Farmstead Care of Moorhead Lp.

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. #HL315579801C PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On June 4, 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 order FEDERAL DEFICIENCIES ONLY. THIS is issued. At the time of the complaint WILL APPEAR ON EACH PAGE. investigation, there were 75 residents receiving services under the provider's Assisted Living with THERE IS NO REQUIREMENT TO Dementia Care license. SUBMIT A PLAN OF CORRECTION FOR VIOLATIONS OF MINNESOTA STATE The following correction order is issued for STATUTES. #HL315579801C, tag identification 0730. 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. 0 730 144G.43 Subd. 3 Contents of resident record 0 730 SS=D Contents of a resident record include the LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 H39111 If continuation sheet 1 of 5 PRINTED: 07/23/2025 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 _____________________________ 31557 06/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3200 28TH STREET SOUTH FARMSTEAD CARE OF MOORHEAD LP MOORHEAD, MN 56560 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) 0 730 Continued From page 1 0 730 following for each resident: (1) identifying information, including the resident's name, date of birth, address, and telephone number; (2) the name, address, and telephone number of the resident's emergency contact, legal representatives, and designated representative; (3) names, addresses, and telephone numbers of the resident's health and medical service providers, if known; (4) health information, including medical history, allergies, and when the provider is managing medications, treatments or therapies that require documentation, and other relevant health records; (5) the resident's advance directives, if any; (6) copies of any health care directives, guardianships, powers of attorney, or conservatorships; (7) the facility's current and previous assessments and service plans; (8) all records of communications pertinent to the resident's services; (9) documentation of significant changes in the resident's status and actions taken in response to the needs of the resident, including reporting to the appropriate supervisor or health care professional; (10) documentation of incidents involving the resident and actions taken in response to the needs of the resident, including reporting to the appropriate supervisor or health care professional; (11) documentation that services have been provided as identified in the service plan; (12) documentation that the resident has received and reviewed the assisted living bill of rights; (13) documentation of complaints received and any resolution; STATE FORM 6899 H39111 If continuation sheet 2 of 5 PRINTED: 07/23/2025 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 _____________________________ 31557 06/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3200 28TH STREET SOUTH FARMSTEAD CARE OF MOORHEAD LP MOORHEAD, MN 56560 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) 0 730 Continued From page 2 0 730 (14) a discharge summary, including service termination notice and related documentation, when applicable; and (15) other documentation required under this chapter and relevant to the resident's services or status. This MN Requirement is not met as evidenced by: Based on interview and record review, the licensee failed to ensure the resident's advanced directives were accurately reflected in the resident's record for one of one residents (R1) with records reviewed. This practice resulted in a level two violation (a violation that did not harm a resident's health or safety but had the potential to have harmed a resident's health or safety, but was not likely to cause 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 was admitted June 1, 2020. R1's diagnoses included Fahr Syndrome (a neurological disorder characterized by abnormal deposits of calcium in areas of the brain that control movement, including the basal ganglia and the cerebral cortex), neuromuscular weakness and respiratory disorder. R1's Master Care Plan dated March 19, 2025, indicated on page one the Code status was CPR (Cardio-pulmonary resuscitation) and on page three the form indicated that the code status and advanced directives were reviewed, and the STATE FORM 6899 H39111 If continuation sheet 3 of 5 PRINTED: 07/23/2025 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 _____________________________ 31557 06/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3200 28TH STREET SOUTH FARMSTEAD CARE OF MOORHEAD LP MOORHEAD, MN 56560 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) 0 730 Continued From page 3 0 730 status was DNR (Do not resuscitate). R1's assessment dated March 19, 2025, indicated on page one, R1's code status was CPR. Further into the form, on page three, the form indicated R1's code status was DNR. R1's face sheet dated June 4, 2025, indicated a code status: CPR. On June 4, 2025, the licensee provided an unsigned service plan (titled as a contract), dated March 19, 2025, which indicated R1 received services including assistance with bathing, dressing, grooming, bed mobility, brace application, catheter care, equipment care, G-J tube care, housekeeping, laundry, medication administration, toileting, tube feeding, vest therapy. The Code Status on page one, indicated DNR - Do not resuscitate. On June 11, 2025, at 11:15 a.m., registered nurse (RN)-B confirmed R1's code status was CPR. When it was brought up that the service plan received was listed as DNR, RN-B stated that she compared it to the POLST (provider orders for life sustaining treatment) for accuracy and had sent a family member the face sheet showing the status was changed to CPR. RN-B stated that it was all updated now. R1's POLST and current signed service plan was requested and received. The POLST indicated CPR but the signed service plan dated March 19, 2025, still listed R1's code status as DNR- Do not resuscitate. The licensee's Resident Code Status policy, dated March 10, 2025, indicated the licensee uses the Physician Orders for Life-Sustaining Treatment (POLST) form for each resident's code status preference. The POLST is signed upon STATE FORM 6899 H39111 If continuation sheet 4 of 5 PRINTED: 07/23/2025 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 _____________________________ 31557 06/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3200 28TH STREET SOUTH FARMSTEAD CARE OF MOORHEAD LP MOORHEAD, MN 56560 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) 0 730 Continued From page 4 0 730 admission, reviewed every 90 days with assessments, and change/updated as needed per resident/POA request. The POLST from is completed and signed by resident/POA and sent to PCP for signature to activate the form. If the POLST from is not signed by resident/POA or PCP, residents code status to be CPR until the form is completed. TIME PERIOD FOR CORRECTION: Twenty-one (21) days.

Finding: Substantiated, facility 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 facility neglected the resident when facility staff failed to implement cares and interventions to meet the resident’s needs when the resident had multiple falls, experienced a significant weight loss, and developed a sacrum (tail bone) wound. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was substantiated. The facility was responsible for the maltreatment. The facility’s assessments did not accurately depict the resident’s health care status and failed to provide unlicensed staff with interventions or directions to meet the resident’s changing needs. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted a hospice agency. The investigation included review of the resident record, death record, hospital records, pharmacy records, facility incident reports, personnel files, staff schedules, and related facility policy and procedures. Also, the investigator observed facility staff provide direct cares. The resident resided in an assisted living memory care unit. The resident’s diagnoses included severe protein malnutrition and Alzheimer’s dementia. The resident’s service plan included assistance with medication administration, safety checks, fall interventions as needed, dressing, grooming, toileting, bathing, housekeeping, and laundry. The resident was on hospice care and was unable to answer questions due to altered mental status, required assistance of one for ambulation, utilized a wheeled walker, was independent with bed mobility, and was educated to wait for staff to assist with toileting transfers. The resident’s record indicated the resident had numerous falls and a significant weight loss while a resident at the facility. The resident’s record included fall incident summaries, recorded weights and progress notes that indicated the facility’s licensed staff had knowledge of the resident’s changes in condition. Fall incident summaries indicated the resident had four falls within 48 hours during the six days prior to the resident death and weight reports indicated the resident had a 35 lb. weight loss over the last six months the resident resided at the facility. The resident’s record indicated licensed staff completed three comprehensive reassessments during the last month the resident resided at the facility and all three inaccurately depicted the health status of the resident at the time the reassessments were completed. The resident’s third and last assessment completed two days prior to the resident’s death, indicated the resident required one staff to assist with ambulation, transfers, toileting and the resident was independent with bed mobility, however, at the time the third reassessment was completed the resident was bed bound, non-verbal and non-ambulatory. The resident’s assessments lacked interventions or directions for unlicensed personnel to assist the resident with fall prevention, repositioning, or nutritional monitoring leading up to, during, and following the resident’s changing needs. The resident’s progress notes indicated four falls occurred during the last six days prior to the resident death. Progress notes indicated the resident was found by family on the floor, however, did not include information the resident was found by family laying on the floor with a blanket over him, a slipper under his head and was extremely cold. The progress note did not include what unlicensed staff reported to family and a social worker, that they had no idea how long the resident had been on the floor. Progress notes indicated the resident was too cold to obtain an accurate oxygen saturation level by unlicensed staff when found by family. The resident’s clinic provider record indicated the resident was seen by his provider two and a half weeks prior to his hospice admission and the provider noted a 35 lb. weight loss. The provider ordered the resident to have good size lunches with a nutritional supplement drink daily. The facility added the supplemental nutrition drink to the resident’s electronic medication record (EMAR) once daily, however, failed to assess and implement any meal assistance services or provide unlicensed staff with meal support interventions and the resident was hospitalized 17 days later. Hospital records indicated the resident was hospitalized for two days with bloody vomiting, was treated with fluid resuscitation and the resident stabilized. Hospital records indicated medications were suspected to have caused the complication and medication adjustments were made. The hospital discharged the resident back to the facility in stable condition with recommendations for physical and occupational therapy and hospice support. The resident admitted to hospice the day after returning from the hospital. Hospice records indicated the resident admitted for severe protein calorie malnutrition. Hospice records indicated the resident was declining foods, however, would eat select favorites when offered. Hospice records indicated hospice staff would effectively collaborate with facility staff to promote individualized, safe and effective care after each visit. Hospice records indicated caregivers (facility staff) were educated on fall prevention strategies and encouraged to implement practices to reduce the resident’s fall risk and interventions to prevent skin breakdown. Hospice records indicated hospice staff assessed the resident after falls, at each visit and made attempts to collaborate with facility licensed staff, however, were unable to complete collaboration at times due to unavailability of facility licensed staff. The resident’s death record indicated the cause of death was severe protein calorie malnutrition and Alzheimer dementia. During an interview facility licensed staff stated there was a second licensed staff overseeing the resident during the last month the resident resided at the facility. Licensed staff stated she was new to the role and found there had not been enough follow up assessments following falls in the past. Facility licensed staff stated fall interventions were implemented based on resident need and stated it was possible the facility could have done more but felt the facility did its part and notified hospice each time the resident fell. Facility licensed staff stated hospice assessed the resident at the facility after each fall, but hospice had not made recommendations or initiated new orders to prevent the resident’s falls and licensed staff felt hospice would instruct facility staff to make changes if it was needed. Facility licensed staff stated the facility licensed staff did not assess the resident after each fall or review the resident’s 35 lb. weight loss because hospital discharge paperwork indicated those were expected changes for the resident, even though the resident’s significant weight loss occurred over a six-month period prior to the hospice admission. Facility licensed staff stated an expected event would not be considered a change in condition and the licensee did not monitor the resident’s weight loss because the licensee was not given orders to monitor or track eating, drinking or weight loss. Additionally, facility licensed staff were unaware the resident had an open wound and "couldn't speak to why it wasn't addressed". During an interview a family member stated communication with facility licensed staff was difficult and communication occurred only when the resident fell. A family member stated the resident had falls in his past however, the last month of the resident’s life, seemed “excessive”, and the family noticed bruises on the resident’s head and arms. A family member stated the family was concerned that the facility’s licensed staff had not attempted to implement interventions to prevent the falls. A family member stated the family found the resident on the floor on two occasions during the week prior to the resident’s death and one incident when family found the resident, the resident was on the floor, cold, and uncomfortable, “his hands were freezing” with a blanket over him, a slipper under his head as a pillow and “he was there a long time”. A family member phoned the hospice agency to request the resident be assessed and the resident be transferred out of the facility due to safety concerns. Family collaborated with the hospice agency to find new placement, however, due to the holidays and the resident’s rapid decline a transfer at the time was not possible so a family member stayed with the resident to assure the resident’s safety. A family member stated they were unaware the resident had not been eating and at one point asked the unlicensed staff how long it had been going on that the resident had not been eating.

Finding: Substantiated, facility 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 facility neglected the resident when staff failed to implement interventions after the resident had a series of falls. The resident sustained a fall which resulted in a brain bleed requiring hospitalization in the intensive care unit. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was substantiated. The facility was responsible for the maltreatment. The facility failed to assess the resident’s risk for falls and implement individualized interventions to prevent falls or reduce the risk of serious injury after falling. The resident had approximately 14 falls in the month prior to the fall that resulted in a brain bleed requiring hospitalization in the intensive care unit. Emergency room physicians considered the possibility that the resident had been assaulted or abused at the facility since the injuries from the fall were so significant and the bruises observed were in various stages of healing. An equal opportunity employer. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted law enforcement, emergency medical services staff, hospice staff, the primary care provider, and the resident’s neurologist. The investigation included review of facility records, the resident’s medical record, hospital records, and the ambulance report. At the time of the onsite visit, the investigator observed care and services in the facility and the resident’s room where she fell. The resident resided in an assisted living facility. The resident’s diagnoses included Huntington’s disease (a condition that leads to progressive degeneration of nerve cells in the brain that affects movement, cognitive functions, and emotion) and anxiety. The resident’s service plan included assistance with toileting, showering, meal set up, dressing, and medication administration. In addition, the resident’s service plan included safety checks six times per day to ensure she was safe in her room or the facility. The resident’s assessment indicated the resident had three or more falls in the past three months and balance problems while standing or walking, decreased muscular coordination/jerking movements, and required the use of assistive devices like a walker or wheelchair. The assessment lacked an individualized assessment of the resident's current health status or individualized needs and lacked interventions specific to the resident. The resident’s progress notes indicated the resident sustained approximately 14 falls in the month leading up to her hospitalization. The facility reviewed the falls periodically at fall meetings but failed to identify interventions or assess risks related to the resident not wanting to accept additional services or participate in physical therapy. The resident was noted to be impulsive with transfers and did not remember to call for transfer assistance; however, no interventions were in place related to that risk. Approximately two weeks prior to the resident’s hospitalization, the resident requested to start using her wheelchair for locomotion, as she was frequently falling while trying to walk with a walker. A facility nurse discouraged the resident from using her wheelchair, and documented the resident “should continue to be using their walker to keep their independence they have…” The nurse told the resident that she and the resident’s provider would let her know when it was time for her to start using the wheelchair. Progress notes indicated the resident had various bruising and skin tears, in various stages of healing, throughout her body due to her numerous falls. The resident’s record contained an incident report, which indicated the resident complained of feeling dizzy in the hours leading up to the fall. The resident tripped while walking in her room and hit a table before landing on the floor. The resident was unable to use her call pendant and yelled out for help. Facility staff responded and called the on-call nurse, who directed staff to call 911. Ambulance records indicated that when emergency medical crews arrived, staff didn’t know what happened. The resident was found on her bed “covered in blood and bleeding heavily from the head. When EMS approaches the room there is blood all over the floor, walls, bed, pillows, and the patient is completely saturated in blood from head to toe.” The resident reported that she “fell five or six times and had been calling for help, but nobody had heard her calls.” Hospital records indicated the resident’s injuries were so traumatic and significant, with many bruises in various stages of healing, that doctors considered the possibility that the resident had been abused or assaulted at the facility. The resident reported falling six times that day, and doctors were able to rule out assault or abuse. The resident was diagnosed with two subdural hematomas (bleeding in the brain) and contusions to the scalp and eyelid. The resident was admitted to the intensive care unit and spent 13 days in the hospital. Photographs taken of the resident when she arrived at the emergency room showed the resident’s face covered in dried blood, along with multiple bruises on her legs and arms. During an interview, the clinical nurse supervisor (CNS) stated she worked remotely and did not work in the facility. The CNS confirmed she reviewed assessments completed by RNs in the facility and was on-call for emergencies and questions. The CNS stated she was aware the resident had a history of falls but was not sure what specific interventions were identified for the resident. During an interview, a facility nurse confirmed the assessment form lacked individualized interventions but stated interventions would be identified within the progress notes. The facility nurse stated the electronic medical record used by the facility did not populate assessment forms and was not user friendly for nursing documentation. During an interview, another facility nurse stated that the resident fell quite frequently due to her diagnosis of Huntington’s disease. The nurse stated they tried to implement new interventions after each fall, but the resident refused to add additional services and stopped working with physical therapy. The nurse did not know why interventions beyond that were not considered. The nurse stated she completed assessments on the resident but relied on the assessment form provided by the facility and completed assessments as directed. A different facility nurse stated the resident was very anxious, and many of her falls were not witnessed. The nurse indicated the resident wouldn't push her call button but instead, walked out to the nurse's station to tell someone that she fell. The facility nurse stated that the resident struggled with remembering things and was impulsive so "we would tell her if you're feeling weak, push your call light and we can help you, but that's not something she would utilize." The facility nurse stated she was not sure if the RN assessed that risk factor on the resident's assessments. The facility nurse stated she noticed the resident fell more after she received PRN (as needed) doses of clonazepam (an antianxiety medication). The nurse stated whenever staff wanted to give a PRN dose, she asked them to try non-pharmacological interventions first to decrease the resident’s risk for falls. The facility nurse stated she was not sure if the RN identified or assessed the risk certain medications presented that increased the risk for falls. During an interview, the licensed assisted living director (LALD) stated that the day the resident fell and was hospitalized, she hit her head on a table in her room. The LALD was not sure why the resident's assessments failed to identify the resident’s risk for falls or why specific interventions were not in place. During an interview, the resident’s neurologist stated that she had not seen the resident in over a year, as the resident had stopped coming to the clinic. The neurologist stated when the resident was last in the clinic, it was noted her chorea, (rapid, jerky, involuntary body movements) was mild to moderate, and given the progressive nature of Huntington's disease, it would be expected to have worsened over the last year. The neurologist stated that if they had been informed of the resident’s multiple falls while trying to walk with a walker, "we would have said you need to live from a wheelchair-based setting.