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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 perpetrators (AP) #1 and AP #2 verbally abused the resident by threatening to call the police and evict the resident from the facility. Investigative Findingsand Conclusion: The Minnesota Department of Health determined abuse was substantiated. AP#1 andAP#2 was were responsible for the maltreatment.AP #1 and AP #2Facility staff membersattempted to stop the resident from speaking with a community staff person. At the time the resident was waiting for the meeting with the community staff, both AP #1 andAP #2 threatened to call the police and evict the resident if he did not move away from the door. The investigator conducted interviews with facility staff members, including administrative staffs. The investigation included review of the resident’s records, personnel files, staff schedules, policies, and procedures. The resident resided in an assisted living facility. The resident’s diagnoses included generalized anxiety disorder. The resident’s service plan included assistance with wound care and medication administration. One day, the resident was waiting outside a room for a scheduled meeting with a community staff member conducting field interviews with residents. While he waited, AP #1 approached and asked him to move away from the door, expressing concern that he was blocking access and might overhear private conversations. AP #1 reportedly told the resident he could not talk with the community staff member. AP #1 told the resident, the community staff did not want to talk to him and if he was going to continue to cause problems, AP #1 would issue him a lease violation to have the resident “kicked out.”AP #2 then threatened to call the police to have the resident kicked out. During an interview, the resident stated he wanted to speak with the community staff, so he requested for an interview and waited outside her door. He said AP #1 was unaware he had an arrangement with the community staff, so she asked him to move away fromthe door. When he refused, AP #1 went to get AP #2, and together they moved his scooter 15–20 feet away from where he had been waiting. He stated they told him he would receive a lease violation, and they would call the police and kick him out of the facility if he did not move away from the door. During an interview, the community staff member stated the resident had requested a meeting with her, so she asked him to wait outside the room while she prepared. She said she was standing about one foot inside the door, while the resident was about one foot outside. She clearly heard AP #1 holler at the resident and threaten to call the police, falsely telling him the community staff memberdid not want to speak with him and he would be evicted if he did not comply. She also reported hearing a different voice, identified as AP #2 saying they would call the police if necessary and asking the resident if he wanted to be evicted from the facility. She said AP #1 and AP #2 were unaware she was in the room, and as soon as she opened the door, both of them left quickly. During an interview, AP #1 stated the resident had parked his scooter outside the door, and she was concerned the community staff member would not be able to open the door, so she asked him to move away from the room. Additionally, she did not want him to overhear the conversation taking place inside. She said the resident refused to move, so she asked AP #2 for help in persuading him. She stated she did not threaten to call the police or evict him from the facility. During an interview, AP #2 stated the community staff member was in the private dining room with the door closed. The resident had parked his scooter close to the door, which could have prevented them from opening it when they were ready to leave. She saidshe heard AP #1 ask the resident to move, but he began raising his voice, so she stepped in. AP #2 told him the staff knew he wanted to talk with them and they would call him when it was his turn. She told him he needed to move because the person inside the room had the same right to confidentiality as he did. She said when he refused to move, they left him alone. She also stated she did not hear AP #1 threaten to call the police or evict him from the facility, and she herself did not say anything like that to him either. 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; 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 section609.341, 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: Yes. Family/Responsible Party interviewed: Not Applicable. Alleged Perpetrator interviewed: Yes. he Action taken by facility: No action taken. 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. 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 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 Sherburne County Attorney Saint Cloud City Attorney Saint Cloud Police Department Board of Executives for Long-Term Services and Supports

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 perpetrators (AP #1 and AP #2) neglected a resident when they failed to do safety checks on a resident. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was substantiated. AP #1 and AP #2, who were both unlicensed caregivers, were responsible for the maltreatment. Neither AP followed the resident’s service plan which included safety checks to be done every two hours over a period of 14 hours during which time the resident had fallen in her room and was unable to get up nor call for help. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator also contacted family members. The investigation included review of facility records, hospital records, resident records, facility An equal opportunity employer. internal investigation, policy’s, staff records and training records. Also, the investigator observed staff interactions with other staff, visitors, and residents. The resident resided in an assisted living facility. The resident’s diagnoses included high blood pressure, diabetes, and coronary artery disease. The resident’s service plan included assistance with meals, laundry medication management and assistance getting to the dining room and needed assistance for toileting 8-12 times a day. The resident’s assessment indicated the resident was hard of hearing and forgetful. An incident report indicated the resident was found on the floor of her room. The resident was found to be shaky and quiet, and she had swelling on her right side of her face. This record also indicated the nurse and physician were notified and the resident was sent to the local emergency department for evaluation. The internal investigation report indicated the facility reviewed facility video footage to validate the residents all two-hour safety checks were done as documented. These documents indicated a review of the video footage determined neither AP entered the resident’s room from 7:20 pm until 9:20 am the following morning when the resident was found on the floor and the resident transferred to the hospital. The same document indicated the hospital indicated the resident said she laid on the floor most of the night and had increased fluid “pooling” on the right side of her face. The hospital record reports the resident had elevated creatine kinase, an enzyme that is released when there is muscle damage, likely from lying on the floor for a prolonged period of time. The facility service checkoff list indicated the resident was on every 2-hour safety checks every two hours, day and night. The document indicated a “safety check” meant the unlicensed caregiver was to perform a face-to-face check on the resident’s status. The same document indicated the following during the time the video footage showed no unlicensed caregivers entered the resident’s room. AP #1’s initials appeared on the night shift indicating services were provided by AP #1 at  9 PM and 11 PM on the previous evening then 1 AM, 2 AM, 3 AM, and 5 AM after midnight AP #2’s initial appeared on the day indicating services were provided by AP #2 at 7 AM,  730 AM, and 8 AM A document titled supervision of unlicensed personnel, list specifically accurate documentation of services and expectation of documentation and completion of services. Both the AP’s received this education. During an interview, leadership stated that video footage confirmed that neither AP had gone into the resident’s room over a 14-hour period. Leadership also stated both APs admitted to documenting the safety checks had been done but they actually did not do them. Leadership also stated both APs were terminated immediately for not following policies and procedures. During an interview, nursing stated that both APs had received education on the importance of safety checks and the correct documentation for the safety checks. Nursing also stated that all staff were re-educated on these points after this incident and that the facility has implemented random audits for safety checks matching documentation with video timing. During an interview, AP #1 stated she documented the safety checks for the resident but did not actually do them. During an interview AP #2 stated she documented providing services for the resident but did not actually do them. During an interview, the resident’s family member stated they were saddened to find out the resident laid on the floor for an undetermined amount of time. The family member also stated that overall, they were happy with the care at the facility and agreed that the facility did the right thing by terminated the APs. 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: Yes Family/Responsible Party interviewed: Yes Alleged Perpetrator interviewed: Yes the Action taken by facility: The facility did an internal investigation and immediately terminated both APs. The facility also implemented re-education of all staff and random audits to ensure staff are doing what they are documenting. 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 PRINTED: 06/27/2024 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 _____________________________ 33613 06/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2410 20TH AVENUE SE THE SANCTUARY AT ST CLOUD SAINT CLOUD, MN 56304 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 ASSISTED LIVING PROVIDER CORRECTION No plan of correction is required for this ORDER tag. In accordance with Minnesota Statutes, section 144G.08 to 144G.95, these correction orders are issued pursuant to a complaint investigation. Determination of whether a violation is corrected requires compliance with all requirements provided at the statute number indicated below. When a Minnesota Statute contains several items, failure to comply with any of the items will be considered lack of compliance. INITIAL COMMENTS: #HL336133261C/#HL336133202M On June 5, 2024, the Minnesota Department of Health conducted a complaint investigation at the above provider, and the following correction orders are issued. At the time of the complaint investigation, there were 105 residents receiving services under the provider's Assisted Living with Dementia Care license. The following correction order is issued/orders are issued for #HL336133261C/#HL336133202M , tag identification 2360. 02360 144G.91 Subd. 8 Freedom from maltreatment 02360 SS=F Residents have the right to be free from physical, sexual, and emotional abuse; neglect; financial exploitation; and all forms of maltreatment covered under the Vulnerable Adults Act.