565 or 4626.1570; (3) notwithstanding Minnesota Rules, part 4626.0685, item A, the facility is not required to provide integral drainboards, utensil racks, or tables large enough to accommodate soiled and clean items that may accumulate during hours of operation provided soiled items do not contaminate clean items, surfaces, or food, and clean equipment and dishes are air dried in a manner that prevents contamination before storage; (4) notwithstanding Minnesota Rules, part 4626.1070, item A, the facility is not required to install a dedicated handwashing sink in its existing kitchen provided it designates one well of a two-compartment sink for use only as a handwashing sink; (5) notwithstanding Minnesota Rules, parts 4626.1325, 4626.1335, and 4626.1360, item A, existing floor, wall, and ceiling finishes are STATE FORM 6899 YPC111 If continuation sheet 2 of 23 PRINTED: 04/10/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 34079 03/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 11124 183RD CIRCLE NW ELK RIVER SENIOR LIVING ELK RIVER, MN 55330 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) 0 480 Continued From page 2 0 480 allowed provided the facility keeps them clean and in good condition; (6) notwithstanding Minnesota Rules, part 4626.