Oak Terrace Senior Housing of.

Finding: Substantiated, individual responsibility, AP1. Inconclusive, individual responsibility AP2. 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 #1 and AP #2) abused the resident when AP #1 and AP #2 were in the bathroom to assist the resident after he used the toilet. AP #2 saw AP #1 begin recording a video of the resident while his pants were down and swinging his T-shirt at them. AP #2 asked AP #1 To send her the video since it was funny. Investigative Findings and Conclusion: The Minnesota Department of Health determined abuse was substantiated. AP#1 was found and AP#2 were responsible for the maltreatment. AP#1 recorded the resident and shared the video with AP#2 via Snapchat. The investigator conducted interviews with facility staff members, including administrative staff and unlicensed staff. The investigator contacted the resident's family member. The investigation included review of resident's records, the AP#1 and AP#2’s personnel record, facility's policies and procedures, incident reports. 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, and medications. One afternoon, AP#1 and AP#2 assisted the resident in using the bathroom. The resident became agitated and started throwing punches at the staff. While AP#2 tried to calm the resident, AP#1 took out her phone and recorded the resident as he swung his shirt toward them. The video screen shot showed the resident sitting on the toilet, half-naked with his pants down, holding his t-shirt with one hand. After the incident, AP#1 shared the video via Snapchat, and AP#2 asked her to send the video to her phone. During an interview, AP#1 stated she had worked at the facility for around six months. She said she was with AP#2 in the bathroom to assist the resident when the resident became aggressive and started swinging his shirt around. While AP#2 was trying to calm him down, she said she stepped back and began recording a video of him. She claimed her intention was to show others how bad his behavior was. She stated that she and AP#2 discussed the incident but did not laugh about it. She said she sent the video to AP#2 but deleted immediately after another unlicensed caregiver saw it. She stated she did not send it to anyone else. She said the incident happened on Friday, and she was fired on Monday. She explained that the reason she did not tell anyone was because it was the weekend, and no manager was in the building. During an interview, AP#2 stated that she and AP#1 went to the bathroom to help the resident get changed. The resident became agitated and started throwing punches at both her and AP#1. She said she was trying to calm him down while AP#1 recorded a video of him. She stated the video did not show any of his private areas. She said AP#1 shared the video with her on Snapchat, although she had not asked for it. She explained that on Snapchat, a person can choose who to send a picture or video to and can snap back and forth. AP#1 only sent that video to her, and it disappeared after being viewed. She stated while it is possible to screenshot a snap, she said she did not do that. She said that AP#1 should not have recorded the video but explained that she had no one to report it to since there was no nurse in the building over the weekend. She acknowledged she should have reported the incident immediately but did not. She said another unlicensed caregiver made the report and she and AP#1 were let go after the incident. During an interview, an unlicensed caregiver stated that she saw AP#1 and AP#2 at the nurses' station, laughing while on their phones. She said she heard AP#2 ask AP#1 to send her the video because it was so funny. Then, AP#1 asked the unlicensed caregiver if she wanted to see the video of the resident and showed it to her. She said AP#1 showed her a video of the resident sitting on the toilet, half-naked with his pants down, holding his t-shirt in one hand and trying to hit AP#1 and AP#2 with it. She said she then emailed the facility manager to report what happened and also sent a picture of AP#1 showing her the video to the director. During an interview, a manager stated she received a report from the unlicensed caregiver about AP#1 and AP#2. She said the complaint was about AP#1 recording a video of the resident throwing his shirt in the air. She began the investigation and spoke with AP#2, while another manager spoke with AP#1. She said they fired AP#1 immediately, and since AP#2 changed her story multiple times and was not honest, they decided to let her go as well, even though she was not the one who recorded the resident. The manager stated there was also a witness who reported that she heard AP#2 asked AP#1 to send her the video. The manager also stated that she notified the police department and the resident’s family about the incident. In conclusion, the Minnesota Department of Health determined abuse was substantiated for AP1 and inconclusive for AP2. 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: (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: no, unable to be interviewed due to dementia. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Yes. Action taken by facility: The facility reported to the police department, started the investigation. AP#1 and AP#2 are no longer employed by 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. 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.

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 facility neglected the resident when the resident was admitted to the hospital with an unstageable coccyx (tailbone) wound. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. The facility was responsible for the maltreatment. The resident was admitted to the hospital with an unstageable pressure ulcer on her coccyx. The facility denied having any prior knowledge of the pressure injury before the resident’s hospitalization. The investigator conducted interviews with facility staff members, including administrative staff, and nursing staff. The investigation included review of the resident’s records, internal investigation documentation, incident reports, personnel files, staff schedules, policies, and procedures. The resident resided in an assisted living facility. The resident’s diagnoses heart failure and muscle weakness. The resident’s service plan included assistance from one person for bed mobility and two persons with a Sara Steady [partial assist mechanical lift] for all transfers. According to the assessment three months prior to the incident, the resident was at risk for skin breakdown and had no active wounds. The same document indicated facility provided assistance with a shower scheduled once a week. One day, the resident complained of shortness of breath and was admitted to the hospital due to fluid overload. During this hospitalization, the resident was found to have an unstageable pressure ulcer [a type of pressure ulcer which occurs when prolonged pressure on the skin cuts off blood flow and oxygen to the tissue] on her coccyx and her left heel. Hospital records indicated the wound on the resident’s coccyx had necrotic [dead] tissue, and the depth was unclear. The same records indicated the wound had a foul smell and yellow drainage. Additionally, the hospital identified a pressure wound on her left heel. The progress notes indicated the facility was unaware of the wound until the hospital provided notification of it. During an interview, a manager stated she did not know about the wound until the hospital called. The manager said before the resident’s hospitalization, the resident would call if she needed to change positions. After her hospitalization, the resident was placed on a schedule of repositioning every two hours. The manager also stated that she performed a basic skin assessment during admission and the facility only conducts skin assessments when a resident has a concern about their skin. During an interview, a nurse stated the resident did not have the wound before she went to the hospital, or at least she was unaware of it. The nurse said the wound was present and open when the resident returned. According to the nurse, the facility’s policy required staff to check the resident’s skin on their shower day or whenever staff assist the resident with toileting. In conclusion, the Minnesota Department of Health determined neglect was not 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 was deceased. Family/Responsible Party interviewed: No, attempted but did not reach. Alleged Perpetrator interviewed: Not Applicable. the Action taken by facility: No action taken. 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 Le Seur County Attorney Le Seur City Attorney Le Seur Police Department PRINTED: 08/29/2024 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 32437 B. WING _____________________________ 07/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 811 SOUTH 4TH STREET OAK TERRACE OF LE SUEUR LLC LE SUEUR, MN 56058 (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 On July 16, 2023, the Minnesota Department of Minnesota Department of Health is Health initiated an investigation of complaint documenting the State Correction Orders HL324372180M/HL324371123C . The following using federal software. Tag numbers have correction order is issued, tag identification 2310 been assigned to Minnesota State and 2360. 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 is listed in the "Summary Statement of Deficiencies" column. This column also includes the findings which are in violation of the state requirement after the statement, "This Minnesota requirement is not met as evidenced by." Following the evaluators ' findings is the Time Period for Correction. PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH STATES,"PROVIDER'S PLAN OF CORRECTION." THIS APPLIES TO FEDERAL DEFICIENCIES ONLY. THIS 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. 02310 144G.91 Subd. 4 (a) Appropriate care and 02310 SS=G services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 A8RQ11 If continuation sheet 1 of 4 PRINTED: 08/29/2024 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 32437 B. WING _____________________________ 07/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 811 SOUTH 4TH STREET OAK TERRACE OF LE SUEUR LLC LE SUEUR, MN 56058 (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) 02310 Continued From page 1 02310 (a) Residents have the right to care and assisted living services that are appropriate based on the resident's needs and according to an up-to-date service plan subject to accepted health care standards. This MN Requirement is not met as evidenced by: Based on interview and document review, the licensee failed to provide appropriate care and services for one of one resident (R1) reviewed. The licensee failed to implement an up-to-date individualized service plan following accepted health care standards for R1 who had a risk for skin breakdown. This practice resulted in a level three violation (a violation that harmed a resident's health or safety, not including serious injury, impairment, or death, or a violation that has the potential to lead to serious injury, impairment, or death) and was issued at an isolated scope (when one or a limited number of residents are affected or one or a limited number of staff are involved or the situation has occurred only occasionally). The findings include: R1 moved into the facility on August 28, 2023, due to diagnoses including heart failure and muscle weakness. R1's service plan no dated, indicated the resident needed assistance from one person for bed mobility and two persons with a Sara Steady (partial mechanical lift device) for all transfers.