Whispering Oak Place.

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: The alleged perpetrator (AP) abused the resident when the AP placed his hand under the resident’s shirt and on her chest after she asked the AP to check her heart rate. The AP also touched her thigh and groin area later the same night. Investigative Findings and Conclusion: The Minnesota Department of Health determined abuse was inconclusive. The AP, who was an unlicensed caregiver, and the resident had different accounts of their interactions that night and there were no witnesses to the incident. The investigator conducted interviews with facility staff members, including administrative staff and unlicensed staff. The investigator contacted law enforcement and case workers. The investigation included review of the resident record, facility internal investigation, facility incident reports, personnel files, staff schedules, and related facility policy and procedures. The resident resided in an assisted living facility. The resident’s diagnoses included heart failure and diabetes. The resident’s service plan included assistance with insulin and blood sugar management, medications and stand-by bathing assistance. The resident’s assessment indicated she was oriented, independent with decision-making and able to make her needs known. A concern arose when it was reported the AP responded to a request to check the resident’s pulse as she felt it was low. While she offered her wrist for palpation, the AP checked her pulse on her chest claiming that was better. It was also reported the AP touched the resident’s legs and groin later that same night. The concern was reported about two days after it was alleged to have occurred [the alleged event occurred Wednesday and was reported Friday]. The resident’s progress notes indicated the resident provided an account of the incident and stated the AP came into her room and put his hand under her shirt and groped her legs and groin. When the resident was asked if she needed to talk about the incident, the resident stated that she did not remember whether she took her medication or not that night and did not know if she was dreaming or if it really happened. The same document indicated the resident was told the incident was being investigated. The facility provided an email from the AP dated the same day the event was reported, Friday, which indicated he did enter the resident’s room to administer her medications that evening but denied touching or fondling the resident. A review of the electronic medication record indicated the AP did document giving the resident her medications the previous Wednesday evening. The following Monday the resident’s progress notes indicated the resident was asked to write a description for what occurred. The resident wrote a note stating the event occurred as the caregiver wrote it down, but did not provide further description. Also on that Monday, a police report indicated the facility contacted law enforcement. The police report indicated the resident reported she requested a pulse check and offered her wrist, but the AP said he had a “better way”, put his hand under her shirt, and touched her breast over her bra. Later, the same evening he returned to check on her, put his hand down her pants, and rubbed her thigh and her vagina over her underwear. About a month later, the police were advised by the facility she may have been dreaming about the sexual assault and so the police re-interviewed the resident again. During that interview, the resident related the same events and denied it was a dream although she described is as a “nightmare”. The same document indicated the resident said no one was else was present and the AP neither said anything nor asked the resident to touch him. During an interview, the AP denied having any physical contact with the resident other than to give her medications, empty her garbage and have a brief conversation. During an interview, the resident stated the AP touched her and, while she did not recall the date, she stated it occurred on a Wednesday. 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; 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: No. Alleged Perpetrator interviewed: Yes. Action taken by facility: The facility suspended the AP and conducted an internal investigation. The facility notified the resident’s provider and reported the incident to law enforcement. Action taken by the Minnesota Department of Health: No further action taken at this time. cc: The Office of Ombudsman for Long Term Care The Office of Ombudsman for Mental Health and Developmental Disabilities PRINTED: 03/14/2025 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 _____________________________ 30599 02/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 903 CALVERLY COURT WHISPERING OAK PLACE ELLENDALE, MN 56026 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 On February 19, 2025, the Minnesota Department of Health initiated an investigation of complaint #HL305997584M /HL305993046C and HL305997324M / HL305992520C. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 KH4I11 If continuation sheet 1 of 1

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: The alleged perpetrator (AP) abused the resident when the AP took the resident by her arm to her room after an incident. This resident sustained two bruises on her arm. Investigative Findings and Conclusion: The Minnesota Department of Health determined abuse occurred was inconclusive. While it was true the interaction between the AP and resident likely caused a bruise on the resident’s arm, it was in the context of the resident swinging to hit the AP. The AP then walked the resident to her apartment while holding her arm in an effort to calm her down. The investigator conducted interviews with facility staff members. The investigation included review of the resident record, facility internal investigation, facility incident reports, personnel files, staff schedules, and related facility policy and procedures. Also, the investigator observed resident’s during day activities and staff interactions with them during a visit to the facility. The resident resided in an assisted living facility. The resident’s diagnoses included mild cognitive impairment and vitamin B12 deficiency (which increases the risk of bruising). The resident’s service plan included assistance with medication administration and reminders with personal hygiene. The resident’s assessment indicated she had difficulty with memory and displayed deficit in judgement. The nursing progress notes indicated the resident got upset with the AP, who worked in the activities department, swung out and hit him in the face. The AP then escorted the resident back to her room in an effort to calm her down. The nursing notes indicated the resident’s primary doctor was contacted regarding a bruise to her upper right arm. An employee counseling note indicated the AP reported an incident when the resident became angry, hit at the AP, and threw a bag of crackers at him. The AP attempted to verbally redirect the resident, however when the resident hit out at the AP, he tried to stop the resident from hitting him and walked the resident to her apartment. The AP received verbal coaching after the incident. The AP gave a written statement at the time of the incident which indicated the resident became verbally and physically upset with him when the activity program was not getting started. The AP walked the resident to her apartment while holding her hands to prevent any harm to either of them. During an interview, the nurse stated the resident was asked about what happened during the incident and the resident knew which staff member the incident was with but was confused about what happened. A resident who witnessed the incident stated it started when the resident swung out at the AP. During an interview with this investigator, the AP stated he was asked to cover some unlicensed caregiver duties prior to the start of his activities until a replacement arrived. While he waited for his replacement to show up and d tending to other residents, the resident became upset when activities were not started. He stated the resident became verbally confrontational, threw a package of crackers at him and swung out at him, which he caught in midair and held. The resident began to hit, bite, and scratch the AP so he walked her to her apartment. The AP stated he did not force her but held her by the arm. The AP stated he saw the thumbprint bruise on her arm the next day and admitted it probably occurred during the incident. During interview with this investigator, the resident recalled the incident but did not know why it happened. She stated the AP grabbed her arm and “hauled” her down the hallway. During an interview, a family member stated they became aware of the incident with the AP when, on the following day, the resident said she was afraid to go on the bus for an outing with AP aboard and observed the bruising on her arm. 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; 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: Yes. Action taken by facility: The facility suspended the employee and conducted an internal investigation of the incident. The AP was given verbal coaching and retraining on handling workplace situations and returned to work at the facility. Action taken by the Minnesota Department of Health: No action at this time. cc: The Office of Ombudsman for Long Term Care The Office of Ombudsman for Mental Health and Developmental Disabilities PRINTED: 03/14/2025 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 _____________________________ 30599 02/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 903 CALVERLY COURT WHISPERING OAK PLACE ELLENDALE, MN 56026 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 On February 19, 2025, the Minnesota Department of Health initiated an investigation of complaint #HL305997584M /HL305993046C and HL305997324M / HL305992520C. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 KH4I11 If continuation sheet 1 of 1

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 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 Whispering Oak Place August 16, 2024 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 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, Jodi Johnson, Supervisor State Evaluation Team Email: Jodi.Johnson@state.mn.us Telephone: 507-344-2730 Fax: 1-866-890-9290 HHH PRINTED: 08/16/2024 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 30599 07/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 903 CALVERLY COURT WHISPERING OAK PLACE ELLENDALE, MN 56026 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 LICENSING using federal software. Tag numbers have CORRECTION ORDER(S) been assigned to Minnesota State Statutes for Assisted Living Facilities. The In accordance with Minnesota Statutes, section assigned tag number appears in the far 144G.08 to 144G.95, these correction orders are left column entitled "ID Prefix Tag." The issued pursuant to a survey. state Statute number and the corresponding text of the state Statute out Determination of whether violations are 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 Minnesota Statute contains several items, are in violation of the state requirement failure to comply with any of the items will be after the statement, "This Minnesota considered lack of compliance. requirement is not met as evidenced by." Following the evaluators ' findings is the INITIAL COMMENTS: Time Period for Correction. SL30599015-0 PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On July 22, 2024, through July 24, 2024, the STATES,"PROVIDER'S PLAN OF survey at the above provider, and the following FEDERAL DEFICIENCIES ONLY. THIS correction orders are issued. At the time of the WILL APPEAR ON EACH PAGE. survey, there were 28 resident(s); 25 receiving services under the provider's Assisted Living THERE IS NO REQUIREMENT TO Facility with Dementia Care license. 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. 0 470 144G.41 Subdivision 1 Minimum requirements 0 470 SS=F (11) develop and implement a staffing plan for LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 HSS411 If continuation sheet 1 of 30 PRINTED: 08/16/2024 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 30599 07/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 903 CALVERLY COURT WHISPERING OAK PLACE ELLENDALE, MN 56026 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) 0 470 Continued From page 1 0 470 determining its staffing level that: (i) includes an evaluation, to be conducted at least twice a year, of the appropriateness of staffing levels in the facility; (ii) ensures sufficient staffing at all times to meet the scheduled and reasonably foreseeable unscheduled needs of each resident as required by the residents' assessments and service plans on a 24-hour per day basis; and (iii) ensures that the facility can respond promptly and effectively to individual resident emergencies and to emergency, life safety, and disaster situations affecting staff or residents in the facility; (12) ensure that one or more persons are available 24 hours per day, seven days per week, who are responsible for responding to the requests of residents for assistance with health or safety needs. Such persons must be: (i) awake; (ii) located in the same building, in an attached building, or on a contiguous campus with the facility in order to respond within a reasonable amount of time; (iii) capable of communicating with residents; (iv) capable of providing or summoning the appropriate assistance; and (v) capable of following directions; This MN Requirement is not met as evidenced by: Based on interview and record review, the licensee failed to ensure the required staffing plan was developed as required, potentially affecting the licensee's residents, staff, and any visitors of the licensee. This practice resulted in a level two violation (a violation that did not harm a licensee's health or safety but had the potential to have harmed a resident's health or safety, but was not likely to STATE FORM 6899 HSS411 If continuation sheet 2 of 30 PRINTED: 08/16/2024 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 30599 07/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 903 CALVERLY COURT WHISPERING OAK PLACE ELLENDALE, MN 56026 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) 0 470 Continued From page 2 0 470 cause serious injury, impairment, or death), and was issued at a widespread scope (when problems are pervasive or represent a systemic failure that has affected or has potential to affect a large portion or all of the residents). The findings include: The licensee held an assisted living with dementia care license and was licensed for a capacity of 48 residents, with a current census of 28 residents. On July 22, 2024, at 1:15 p.m.

Findings: 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): Allegation #1: The facility abused the resident when multiple bruises were discovered on the resident’s arms and legs. Allegation #2: The facility neglected the resident when the resident was found lying in bed and soiled on several occasions. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted resident family member and the hospice agency. The investigation included review of facility progress notes, incident reports, service plan, medications, treatments, and hospice records. During an onsite visit, the investigator made observations of staff interactions with residents. The resident resided in an assisted living memory care unit. The resident’s diagnoses included: dementia, anxiety, protein calorie malnutrition, and fall history. The resident’s facility assessment indicated the resident required full help with bathing, dressing, transfers, and toileting needs. This same document indicated the resident required check and change every two hours related to incontinence and repositioning to prevent pressure sores. The resident was enrolled in hospice. The resident’s hospice care plan indicated services to included weekly nursing visits, hospice aide to assist with weekly shower, and massage therapy for tension and circulation. The hospice plan of care indicated hospice provided a Hoyer lift (mechanical lift with sling used to lift and transfer) for two staff to transfer the resident from bed to wheelchair and wheelchair to bed. The resident’s assessment indicated the resident was at risk for abuse as she is difficult to understand, and staff members had been trained to report any suspected abuse to facility manager. Investigative Findings and Conclusion: Allegation #1: The Minnesota Department of Health determined abuse was not substantiated. Although the resident presented with multiple bruising, both facility staff and family member stated the resident’s skin was fragile along with her long history of bruising that resident had experienced before entering the facility. The resident’s care plan indicated the facility was aware of the resident’s prone to bruising on both arms and legs. At times resident displayed agitation and physical aggression towards staff members including kicking, hitting, pinching, and biting. At times, the resident would fold her arms tightly to her body to her chest to prevent cares. The assessment indicated the resident was at high risk for falls and did not walk. The progress notes documented occurrence of falls which resulted in skin tears and bruising. The medical record indicated the resident’s behaviors included striking out at staff members and kicking. The use of the Hoyer lift sling for transfers in combination with the resident’s behaviors increased the risk of bruising to arms, hands, and legs. Facility progress notes indicated monitoring of skin and wounds were completed both by the facility and hospice. Hospice services included weekly nurse visits along with a home health aide who provided one shower a week. The hospice services increased as the resident’s health declined. Hospice provided medical equipment such as a knee pillow to place between resident’s legs due to her history of bruising, specialty mattress, and a Broda chair (chair that provides supportive positioning) to alleviate pressure to bony areas. The same documents indicated resident had arm edema compression wraps were used to decrease the edema (swelling) along with heel protectors to prevent heel breakdown. During an interview, an unlicensed caregiver stated the resident was on hospice cares and required a mechanical lift and two staff for transfers and bed mobility. The caregiver stated the resident had periods of resistance by striking out, biting, and hitting staff. The resident bruised easily even when just touched. The resident’s refusal of care or skin concerns were documented. Multiple hospice nurses were interviewed and concurred that the hospice admitting diagnosis was severe protein and calorie deficient malnutrition. The resident did experience frequent falls as she was not aware of her deficits. Nurse #1 stated the resident experienced bumps, bruises, and skin tears. Nurse #1 stated there was discussion of relocating the resident to another facility due to falls and bruising. Nurse #2 stated she took over the resident’s hospice cares during the last six months prior to her death. She stated the resident required additional assistance due to her expected decline in health such as an increase from one person to two people for transfers and cares. Nurse #2 said the resident had extremely fragile skin and provided teaching and assistance to help elevate limbs and reduce swelling. During an interview, a family member stated the resident has always bruised easily. The family member stated the resident would fight and strike out at staff during cares. She stated she witnessed the staff members offers cares that the resident sometimes refused. In conclusion, the Minnesota Department of Health determined abuse was not substantiated. Allegation #2: The Minnesota Department of Health determined neglect was not substantiated. The resident at times refused cares, which was consistent with the facility staff members documentation. The residents’ refusals included times when the resident was incontinence and frequently would not allow staff members to change her. The assessment indicated the resident preferred to sleep late in the morning and majority of the days she preferred to sleep all day. The same document indicated she was also incontinent of bowel and bladder. The care plan indicated the resident was to be checked and changed every two hours and as needed. The progress notes indicated that at times the resident refused to get out of the bed and would be in bed the entire duration of a shift and into the next shift. When the resident refused cares the staff members would reapproach and/or have a different staff member or nurse offer cares. Hospice records indicate the resident’s health declined and would sleep for exceptionally long periods. The same notes indicated resident would have arm edema compression wraps were used to decrease the edema along with heel protectors to prevent heel breakdown. Facility staff worked closely with hospice staff to provide care. During an interview, unlicensed caregiver stated the facility had trained staff on how to approach the resident during refusals, but also about the residents’ right to refuse cares. During an interview hospice nurse #1 stated she did at times find the resident with soiled with dried bowel movement during hospice visits. The licensed hospice staff (RN-1) stated this was from resident being in bed for extended periods of time. During an interview hospice nurse #2 stated he worked with the facility to provide medical equipment for resident comfort. Nurse #2 stated the facility contacted her with any concerns and she increased hospice nurse visits and hospice aide visits as the resident declined. During an interview, a family member stated the resident goes through patterns where she will sleep for days and not allow staff to perform cares. The family member stated refusing cares by holding her arms tightly over her chest and staff attempting interventions to care for the resident. The family member stated she was there almost daily and felt the resident received diligent care by the facility. In conclusion, the Minnesota Department of Health determined neglect 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 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 Neglect: Minnesota Statutes, section 626.5572, subdivision 17 "Neglect" means neglect by “Neglect” means neglect by a caregiver or self-neglect.