Ridgeview Senior 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) abused the resident when she grabbed the resident on his buttocks and made inappropriate comments that made the resident feel uncomfortable. Investigative Findings and Conclusion: The Minnesota Department of Health determined abuse was substantiated. The AP was responsible for sexual abuse. The resident stated the AP straddled his legs and hovered over him in his recliner while making comments about wanting to sleep with the resident which made him feel uncomfortable. Then the AP reached into the recliner, grabbed the resident’s buttocks in a sexual manner and squeezed while stating, “there, that ought to make you smile”. The resident’s wife witnessed the incident and her statement aligned with the resident’s. The AP denied the allegation. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted law enforcement, and the resident’s provider. The investigation included review of the resident record(s), medical records, facility internal investigation, personnel files, staff schedules, and related facility policy and procedures. Also, the investigator observed residents and staff at the facility. The resident resided in an assisted living facility with diagnoses including Cerebral Palsy, generalized anxiety disorder, and colon cancer. The resident’s assessment indicated he was cognitively intact and able to report concerns of abuse. A concern arose when the facility received reports the AP, an unlicensed personnel, made inappropriate sexual comments to the resident and touched is buttocks in a sexual way. The resident’s progress notes indicated reported the resident had an inappropriate encounter with another staff member [the AP] the previous day when the resident’s spouse was present. The progress notes indicated the resident had no bruising or physical signs of abuse but reported anxiety and inability to sleep following the incident. The resident’s medication administration record (MAR) indicated the AP documented providing medication administration to the resident at 6:50 p.m. the day the incident occurred. A facility investigation indicated the AP had flirtatious inappropriate conduct including standing over the resident with unnecessary close contact then touched, grabbed, and squeezed the resident’s buttocks. The investigation indicated when interviewed about the incident the resident stated while he was resting in his recliner the AP got close to him and said, “you haven’t smiled for me all shift, where is your smile for me?” Then proceeded to reach down and grab the resident’s hip and buttocks area and squeezed stating, “well that will give you a smile!” The resident stated the AP then said something “creepy” like “you look pretty cozy and warm in your chair; I’m going to crawl up next to you and take a nap”. The resident stated he responded, “my wife would not appreciate that”, and the AP shrugged then left the room. The investigation indicated the resident’s wife witnessed the incident and stated she saw the AP reach into the resident’s recliner and “grabbed his ass” and said, “that will make you smile”. The resident’s wife stated the resident’s eyes got wide like what just happened. The resident’s wife stated the AP made a comment about wanting to cuddle up and sleep with the resident in his chair which was creepy and made them both feel uncomfortable. The investigation indicated during a facility interview the AP admitted she “tried to get the resident to smile by touching his leg” and said “that ought to make you smile” but denied grabbing and squeezing the resident’s buttocks. The investigation indicated the AP stated she had not intended to make the resident feel uncomfortable and was not trying to be inappropriate and apologized. When interviewed facility leadership stated the resident was a reliable reporter of abuse and had no history or pattern of abuse allegations. During an interview, a unlicensed personnel (ULP) stated when she was in the resident’s room the following morning the resident’s wife asked if the resident had told her what happened with the AP last evening. The resident’s wife stated when the AP entered the room to pass evening medications, she mentioned how the resident had not smiled for her shift and touched him inappropriately and said, “that will give you a smile”. The staff stated she then asked the resident to tell her what happened and the resident reported the AP grasped his buttocks and said, “that should make you smile”. The resident stated the AP then said she wanted to snuggle up and take a nap with him to which the resident responded, “my wife would not appreciate that”, then the AP left. The resident stated the interaction made him feel very uncomfortable and they did not want the AP in their room anymore. When interviewed the AP denied the allegation and stated she only touched the resident on the knee but did not grab or squeeze his bottom, which did not align with her previous statement to facility leadership. The AP denied making inappropriate statements, then stated she had a friendly relationship with the resident, and they had made mutually inappropriate jokes and statements during casual conversations. The AP did not elaborate on what inappropriate jokes/statements were made and stated she did not recall. When interviewed the resident stated the day of the incident he had just returned from having chemotherapy and was resting in his recliner when the AP entered his room and straddled his legs in the recliner, hovered over him, and asked, “what was wrong, why aren’t you smiling”. The resident stated then AP made comments about wanting to crawl into the chair with him, to which he responded, “my wife would not like that”, and the AP left the room. The resident stated the interaction made him feel very uncomfortable but indicated it was not the first time the AP’s interactions and statements had made him feel uncomfortable. The resident stated when the AP returned, she sat on the arm of his recliner chair, reached down into the left side of his recliner chair, grabbed his left buttocks cheek, and ran her hand down his leg toward his groin in a sexual manner and said “there, that ought to make you smile”. The resident stated the incident had caused increased anxiety and difficulty sleeping related to nightmares about the incident with the AP. When interviewed the resident’s wife stated she observed the AP’s inappropriate interactions toward the resident and demonstrated how the AP straddled the resident’s legs and leaned over his body in the recliner, then made sexual advances when she reached into the chair to grab the resident’s buttocks. The resident’s wife stated they were shocked by what had happened and reported the incident. When interviewed the resident’s provider indicated the resident was struggling with anxiety and depression following a cancer diagnosis at the time the incident with the AP occurred. The provider stated the incident with the AP had affected the resident’s mood adversely and indicated the resident was receiving services to help manage his symptoms. 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: (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: (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. Section 609.341 Subd. 5.Intimate parts. "Intimate parts" includes the primary genital area, groin, inner thigh, buttocks, or breast of a human being. Section 609.341 Subd. 11.Sexual contact. (a) "Sexual contact," for the purposes of sections 609.343, subdivision 1, clauses (a) to (e), and subdivision 1a, clauses (a) to (f) and (i), and 609.

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 supervision was not provided in accordance with the resident’s service plan. The resident was left unattended in the bathroom when she fell, requiring her to be evaluated in the emergency room. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was substantiated. The facility was responsible for the maltreatment. The facility failed to reassess the resident after she began requiring additional assistance with transfers and required the use of a wheelchair for mobility. Facility staff noted a brake on the wheelchair was not locking properly but continued to use the wheelchair. The resident tried to self-transfer out of the wheelchair and fell on the floor. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted the primary care provider. The investigation included review of the resident record, hospital records, facility internal investigation documentation, facility incident reports, staff schedules, and related facility policy and procedures. Also, the investigator observed the resident’s room and location where she fell. The resident resided in an assisted living facility. The resident’s diagnoses included dementia. The resident’s service plan included assistance with mobility, transfers, toileting, and activities of daily living. The resident’s assessment indicated the resident used a walker and needed redirection due to being disoriented to person, place, and time. The resident’s record lacked documentation to show when she began using a wheelchair, who provided the wheelchair, or what condition the wheelchair was in. The service plan was not updated to reflect the resident using a wheelchair. An assessment was not completed to reflect the resident’s change in condition when she began using a wheelchair. The facility did not have any records related to the wheelchair being used by the resident. The incident report indicated the resident had been set up in front of the bathroom sink in her wheelchair with brakes on for independent grooming. When staff returned, the resident was on the floor next to the cupboard, with the wheelchair “located with brakes on next to resident.” Hospital records indicated the resident had bruising and a laceration on her right thumb, right ankle pain, and a scalp contusion/hematoma. After evaluation in the emergency room, she was discharged back to the facility with a cam walker, a type of orthopedic boot. During an interview, an unlicensed personel (ULP) working the day the resident fell, stated she helped get the resident up and ready and the resident only required set-up assistance. Another resident called for assistance so the ULP left the room to answer the call light and asked a housekeeper to go check on the resident in a few minutes. The ULP stated the housekeeper later called on the walkie talkie for her to return to the room as the resident had fallen. The ULP stated the resident’s care plan at that time did not require staff to stay with her at all times. The ULP stated the resident was using a wheelchair provided by the facility and that staff had told facility management that the locks on the wheelchair didn’t lock. The ULP stated they were told by management they were going to get the wheelchair fixed or find another one, but it was “too little, too late” and it never got fixed. During an interview, another ULP working the day the resident fell, stated the resident’s care plan did not require anyone to stay with her in the bathroom at the time she fell. The ULP stated she was called into the room after the resident fell and was told the resident was alone in the bathroom at the time of the fall. The ULP stated the resident had been using a facility wheelchair and it was “not in good condition.” The ULP stated one brake was not working and people had talked to management about it, but nothing got fixed. The ULP stated there was some turnover with management around the time concerns were brought forward so that may have been why it was never addressed. 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. 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, deceased. Family/Responsible Party interviewed: Yes Alleged Perpetrator interviewed: Not Applicable Action taken by facility: No action taken. Action taken by the Minnesota Department of Health: 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 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 Benton County Attorney Sauk Rapids City Attorney Sauk Rapids Police Department PRINTED: 02/25/2025 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 _____________________________ 20619 02/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1009 10TH AVENUE NE RIDGEVIEW SENIOR LIVING SAUK RAPIDS, MN 56379 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 144G.08 to 144G.95, these correction orders are far-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. #HL206196328M/ #HL206199568C PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On February 3, 2025, the Minnesota Department STATES,"PROVIDER'S PLAN OF of Health conducted a complaint investigation at CORRECTION." THIS APPLIES TO the above provider, and the following correction FEDERAL DEFICIENCIES ONLY. THIS order is issued. At the time of the complaint WILL APPEAR ON EACH PAGE. investigation, there were 57 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. #HL206196328M/ #HL206199568C, tag identification 2360.

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 resident was abused when the alleged perpetrator (AP) was observed on video surveillance following the resident in close proximity causing agitation. The AP grabbed the resident and pulled the resident to the couch and then the ground, and physically restrained the resident using the weight of her body and a bear hug for several minutes while the resident fought to get away. Investigative Findings and Conclusion: The Minnesota Department of Health determined abuse was substantiated. The AP was responsible for the maltreatment. The AP was observed on video pursuing the resident in close proximity causing agitation as the resident repeatedly tried to get away from the AP. Then, the AP grabbed the resident and forced the resident onto the couch where the AP physically restrained the resident for several minutes using her arms, legs, and weight of her body causing the resident distress. The AP continued to restrain the resident until separated by another staff. The AP admitted to restraining the resident. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted law enforcement and the resident’s family member. The investigation included review of the resident record(s), hospital records, facility internal investigation, facility incident reports, facility video surveillance, personnel files, law enforcement report, and related facility policy and procedures. Also, the investigator observed resident’s and staff in the facility. The resident resided in an assisted living facility memory care unit with diagnoses including Alzheimer's disease, impaired memory, and generalized anxiety disorder. The resident’s assessment indicated the resident had severe cognitive impairment, wandered, and required a secure memory care unit. The assessment indicated due to advanced dementia the resident did not always understand what was being asked and was not able to respond or answer appropriately. The assessment identified the resident showed signs of distress by having tense body language, pacing, and fidgeting. The resident’s care plan/service agreement indicated the resident was ambulatory but needed redirection, reorientation, and reminders as needed. The care plan indicated staff completed behavior monitoring for verbal aggression and directed staff to provide non pharmalogical interventions including music, redirect to her room, television, and give her a stuffed dog. The care plan indicated if non pharmalogical interventions failed staff should administer as needed (PRN) medications. The care plan indicated if the resident was resistant staff should reapproach. The resident’s service delivery record indicated staff were directed to monitor the residents behavior each shift. The behavior monitoring documentation the day of the incident lacked documentation of behavioral concerns for the resident prior to the incident and indicated the resident had done lots of wandering that day but was in good spirits. The resident’s medication administration record (MAR) indicated the AP documented administering PRN Risperidone 0.25 at 3:46 p.m. for behavioral disturbance and documented the results were effective at 7:50 p.m. (almost 2 hours after the incident occurred). The resident’s MAR included other PRN medication for behavioral disturbances including Depakote 100 mg every 4 hours PRN, but the MAR indicated the medication was not utilized the day of the incident. The progress notes included documentation the resident wandered and had verbally aggressive behaviors after admission to the facility. The progress notes indicated the resident’s behaviors had been improving after admission with one episode of striking out at staff in response to being startled which was an isolated incident. The resident’s progress notes the day of the incident lacked documentation of behaviors or interventions provided prior to the resident being restrained by the AP. Following the incident, a progress note indicated the resident was transferred to the hospital by ambulance for becoming aggressive and violent towards staff posing a safety risk to staff and residents. A facility incident report indicated the AP reported the resident became increasingly agitated for no apparent reason. The incident report indicated the AP tried to calm the resident down and keep her away from other residents, but the resident swore at the AP, bit the AP, and threatened the AP’s life. The incident report indicated the AP called 911 and the resident’s family member. The incident report lacked documentation the AP restrained the resident. A facility investigation indicated at 6:06 p.m. the AP was observed on video following the resident in very close proximity around the common space for approximately 4 minutes. During that time the AP was observed toe to toe with the resident and stepped in front of the resident preventing the resident from moving freely through the common space. The investigation indicated during the encounter the AP was observed forming a fist by her side. The AP was observed aggressively forcing the resident to sit on the couch, where the AP began physically restraining the resident using a bear hug-type hold at 6:10 p.m. The resident was observed resisting the AP’s restraint by pushing at the AP’s arms, kicking at the AP, and bit the AP as the resident struggled to get away. The situation escalated, resulting in both the AP and resident falling to the floor, at which point another staff member intervened and separated them. The investigation indicated the AP restrained the resident until 6:14 p.m. (approximately 4 minutes). The investigation indicated the AP reported the resident made threats against her life justifying her actions as necessary to protect herself and other residents. However, the investigation indicated the video footage did not support the AP’s claim because the resident possessed no weapons, and the other residents appeared unaffected. When the investigator reviewed the video footage (no audio) the AP was observed closely follow the resident in the common area for several minutes prior to the incident which appeared to cause agitation for the resident. The resident was observed repeatedly trying to get away from the AP, and motioned/pointed for the AP to go away, but the AP refused and persistently pursued the resident in an intimidating manner. The AP was observed to have threatening body language with an expression of anger on her face and clenched fists at her side while standing toe to toe as she appeared to get in the resident’s face. Then the AP aggressively grabbed the resident by the arms and forced the resident to a seated position on the couch. The AP was observed physically restraining the resident by wrapping her arms and legs around the resident and used the weight of her body on top of the resident to hold the resident down against her will as the resident struggled and fought against the AP to get away. The AP continued to restrain the resident until both the resident and the AP fell onto the floor where the AP continued to restrain the resident until separated by another staff. When the resident was released from the AP’s restraint, she made no attempt of physical aggression toward residents or staff, wandered off, and then calmly sat in a recliner in the corner of the room. At no point was the resident observed to be physically aggressive or a danger toward other residents of the facility. The resident was not observed to be physically aggressive toward the AP until after the AP restrained the resident. An email statement from the AP to facility leadership indicated when the AP’s coworker left the unit to bring back a food cart the resident spoke aggressively and made threats toward the AP, so the AP had the resident “sit down on the sofa to calm down.” Then, the resident began hitting the AP, and bit the AP’s hand, while the AP held the resident’s arms to keep the resident contained. The AP’s statement indicated she restrained the resident to prevent the resident from possibly hitting another resident. However, the AP’s statement indicated there was no physical aggression prior to being restrained by the AP, and the resident had made no attempts to harm another resident. When interviewed unlicensed personnel (ULP) working with the AP at the time of the incident stated the resident had verbal behaviors but was not physically aggressive and was able to be redirected.