Windy Acres Long Term Care 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) financially exploited the resident when the AP took the residents narcotic medication for her own personal use. The resident experienced continued pain because she did not receive her prescribed pain medication. Investigative Findings and Conclusion: The Minnesota Department of Health determined financial exploitation was substantiated. The AP was responsible for the maltreatment. The AP sign out the resident’s narcotic pain medication, hydromorphone (Dilaudid), on multiple occasions and placed the tablets in her pocket. The AP told staff and the police she took the resident’s Dilaudid for her own personal use. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted law enforcement. The investigation included review of the resident record, death record, pharmacy records, facility medication errors, personnel files, staff schedules, law enforcement report, and facility policy and procedures. Also, the investigator observed resident interactions with staff. The resident resided in an assisted living facility memory care unit. The resident’s diagnoses included breast cancer and diabetes. The resident’s services included assistance with activities of daily living, housekeeping, laundry, meals, and medication management. The resident’s assessment indicated the resident was vulnerable to financial exploitation. The resident’s medication administration record (MAR) indicated the resident was prescribed Dilaudid 2 milligram (mg) tablets, ½ a tablet as needed every two hours. On the MAR, highlighted in pink, were the dates and times the AP signed out the resident’s Dilaudid that corresponded with facility recorded videos where the AP was observed signing out and placing the resident’s Dilaudid in her pocket. The police report indicated police reviewed the video footage and interviewed the AP. The AP said she was, “definitely not” following medication passing procedures, and what the AP did was “100% against every policy,” for passing medications. The AP stated she took six of the resident’s Dilaudid tablets. She took a pill one night to try and help her sleep and it did not work. The AP said she did not think the dose was high enough, so the next time she took three of the resident’s Dilaudid tablets. The AP said she took the last remaining two pills she had left because she was “waiting to get a third one” but was fired before she could get it. The case was forwarded for consideration of charges for Theft and Criminal Neglect. Video footage revealed, on eight separate occasions, the AP signing out the resident’s narcotic medication and placing it in her pocket. When interviewed, an administrator stated she reviewed video footage for an unrelated incident and witnessed the AP sign out the resident’s Dilaudid and place it in her pocket. The administrator pulled up the resident’s MAR to compare it with the video footage. The administrator printed out the resident’s MAR and highlighted in pink all the AP’s medication passes that were associated with video clips showing the AP placing the resident’s Dilaudid in her pocket. The administrator filed a police report and met with the AP, who told her she did take the Dilaudid for her personal use. When interviewed, an office assistant said the resident was on hospice care and received Dilaudid for pain management. When reviewing camera footage for an unrelated incident, she and other staff witnessed the AP sign out the resident’s Dilaudid and place it in her pocket. The resident had died the previous day, so staff pulled the resident’s MAR and compared them to times and days the AP did the medication pass. Staff were able to coordinate video footage with the medication passes and found eight instances where the AP placed the resident’s Dilaudid in her pocket. The office assistant said the AP told her she took the resident’s Dilaudid for her own use. During a consultation, a police officer said the AP told police she took the Dilaudid. The case was forwarded to the county attorney for charges of felony theft of narcotics and criminal neglect. In conclusion, the Minnesota Department of Health determined financial exploitation 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. Financial exploitation: Minnesota Statutes, section 626.5572, subdivision 9 "Financial exploitation" means: (b) In the absence of legal authority a person: (1) willfully uses, withholds, or disposes of funds or property of a vulnerable adult; (2) obtains for the actor or another the performance of services by a third person for the wrongful profit or advantage of the actor or another to the detriment of the vulnerable adult; (3) acquires possession or control of, or an interest in, funds or property of a vulnerable adult through the use of undue influence, harassment, duress, deception, or fraud; or (4) forces, compels, coerces, or entices a vulnerable adult against the vulnerable adult's will to perform services for the profit or advantage of another. Vulnerable Adult interviewed: No, deceased. Family/Responsible Party interviewed: No, the resident was her own guardian. Alleged Perpetrator interviewed: No, the AP did not respond to interview requests. the Action taken by facility: The facility retrained staff regarding narcotic medications and filed a police report. The AP is no longer employed at the facility. 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. 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 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 Chisago County Attorney Forest Lake City Attorney Forest Lake Police Department Minnesota Board of Executives for Long Term Services and Supports PRINTED: 04/30/2025 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 _____________________________ 30515 04/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 7040 LAKE BOULEVARD WINDY ACRES LONG TERM CARE INC FOREST LAKE, MN 55025 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 CORRECTION using federal software. Tag numbers have ORDER been assigned to Minnesota State Statutes for Assisted Living Facilities. The In accordance with Minnesota Statutes, section assigned tag number appears in the 144G.08 to 144G.95, these correction orders are far-left column entitled "ID Prefix Tag." The issued pursuant to a complaint investigation. state Statute number and the corresponding text of the state Statute out Determination of whether a violation is 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 a Minnesota Statute contains several are in violation of the state requirement items, failure to comply with any of the items will after the statement, "This Minnesota be considered lack of compliance. requirement is not met as evidenced by." Following the evaluators' findings is the INITIAL COMMENTS: Time Period for Correction. #HL305158943C/#HL305159622M PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On April 1, 2025, the Minnesota Department of STATES,"PROVIDER'S PLAN OF Health conducted a complaint investigation at the CORRECTION." THIS APPLIES TO above provider, and the following correction FEDERAL DEFICIENCIES ONLY. THIS orders are issued. At the time of the complaint WILL APPEAR ON EACH PAGE.