Diamond Willow Assisted Living.

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), facility staff, abused a resident when the AP yelled at the resident and repeatedly acted in an intimidating, threatening, manner while the AP stomped and swung their arms around and threatened to slash the resident's throat. Investigative Findings and Conclusion: The Minnesota Department of Health determined abuse was substantiated. The AP was responsible for the maltreatment. The AP was witnessed slamming her fists on the table, stomping her feet, and swinging her arms around while yelling in the resident’s face, “Fuck you, you want to see mad, now I am fucking mad!” “You just couldn’t leave me alone”! The AP continued to yell at the resident despite staff intervening twice. The AP stated she would, “slash [residents] throat from ear to ear.” The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigation included review of AP personnel files, An equal opportunity employer. training records, resident records, progress notes, incident report, facility investigation documentation, and witness statements. The resident resided in an assisted living facility memory care unit with diagnoses including early onset Alzheimer’s Disease, moderate depressive disorder, and anxiety. The resident’s assessment indicated the resident was cognitively impaired and could be disoriented and anxious at times. The resident’s care plan and individual abuse prevention plan identified the resident was at risk for abuse and mental abuse related to impaired judgment. The resident required 24-hour supervision and staff assistance, with ques and reassurance to protect the resident from abuse. One day the resident’s progress note indicated the resident was having agitation and behaviors with repetitive questions. A short time later a facility incident report indicated the resident told the AP she was being rude and mean, and the resident did not like how the AP was treating people. The incident report indicated the resident and AP argued and the AP walked away, however the resident followed the AP and they continued to argue. The AP then got up and started yelling and swearing at the resident. Staff intervened and separated the AP from the resident, and the AP left the facility. The report indicated the resident attempted to follow the AP, and the AP continued to yell and swear at the resident. The progress note indicated when the AP returned to the facility she began yelling and swearing at the resident again, staff separated the AP from the resident, and instructed the AP to leave the building. When interviewed a facility nursing staff stated the AP and resident argued back and forth for approximately 10 to 15 minutes. The resident followed the AP and continued asking the AP why she was acting that way. Suddenly, the AP yelled at the resident, “Fuck you, you want to see mad! You want to see fucking mad; now this is mad! You just could not leave me alone!” The nurse stated the AP slammed her fists on the table, stomped her feet, and swung her arms around while yelling in the resident’s face in a threatening intimidating manor. The nurse stated she intervened and sent the AP outside two separate times, but the AP returned and continued to yell and swear at the resident and blamed the resident for making her angry. The nurse stated the incident was frightening, shocking, and the AP’s response toward the resident was pure anger and rage. When interviewed two unlicensed staff stated they witnessed the incident between the AP and the resident. The staff stated the AP and resident were arguing, and suddenly the AP threw her hands up, slammed her fists on the table, started to “storm” and stomp around in a threatening manner, and repeatedly yelled at and swore in the resident’s face. One staff stated she heard the AP tell the resident she would, “slash her throat from ear to ear”. When interviewed the AP stated she had personal issues going on in her life and was having a bad day when the resident accused her of being rude to another resident. The AP stated she initially walked away, but the resident followed her and continued to ask repetitive questions. The AP stated she “blew up” at the resident and yelled at the resident in anger, but stated she never touched the resident. The AP indicated she went outside a couple of times to cool off, but when she came back in the facility the resident continued to accuse her of doing something wrong. The AP stated she yelled at the resident repeatedly over 20-30 minutes but denied swearing at or threatening to harm the resident. When the AP was asked what she said to the resident the AP did not recall. In conclusion, the Minnesota Department of Health determined abuse 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. 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. Vulnerable Adult interviewed: No, unable. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Yes the Action taken by facility: The facility investigated the incident. The AP is 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. 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 St. Louis County Attorney Mountain Iron City Attorney Mountain Iron Police Department PRINTED: 07/27/2023 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 _____________________________ 24664 07/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 8583 UNITY DRIVE DIAMOND WILLOW OF MOUNTAIN IRO N MOUNTAIN IRON, MN 55768 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 been assigned to Minnesota State Statutes for Assisted Living License In accordance with Minnesota Statutes, section Providers. The assigned tag number 144G.08 to 144G.95, these correction orders are appears in the far left column entitled "ID issued pursuant to a complaint investigation.