Lewiston Senior Living.

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(s): The alleged perpetrator abused the resident while applying lotion to her shoulder, then proceeded to apply lotion to her breasts and rubbed them. A few days later, while again applying cream to her back, the alleged perpetrator rubbed the resident's buttocks with both hands, making her feel uncomfortable. Investigative Findings and Conclusion: The Minnesota Department of Health determined abuse was inconclusive. Due to incomplete and conflicting accounts of the incidents, it could not be determined if maltreatment occurred. The resident declined to be interviewed while the alleged perpetrator denied the allegations and there were no witnesses. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed 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 secured memory care building. The resident’s diagnoses include borderline personality disorder and chronic pain syndrome. The service plan included assistance with medications. The same document indicated the resident had chronic or recurring itchiness, rashes, and dry skin. The resident’s assessment indicated she was independent with transfers and mobility. One evening, the resident reported to one of the unlicensed caregivers that two weeks earlier the alleged perpetrator, who was also an unlicensed caregiver, applied lotion to her shoulder but also applied the lotion to her breasts and rubbed them. The resident also said that a few days after the initial event, the alleged perpetrator was applying lotion to her back and rubbed the resident's buttocks with both hands, making her feel uncomfortable. During the interview, a manager stated the unlicensed caregiver reported to her what the resident had said so she immediately spoke with the resident and began the investigation. The manager stated resident did not provide much information about the incident. The manager also spoke with the alleged perpetrator, who said she only applied lotion to the resident's collarbone and never below the waist. The manager instructed the alleged perpetrator was assigned to a different area to work outside of the memory care and if the alleged perpetrator entered the resident’s room accompanied by another team member. During the interview, the alleged perpetrator stated she no longer provided cares for the resident after the resident made her claims. If the memory care unit needed help and she needed to go into the resident’s room, she only did so when accompanied by another staff member. She also said that when she applied ointment/lotion to the resident, she applied it only to her shoulder and lower back only. She stated she did not apply it anywhere else or attempt to touch the resident inappropriately. During the interview, a police officer stated the resident had reported such incidents in the past but generally declined to discuss them when law enforcement inquired. 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: No, the resident refused. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Yes. Action taken by facility: The facility did an internal investigation, filled the report to Minnesota Adult Abuse Reporting Center and notify the police department. 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: 11/07/2024 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 _____________________________ 33311 09/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 505 EAST MAIN STREET LEWISTON SENIOR LIVING LEWISTON, MN 55952 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 September 26, 2024, the Minnesota Department of Health initiated an investigation of complaints #HL333115281M/HL333117222C, and #HL333115242M/HL333117164C. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 9FJW11 If continuation sheet 1 of 1

Finding: Not Substantiated Investigation #2 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(s): Allegation #1: The alleged perpetrator (AP), a culinary staff member, neglected the resident when the AP did not follow the resident’s therapeutic diet causing the resident to choke, aspirate (inhale into the airway or lungs), and required medical attention. Allegation #2: The facility neglected the resident when the resident took an orange from the facility fruit bowl, choked on the fruit, and passed away. Investigative Findings and Conclusion: Allegation #1: The Minnesota Department of Health determined neglect was not substantiated. While an error in therapeutic conduct did occur in that the resident may have been served food without direct supervision, the AP identified the resident’s condition promptly, sought appropriate help, and the resident recovered. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted the resident’s family member. The investigation included review of the resident’s facility care plan, progress notes, incident reports, and behaviors. Also, the investigator toured the facility and observed the dining area and location of resident’s room. The resident resided in an assisted living facility. The resident’s diagnoses included schizophrenia, cognitive impairment, insomnia, and anxiety. The resident’s plan of care indicated the resident required assistance with meal set up, a mechanically soft food diet, and supervision when eating encouraging resident to eat slowly and take drinks of fluids between bites. This same document indicated the resident was at risk of choking related to behaviors of eating too fast and not chewing his food. An incident report indicated that one morning the resident entered the dining room, and the AP placed a small bowl of fresh fruit in front of the resident. While the AP remained in the dining room, she did not provide direct supervision. The resident began to vomit, and the AP immediately notified the nurse. The facility transferred the resident to the emergency room. The hospital records indicated antibiotic treatment was considered for possible pneumonia due to lung aspiration, but this was not pursued as the risk was considered low. The resident returned to the facility the same day. The medical records indicated the resident returned to his baseline. The AP’s employee file indicated the AP was trained in the altered diet, resident’s choking potential and need for supervision. A review of these documents did not identify a pattern of errors such as giving residents food inconsistent with their diet. Facility documents included instructions to culinary staff members to assist with supervision of the resident during meals. The same instructions did not specify if caregivers were required to be present in the dining room while serving the meals. During an interview, a nurse stated the resident was served fruit prior to unlicensed caregivers being present in the dining room. The nurse stated the culinary staff should have waited for the unlicensed staff to arrive in dining room before giving the resident fruit. Nursing staff stated the culinary staff received the same Educare (computer based) training for supervising and feeding the residents as the unlicensed caregivers. Unlicensed staff members are not trained or required have been trained in the Heimlich maneuver but are trained to notify the nurse immediately if present or call 911. During an interview, the AP stated the resident was on a mechanical soft diet with cut fruit. The AP stated she was aware of the resident’s behaviors of consuming his food to fast causing him to choke. The AP stated she was trained in what measures to take if a resident was choking in the dining room. During an interview, a family member stated they were happy with the cares the resident received. The family member stated during visits with the resident they observed the resident receiving good supervision from facility staff. In conclusion, the Minnesota Department of Health determined neglect was not substantiated. Allegation #2: The Minnesota Department of Health determined neglect was inconclusive. The facility was aware the resident required a mechanical soft diet, choking risk, and independent with ambulation. The facility continued to have fruit available to residents at all times located in the entrance of the dining room, however the resident did not have a history of taking food to his room to eat without supervision. In addition to the description in allegation #1, the resident’s care plan was updated after the incident in the dining indicating the resident had a history of lung aspirations with one within the past week. The resident walked independently throughout the facility. The resident’s routine included waking up between two and four o’clock in the morning to get ready for the day. The facility provided every two-hour safety checks. About four days after the resident’s episode in the dining room staff performed a safety check in the morning. At about 5:00 a.m. the resident appeared to be sleeping in his chair, but upon closer inspection he was found unresponsive with a piece of orange in his mouth. The facility called 911 and cardiopulmonary resuscitation (CPR) was attempted, however the resident passed away. The facility incident report indicated the resident had gone to the dining room where a fruit basket was kept and retrieved an orange and returned to his room with it. During an interview, a nurse stated a basket of fruit was available for the residents all the time. The basket of fruit was located at the entrance of the dining room and contained oranges, bananas, and apples. The nurse stated the resident had not taken took fruit out of the basket as he waited for food to be served to him prior to this occasion. She said the overnight shift has one staff member scheduled on the assisted living side and one staff member is scheduled in the memory care unit and, at times, the staff member on the assisted living side went to memory care to assist which left the assisted living unit unattended. During an interview, multiple unlicensed caregivers stated the resident walked outside his room independently and staff members were not always in the hallways due to providing cares. Overnight caregivers stated they performed checks on the resident every hour once awake. The same staff stated the resident at times would go down to the fruit basket and staff would supervise him eating the fruit. Normally the resident would eat a banana but preferred oranges. During an interview, the unlicensed caregiver who found the resident unresponsive stated he checked on resident and then returned an hour later and found him unconscious, with a visible piece of orange in the resident’s mouth which the caregiver removed. The Heimlich was attempted, 911 called, and chest compressions started until emergency medical staff arrived. During an interview, family member stated they were aware of the resident’s behavioral eating habits and requiring supervision when eating. Family member stated the facility cut up his food which did not slow down the resident from consuming food rapidly. Family member stated he was aware of the sleep patterns of the resident getting up for the day early in the morning. Family member stated they were happy with the care the resident received and had no concerns. In conclusion, the Minnesota Department of Health determined neglect was inconclusive. Therapeutic conduct Statutes, section 626.5572, subdivision 20. "Therapeutic conduct" means the provision of program services, health care, or other personal care services done in good faith in the interests of the vulnerable adult by: (1) an individual, facility, or employee or person providing services in a facility under the rights, privileges and responsibilities conferred by state license, certification, or registration; or (2) a caregiver. “Not Substantiated” means: An investigatory conclusion indicating the preponderance of evidence shows that an act meeting the definition of maltreatment did not occur. 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. Neglect: Minnesota Statutes, section 626.5572, subdivision 17 “Neglect” means neglect by a caregiver or self-neglect.