Edgewood Virginia I Senior Liv.

Finding: Not Substantiated 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 resident missed doses of her anti-psychotic medication. As a result, the resident’s mental health declined requiring hospitalization. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. Although the resident’s anti-psychotic medication required a 3 milligram (mg) to be given in conjunction with a 9 mg dose to total 12 mg, the facility made attempts to reorder the 3 mg dose. The medication was not available is a 12 mg dose form. The resident had a history of hallucinations and delusions. During the timeframe of the missed 3 mg doses, the resident’s records did not indicate behaviors of delusions or hallucinations until the day the resident transferred to the emergency room for psychiatric evaluation. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff. The investigation included review of the resident records, pharmacy records, the resident’s medication re-order history, facility internal investigation, and related facility policy and procedures. Also, the investigator observed the facility and staff interactions with other residents. The resident resided in an assisted living facility. The resident’s diagnoses included bipolar disorder, mania, anxiety, and paranoid schizophrenia. The resident’s service plan included assistance with managing the resident’s agitation, anxiety, and hallucinations. The resident received medication management and medication administration services. The resident’s assessment indicated the resident hallucinated and would see or hear things that were not real. The resident’s medication administration record (MAR) and provider orders indicated an order for an anti-psychotic medication given daily. The order required the medication administration of a 3 mg dose and a 9 mg to equal a total of 12 mg for staff administration. Progress notes indicated the resident had hallucinations when she moved her mattress to the adjourning room stating she felt safer because she had been seeing knives. Staff assisted the resident, placed the mattress back in the correct room, and assisted with room order. The resident’s MAR indicated the resident had received her 12 mg dose of antipsychotic thus far during the month and on the day of the hallucination incident. A fax response from the resident’s mental health provider regarding the resident’s delusions indicated to schedule a follow-up appointment if the resident was having concerning delusions causing her distress or if she was at risk of losing her housing. The provider indicated unfortunately sometimes delusions were not able to be addressed with medications. After that, the resident’s MAR indicated the resident missed her 3 mg dose of her antipsychotic 12 times due to the medication was not available. During this timeframe, the resident received her 9 mg dose of the same antipsychotic. The facility reorder history report indicated during this 12-day timeframe of the missed 3 mg doses; staff reordered the resident’s 3 mg dose five times. The MAR also indicated staff reordered the medication and indicated this was “reordered several times.” The facility internal investigation and progress notes indicated the resident’s mental health provider was contacted for refills without success. During the timeframe when the resident did not receive her 3 mg anti-psychotic dose prior to the resident’s emergency room transfer, the resident’s behavior and service delivery records did not indicate behaviors of delusions or hallucinations until the day the resident transferred to the emergency room for psychiatric evaluation. Multiple entries during this timeframe regarding her behaviors included entries such as “no behaviors” “no concerns” “no anxiety” “good.” Progress notes indicated the day of the emergency room transfer, the resident reported to leadership that another identified resident came into her room over a weekend, laid on top of her, and the resident said she was “raped’ by the other resident. The resident also stated the other resident was never in-between her legs. The facility’s internal investigation included pinpoint location and contact tracing reports of both the resident and the other resident the resident identified as being in her room. The reports indicated the other resident had not been in the resident’s room nor had contact with the resident. Progress notes indicated a nurse assessed the resident. The resident’s primary care provider also saw the resident the day the resident reported this. The resident transferred to the emergency room. Progress notes indicated the resident admitted to the hospital for a psychiatric evaluation. While hospitalized the resident’s psychosis continued. The notes indicated her psychosis was not worse however it was not better. The hospital adjusted her medications. During multiple facility updates there was no plan on discharge back to facility. At one point during one of the updates, the provider at the hospital felt the resident was not stable enough for discharge. While hospitalized the resident reported she did not want to return to the facility. The facility informed the hospital the resident was welcome to come back when stable. The resident was discharged from the hospital to a different facility. During an interview, leadership staff, who was also a nurse, stated when the resident alleged another identified resident went into her room, laid on her, and raped her, the facility conducted an internal investigation. Leadership stated the allegation was unfounded. Each resident at the facility wore wrist bands. The wrist band identified pinpoint location of each resident, showed where they are in a room, which room they are in, and does contact tracing of resident contact with other residents. The facility was able to determine the other resident the resident identified as being in her room had not been in the resident’s room. The facility also determined that no other resident had been in the resident’s room, nor did the identified resident have any contact with the resident. A facility nurse assessed the resident and the resident’s primary provider also saw her who happened to be rounding that day. It was determined the resident was in a mental health crisis and was sent to the emergency room. Leadership said she reviewed the resident’s behaviors twice monthly. She said when the resident’s mental health was well managed on medications her delusions and hallucinations would be more joyful like she won the lottery, or she confided in Tinkerbell. Overall, the resident would be in good spirits. However, when the resident’s mental health was not well managed the resident’s delusions and hallucinations became scary such as the resident talking about shootings, stabbings, or like this incident. Leadership said the facility made efforts to refill the resident’s 3 mg anti-psychotic by reordering it from pharmacy, contacting pharmacy, and contacting the mental health provider who was the prescriber. The pharmacy was waiting on orders from the provider. The resident’s 3 mg anti-psychotic did eventually get filled and came to the facility however it was the day the resident transferred to the emergency room. During an interview, a nurse said she recalled the facility had been waiting for some time for the resident’s refill of her anti-psychotic from pharmacy. The nurse said they were waiting on orders from the prescriber. The nurse stated she reached out to the pharmacy and reached out to mental health provider to let them know they needed refill of the resident’s anti-psychotic. The nurse said the resident had a history of delusions and hallucinations. At times the resident required reorientation back into reality. During an interview, the resident’s family member stated the resident had mental health diagnoses and a history of delusions and hallucinations. The day the resident reported she was raped; the resident was sent to the emergency room for psychiatric evaluation. The resident did not return to the facility after hospitalization. In conclusion, the Minnesota Department of Health determined neglect was not substantiated. “Not Substantiated” means: An investigatory conclusion indicating the preponderance of evidence shows that an act meeting the definition of maltreatment did not occur. Neglect: Minnesota Statutes, section 626.5572, subdivision 17 “Neglect” means neglect by a caregiver or self-neglect.

Finding: Inconclusive 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), a licensed practical nurse (LPN) at the facility, financially exploited resident #1 and resident #2 when she took the residents’ narcotic pain medication for her own use. Investigative Findings and Conclusion: The Minnesota Department of Health determined financial exploitation was inconclusive. While both resident #1 and resident #2 had discrepancies in their narcotic medication counts, it was unable to be determined what happened to the medications and there was not a preponderance of evidence that the AP/LPN took the medications. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted law enforcement. The investigation included review of the resident records, facility internal investigation documentation, facility incident reports, personnel files, staff schedules, and related facility policy and procedures. Also, the investigator observed narcotic storage in the facility. Resident #1 resided in an assisted living facility. The resident’s diagnoses included heart failure. The resident’s service plan included assistance with medication administration. The resident’s assessment indicated the resident was on hospice and utilized morphine (narcotic pain medication) for comfort. Resident #2 resided in an assisted living facility. The resident’s diagnoses included neurocognitive disorder and vascular dementia. The resident’s service plan included assistance with medication administration. The resident’s assessment indicated the resident was on hospice. Resident #1 The facility’s internal investigation indicated they attempted to talk to the AP/LPN about a medication error but did not disclose who the resident was or what medication was identified as part of the error. The AP/LPN reported to facility management that she is “allergic to morphine” and denied taking the resident’s morphine medication. The facility investigation included a report showing log in attempts to the facility’s electronic medical record (EMR). Attempts to log into the clinical nurse supervisor and another facility nurse’s profile were made from an IP address the facility attributed to the AP/LPN. In reviewing the resident’s medication administration record (MAR), it was identified the order for resident #1’s 15 milligram (mg) Morphine was deleted and then re-added, which allowed the narcotic count to be reset, so a discrepancy in the pill count would not be flagged. The AP/LPN was the user who deleted and modified the order. The count was initially 24 pills, then 23 after the AP/LPN gave one at 9:58 p.m. When counting that evening around 10 p.m., the count was 19 pills. However, the computer did not flag that four pills were missing because the count had reset after the order was deleted and re-added. The facility was unable to reconcile where the four missing pills went. Resident #2 The facility’s internal investigation indicated the AP/LPN administered three extra doses of Hydrocodone/APAP 5/325 milligrams (mg) to resident #2. The AP/LPN did not document administering the three extra medications or ensure the medication was counted in the narcotic log. Medication error reports indicated the AP/LPN administered an extra dose of Hydrocodone/APAP 5/325 mg around 2:00 p.m. but “did not check the MAR to see if it was already administered, nor did she record in the MAR that she administered it. The medication was correctly documented by another medication passer as being given at 1:28 p.m.” A second medication error report indicated the AP/LPN gave two doses of Hydrocodone/APAP 5/325 mg around 4:30 p.m., [AP/LPN] thought it was 9 pm. She did not sign it out of the MAR. She also did not sign it on the card itself with her initials and date.” A photocopy of the narcotic card showed all but three narcotics were signed out with the date and staff initials written next to the bubble where the medication was. In reviewing resident #2’s MAR, it was identified the order for Hydrocodone/APAP 5/325 mg was deleted and then re-added, which allowed the narcotic count to be reset so a discrespency in the pill count would not be flagged. The user who deleted the order was another facility nurse who denied deleting the order. The other user logged into the EMR under an IP address affiliated with the AP/LPN. The internal investigation included a text message conversation with the AP/LPN. The AP/LPN wrote that she had made a medication error due to have a migraine and could not recall why she gave extra doses and failed to sign them out. Facility management later spoke with the AP/LPN over the phone, and she denied taking the resident’s medications and again attributed the errors to having a migraine. During an interview, facility management stated they were notified of the medication error, so the clinical nurse supervisor came in to assess the resident and make sure she was ok and she seemed fine and they did not suspect she had received three additional doses of her narcotic pain medication over a five hour span. Facility management stated they started an investigation to figure out how the error happened and subsequently identified some other concerns related to the AP/LPN’s nursing practices and narcotic medications, which led to her termination. The AP/LPN provided a text message statement to the investigator but declined to be interviewed. The AP/LPN denied taking medications from residents at the facility and that the allegations were false. In conclusion, the Minnesota Department of Health determined financial exploitation was inconclusive. Inconclusive: Minnesota Statutes, section 626.5572, Subdivision 11. "Inconclusive" means there is less than a preponderance of evidence to show that maltreatment did or did not occur. Financial exploitation: Minnesota Statutes, section 626.5572, subdivision 9 "Financial exploitation" means: (b) In the absence of legal authority a person: (1) willfully uses, withholds, or disposes of funds or property of a vulnerable adult; (2) obtains for the actor or another the performance of services by a third person for the wrongful profit or advantage of the actor or another to the detriment of the vulnerable adult; (3) acquires possession or control of, or an interest in, funds or property of a vulnerable adult through the use of undue influence, harassment, duress, deception, or fraud; or (4) forces, compels, coerces, or entices a vulnerable adult against the vulnerable adult's will to perform services for the profit or advantage of another. Vulnerable Adult interviewed: Resident #1 and resident #2 unable to be interviewed due to cognitive impairment. Family/Responsible Party interviewed: Yes Alleged Perpetrator interviewed: Yes Action taken by facility: The facility suspended the AP/LPN and investigated the incident. The facility contacted law enforcement and made a MAARC report. Upon completion of the investigation, the AP was terminated. All employees were retrained on medication administration practices. Action taken by the Minnesota Department of Health: No further action taken at this time. cc: The Office of Ombudsman for Long Term Care The Office of Ombudsman for Mental Health and Developmental Disabilities PRINTED: 01/31/2025 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 _____________________________ 30738 12/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 705 17TH STREET NORTH EDGEWOOD VIRGINIA I SENIOR LIV ING VIRGINIA, MN 55792 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 On December 4, 2024, the Minnesota Department of Health initiated an investigation of complaint #HL307386201M/#HL307389162C. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 WHJI11 If continuation sheet 1 of 1

correction orders and document the actions taken to comply in the facility's records. The Department reserves the right to return to the facility at any time should the Department receive a complaint or deem it necessary to ensure the health, safety, and welfare of residents in your care. STATE CORRECTION ORDERS The enclosed State Form documents the state correction orders. MDH documents state licensing correction orders using federal software. Tag numbers are assigned to Minnesota state statutes for Assisted Living Facilities. The assigned tag number appears in the far left column entitled "ID Prefix Tag." The state statute number and the corresponding text of the state statute out of compliance are listed in the "Summary Statement of Deficiencies" column. This column also includes the findings that are in violation of the state statute after the statement, "This MN Requirement is not met as evidenced by . . ." In accordance with Minn. Stat. § 144G.31 Subd. 4, MDH may assess fines based on the level and scope of the violations; h owever, no immediate fines are assessed for this survey of your facility. DOCUMENTATION OF ACTION TO COMPLY In accordance with Minn. Stat. § 144G.30, Subd. 5(c), the licensee must document actions taken to comply with the correction orders within the time period outlined on the state form; however, plans of correction are not required to be submitted for approval. The correction order documentation should include the following: Identify how the area(s) of noncompliance was corrected related to the resident(s)/employee(s) identified in the correction order. Identify how the area(s) of noncompliance was corrected for all of the provider’s resident(s)/employees that may be affected by the noncompliance. Identify what changes to your systems and practices were made to ensure compliance with the specific statute(s). An equal opportunity employer. Letter ID: IS7N REVISED 09/13/2021 Edgewood Virginia I Senior Living, LLC February 3, 2025 Page 2 CORRECTION ORDER RECONSIDERATION PROCESS In accordance with Minn. Stat. § 144G.32, Subd. 2, you may challenge the correction order(s) issued, including the level and scope, and any fine assessed through the correction order reconsideration process. The request for reconsideration must be in writing and received by MDH within 15 calendar days of the correction order receipt date. To submit a reconsideration request, please visit: https://forms.web.health.state.mn.us/form/HRDAppealsForm INFORMAL CONFERENCE In accordance with Minn. Stat. § 144A.475, Subd. 8 OR Minn. Stat. § 144G.20, Subd. 20, the Commissioner of Health is authorized to hold a conference to exchange information, clarify issues, or resolve issues. The Department of Health staff would like to schedule a conference call with Edgewood Virginia I Senior Living, LLC. Please contact Jessie Chenze at 218-332-5175 o n or before Thursday, February 6, 2025, to schedule the conference call. The MDH Health Regulation Division (HRD) values your feedback about your experience during the survey and/or investigation process. Please fill out this anonymous provider feedback questionnaire at your convenience at this link: h ttps://forms.office.com/g/Bm5uQEpHVa. Your input is important to us and will enable MDH to improve its processes and communication with providers. If you have any questions regarding the questionnaire, please contact Susan Winkelmann at susan.winkelmann@state.mn.us or call 651-201-5952. You are encouraged to retain this document for your records. It is your responsibility to share the information contained in the letter and state form with your organization’s Governing Body. If you have any questions, please contact me. Sincerely, Jessie Chenze, Supervisor State Evaluation Team Email: Jessie.Chenze@state.mn.us Telephone: 218-332-5175 Fax: 1-866-890-9290 HHH PRINTED: 02/03/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 30738 12/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 705 17TH STREET NORTH EDGEWOOD VIRGINIA I SENIOR LIV VIRGINIA, MN 55792 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 LICENSING Minnesota Department of Health is CORRECTION ORDER(S) documenting the State Correction Orders using federal software. Tag numbers have In accordance with Minnesota Statutes, section been assigned to Minnesota State 144G.08 to 144G.95, these correction orders are Statutes for Assisted Living Facilities. The issued pursuant to a survey. assigned tag number appears in the far left column entitled "ID Prefix Tag." The Determination of whether violations are corrected state Statute number and the requires compliance with all requirements corresponding text of the state Statute out provided at the Statute number indicated below. of compliance is listed in the "Summary When Minnesota Statute contains several items, Statement of Deficiencies" column. This failure to comply with any of the items will be column also includes the findings which considered lack of compliance. are in violation of the state requirement after the statement, "This Minnesota INITIAL COMMENTS: requirement is not met as evidenced by." Following the evaluators ' findings is the SL30738016-0 Time Period for Correction. On December 9, 2024, through December 11, PLEASE DISREGARD THE HEADING OF 2024, the Minnesota Department of Health THE FOURTH COLUMN WHICH conducted a full survey at the above provider. At STATES,"PROVIDER'S PLAN OF the time of the survey, there were 155 residents; CORRECTION." THIS APPLIES TO 132 receiving services under the Assisted Living FEDERAL DEFICIENCIES ONLY. THIS Facility with Dementia Care license. WILL APPEAR ON EACH PAGE. THERE IS NO REQUIREMENT TO SUBMIT A PLAN OF CORRECTION FOR VIOLATIONS OF MINNESOTA STATE STATUTES. 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. 0 100 144G.10 Subdivision 1 License required 0 100 SS=F (a)(1)Beginning August 1, 2021, no assisted living LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 W8MN11 If continuation sheet 1 of 21 PRINTED: 02/03/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 30738 12/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 705 17TH STREET NORTH EDGEWOOD VIRGINIA I SENIOR LIV VIRGINIA, MN 55792 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) 0 100 Continued From page 1 0 100 facility may operate in Minnesota unless it is licensed under this chapter. (2) No facility or building on a campus may provide assisted living services until obtaining the required license under paragraphs (c) to (e). (b)The licensee is legally responsible for the management, control, and operation of the facility, regardless of the existence of a management agreement or subcontract. Nothing in this chapter shall in any way affect the rights and remedies available under other law. (c) Upon approving an application for an assisted living facility license, the commissioner shall issue a single license for each building that is operated by the licensee as an assisted living facility and is located at a separate address, except as provided under paragraph (d) or (e). (d) Upon approving an application for an assisted living facility license, the commissioner may issue a single license for two or more buildings on a campus that are operated by the same licensee as an assisted living facility. An assisted living facility license for a campus must identify the address and licensed resident capacity of each building located on the campus in which assisted living services are provided. (e) Upon approving an application for an assisted living facility license, the commissioner may: (1) issue a single license for two or more buildings on a campus that are operated by the same licensee as an assisted living facility with dementia care, provided the assisted living facility for dementia care license for a campus identifies the buildings operating as assisted living facilities with dementia care; or (2) issue a separate assisted living facility with dementia care license for a building that is on a campus and that is operating as an assisted living facility with dementia care.