Cascade Creek Memory Care.

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 the facility did not address the resident's choking risk. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was substantiated. The facility was responsible for the maltreatment. The facility received an order to alter the resident’s food by cutting into small pieces. However, this information was not provided to direct caregivers which led to two more choking episodes, the second of which led to the resident’s death by choking. 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 record, death record, hospital records, facility internal investigation, facility incident reports, staff schedules, and related facility policy and procedures. An onsite visit was made, and the investigator observed facility staff to resident interactions. The resident resided in an assisted living memory care unit. The resident’s diagnoses included dementia, and a history of a stroke. The resident’s service plan included assistance with cueing three times daily during meals to encourage resident to take small bites, physical assistance of two facility staff members to transfer, and hourly safety checks. The resident’s assessment indicated the resident required medication management, reminders for meals, and indicated the resident had no issues affecting oral intake. The medical record indicated the resident had choking episodes three times within a 3-week period. The first choking episode was documented in a progress note indicating the resident had choked during the evening meal. Emergency medical services (EMS) were called, and the resident was transferred to the hospital. The medical record indicated the resident was transferred to the hospital, where treatment was received in the Emergency Department (ED), then the resident returned to the assisted living facility. A review of the resident’s medical record did not identify an incident report or an internal investigation for that first choking incident. Four days later, the progress notes indicated the resident received a follow-up visit from the primary care provider which included specific dietary orders to cut all food to size smaller than a quarter and to obtain a swallow study. A review of the resident’s medical record indicated this order was acknowledged by the facility, however, the same review did not identify documentation indicating this information was relayed to dietary staff or unlicensed caregivers. A review of the service plan found no indication of the medical provider’s specific instructions to cut food to size smaller than a quarter. Ten days after the first choking episode, the resident choked a second time. The facility incident report indicated the resident had another choking episode when a caregiver gave the resident a cookie for an evening snack. The same report indicated the resident’s face turned red and appeared to have trouble swallowing. EMS was called but the resident was not taken to the hospital. A review of the resident’s medical record indicated no service plan changes were made after this choking episode regarding the specific dietary instructions to cut food to size smaller than a quarter. Two days after the second choking episode the facility completed the resident’s assessment. This document indicated the resident had a history of choking and a referral for a speech therapy evaluation. However, this document made no reference to the resident’s need to have her food cut into quarter-size bites as direct the medical provider. On this same day, the facility updated the resident’s service plan, which included encouraging the resident to take small bites and to prompt resident during meals. These interventions were scheduled at 8 AM, 12 PM, and 5 PM. The same document makes no reference to the resident’s needs to have her food cut into quarter-size bites as direct the medical provider. Six days after the second choking episode, the resident choked a third time. A facility incident report indicated the resident was found turning purple and unable to breathe at an activity event [which took place on a different unit and floor within the facility]. Unlicensed caregivers attempted the Heimlich maneuver and cardiopulmonary resuscitation (CPR) was initiated as directed by the 911 operator before EMS transported the resident to the hospital. The same document indicated the resident had a history of similar episodes and a strong history of choking” and was given corn chips and dip at the event. A report from the ED indicated a significant amount of food and debris was removed form resident’s mouth and pharynx (throat). The resident continued to cough up copious amounts of partially chewed chips that needed to be suctioned to remove. A chest CT indicated six rib fractures resulting from CPR, then the resident developed pleural effusion (fluid buildup in the lungs) and atelectasis (collapse of a part of the lungs). The hospital records indicated the resident died two days later. The resident’s death record indicated the cause of death was due to complications of CPR following choking on food. During an interview, unlicensed caregiver #1 stated caregivers had no access to the resident’s full care plan for directions on how to provide care for the residents. Unlicensed caregiver #1 stated it was frustrating because caregivers do not know if changes are made to care plans. Unlicensed caregiver #1 stated changes in resident cares were communicated during huddles, but not all caregivers in the facility would be present in the huddles. During an interview, unlicensed caregiver #2 stated she was aware the resident had a choking risk due to working with the resident. Unlicensed caregiver #2 stated the staff members present at the activity event may not know the resident was at risk for choking as no information was present on the resident’s care plan. During an interview, a member of administration at the time of incidents stated the resident’s dietary order was not discussed or communicated with the management team, nor was the normal process followed for order transcription. In conclusion, the Minnesota Department of Health determined neglect was substantiated. Substantiated: Minnesota Statutes, section 66.7, Subdivision 19. Substantiated” means a preponderance of evidence shows that an act that meets the definition of maltreatment occurred. Neglect: Minnesota Statutes, section 66.7, 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, resident is deceased. FamilyResponsible Party interviewed: Yes. Alleged Perpetrator interviewed: Not Applicable. Action taken by facility: Facility staff called 911 and the resident was transferred to the hospital. 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 andor correction orders, please visit: https:www.health.state.mn.usfacilitiesregulationdirectoryprovcompselect.html If you are viewing this report on the MDH website, please see the attached Statement of Deficiencies. You may also call 651-21-42 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 Olmsted County Attorney Rochester City Attorney Rochester Police Department Minnesota Board of Nursing PRINTED: 07/25/2024 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.

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 resident #1 and resident #2 when resident #2 threw resident #1 onto the floor. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was substantiated. The facility was responsible for the maltreatment. While the facility moved resident #2 to a new memory care unit to address his behaviors, the facility did not provide communication to caregivers regarding approaches to manage his behaviors or to help him acclimate to the new setting. Resident #1, who lived on the new unit and had a history of loud behavior, was thrown to the ground by resident #2 and required hospitalization. Despite these known concerns, the facility did not put interventions in place to address these risks. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted family members of residents involved. The investigation included review of the resident record(s), death record, facility internal investigation, facility incident reports, staff schedules, related facility policy and procedures. The investigator also toured the facility and observed interactions between staff and residents. Resident #1 Resident #1 lived in an assisted living memory care unit. The resident’s diagnoses included Alzheimer’s disease. Resident #1’s service plan included assistance with behavior management and redirection, medication management and safety checks. Resident #1’s assessment indicated resident #1 walked independently and had nonsensical speech. She had a history of becoming loud and using “babble”-like nonsensical words when frustrated. Resident #1 lived on the first floor of the facility. Resident #2 Resident #2 resided in an assisted living memory care unit. The resident’s diagnoses included Alzheimer’s disease and anxiety. The resident’s service plan included assistance with behavior management and redirection, and safety checks. The resident’s assessment indicated resident #2 walked independently and behaviors were triggered by loud noises. Resident #2 initially lived on the second floor, but later moved to the first floor of the facility. Resident #2’s risk assessment indicated he did not pose a risk for others. One day, while living on the second floor, resident #2’s progress notes indicated he approached and started yelling at another resident. Initially, one of the caregivers was able to redirect resident #2. However, resident #2 reapproached the resident a five minutes later, took the other resident’s wheelchair by the handles, and started lifting the wheelchair up while yelling. A nurse was able to calm R2 by inviting him to a couch, taking deep breaths, and then walking with him. In the aftermath of this event, resident #2’s progress notes indicated the facility planned to move the resident to the first floor because he was "noise triggered" and enjoyed having to room to walk. The same document indicated there would be more room to walk and the atmosphere was "calm" most times of the day on the first floor. About a week after resident #2 moved to the first floor, the facility completed his level of care assessment which indicated he "very noise triggered" and moved to the first floor for a calmer environment with less continuous activity. The same document indicated resident #2 had declined cognitively and could be redirected with the “correct approach" A review of the document did not identify specific descriptions or interventions of the "correct approach". Incident involving Resident #1 and Resident #2 About three weeks after resident #2 moved to the first floor resident #1’s progress notes indicated resident #2 grabbed resident #1 by the arms and threw her to the ground. The incident was witnessed by an unlicensed caregiver but was unable to reach either resident in time to intervene. Resident #1 was transferred to the hospital by emergency medical services and sustained a fractured clavicle. Resident #1 did not return to the facility and died 10 days later. A review of resident #2’s medical record did not identify any updates to his service plan after this event. During an interview, the nurse stated resident #1 was known to get in other people’s faces and babble nonsensical words, but that behavior was only happening one to two times per month. During the same interview, the nurse stated resident #2 was moved to the same area as resident #1 after increasing episodes of disruptive behavior triggered by loud noises, such as sneezing or coughing. The nurse stated no updates were made to resident #2’s service plan during that time, however hourly patient checks were implemented for resident #2 after this incident. During an interview, an unlicensed caregiver, who witnessed the event involving resident #1 and #2, stated prior to the incident she noticed resident #1 and resident #2 were sitting in the common area watching television. The unlicensed caregiver states she had an uneasy feeling as resident #2 had been aggressive in the past. She saw resident #2 reach out to resident #1 but she could not get over to them to separate them in time. The caregiver described the resident #1 took resident #2’s hands and then resident #2 pulled resident #1 by the hands and threw her to the floor striking her head. Then resident #2 turned toward the caregiver and prevented her from providing resident #1 care initially. When asked how the facility provided communication regarding how to manage resident #2’s behaviors, the unlicensed caregiver stated she was unable to say. In conclusion, the Minnesota Department of Health determined neglect 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. Vulnerable Adult interviewed: No, Resident #1 is deceased, and resident #2 is cognitively impaired. Family/Responsible Party interviewed: Yes Alleged Perpetrator interviewed: Not Applicable Action taken by facility: Resident #2 moved to a facility to provide a higher level of care. Resident #1 required hospitalization. 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 Olmsted County Attorney Rochester City Attorney Rochester Police Department PRINTED: 05/23/2024 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 _____________________________ 37785 04/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3530 FAIRWAY RIDGE LANE SW CASCADE CREEK MEMORY CARE ROCHESTER, MN 55902 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 far 144G.08 to 144G.95, these correction orders are 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.