mn DEPARTMENT OF HEALTH Office of Health Facility Complaints Investigative Report PUBI Facility Name: Report Number: Date of Visit: The Commons on Marice 120662013 November 21, 2017 'y Address: Time of Visit: Date Concluded: 1380 Marice Drive 8:00 am to 3:00 pm January 29, 2018 Facility City: Investigator's Name and Title: Eagan Earl F Bakke State: ZIP: County: Minnesota 55121 Dakota [XJ Home Care Provider/Assisted Living Allegation): : i itis alleged that a client was neglected when facility staff failed to provide daily checks according to the service plan. Client passed away and was not discovered for two days, [State Statutes for Home Care Providers (MN Statutes, section 144.43 - 144A.483) [i] State Statutes for Vulnerable Adults Act (MN Statutes, section 626.557) [i] State Statutes Chapters 144 and 144A ‘Conclusion; 4 ae Based on the preponderance of evidence, the allegation of neglect is substantiated. The client had a documented vulnerability with a history of falls and a diagnosis of seizures. The facility had a daily “I'm ok” program used to check on clients to assure safety as a part of a service provided. The facility did not perform that service on at least two days in October 2017 for the client and did not institute any other safety prevention measures to protect the client, The client was not checked on for two days and later discovered deceased. The facility's residency agreement, signed by senior leadership and the client, page 13 Exhibit A, #13: "Daily I'm ok checks", The client received services from the comprehensive home care provider for care with a feeding tube as required, nursing assessments, and vital signs. The facility had a daily "I'm ok" program where it was documented that each client was either seen, checked on by a staff member or an outside health care provider, or called on the phone to assure each was safe and well. The client's individual abuse prevention plan indicated that the client was vulnerable to falls and required the use of a walker. Progress notes indicated the client had five fall events between May of 2017 and September of 2017, The client's individual abuse prevention plan had been reviewed three times between April of 2017 and October of 2017. Each Page 1 of 8Facility Name: The Commons on Marice Report Number: HL20662013 time, a registered nurse indicated there were no changes to be made to the prevention plan. Only two assessments had been completed since the first fall incident in May of 2017. Neither of the assessments mentioned any of the fall events or the history of falls, which had been documented on assessments earlier in the year. A family member for the client arrived at the facility on October 26, 2017, in the evening to visit. The family member arrived at the front door to the client's room to find several boxes had been delivered. There were also two newspapers in front of the door dated October 25th and October 26th, 2017. The family member entered the client's room and immediately found the client laying unresponsive in a recliner, The family member said it was immediately apparent that the client had died, The family member contacted facility staff and Hospice. A Hospice representative contacted the medical examiner's office. The client was found ina reclining chair with the footrest extended, leaning in a horizontal position, eyes partially open, with bruising around the right side of the jawbone, cheek, and both sides of the lower neck area. There was blood on the clients right leg. The client was to receive a daily "I'm ok" check from a member of the facility, The facility's daytime front desk receptionist held the responsibility of performing this task. The daily "I'm ok" checks were documented on a client roster and kept in the receptionist's desk. Ifa client was seen, or a staff member or other outside health care provider saw a client, that client received a check mark by their name. The clients who had not been seen were called by telephone. If a client did not answer, a staff member was supposed to be sent to the client's apartment to check on them. The facility did not have documentation the daily "I'm ok" checks were performed for the client on October 24th or October 25th, 2017, The "I'm ok" daily check form on October 26th, 2017 indicated the client was “ok", noted by a check mark by her name. There is evidence that the client had died or was incapacitated for unknown reasons where he/she could not get out of the chair on the evening of October 24th through the time of discovery (October 26, 2017). The client was found October 26th in the same clothing he/she was wearing from a family meeting held on October 24th. Boxes and newspapers (dated October 25th and 26th) were found in front of the client's door. The bed and bathroom did not appear to have been used since the housekeeper cleaned on the afternoon of October 24th. The client's medications for October 25th and 26th had not been taken. The client did not show up to a Halloween party he/she had planned on attending the evening of October 24th. ‘The newspaper for October 24th was still folded in an undisturbed manner. The client's phone records show the client's phone was not used to make, nor were any calls answered after 6:00 pm on October 24th. The daily "I'm ok" check mark on October 26th, 2017 was falsely documented because the client was not alive. There was documentation of the client having a history falls. During an interview with a facility receptionist, it was stated that on one occasion, the client had called the front desk to ask for help after falling and cutting his/her knees. During an interview with the client's family member, he/she said that on October 24th, 2017, in the early afternoon, there had been a family meeting with the client and a Hospice and Home Care representative. family stated the client had been involved in the meeting, was able to ambulate, and was alert and oriented. Family stated the client, even though listed as an assisted living client, performed a lot of his/her task and activities of daily living independently. Family stated the client had been wearing a black and tan Page 20f8Facility Name: The Commons on Marice Report Number: HL20662013 spotted type shirt and black pants. Family stated after the meeting concluded mid-afternoon, a facility housekeeper arrived to clean the client's apartment. The family member stated he/she left when the housekeeper arrived and told the client that he/she would visit in a couple of days. | The interview with the family member continued with him/her saying that upon entering the room on October 26th, the window blinds were up and that the newspaper, dated October 24th was still folded and on the left side of the client, along with a pair of eye glasses. The family member said the client was wearing the same clothing he/she was wearing on October 24th during the family meeting, The client's medication for October 25th and October 26th had not been taken. The apartment's bed and bathroom did not appear | to have been used since the housekeeper cleaned on October 24th. During an interview with a housekeeper, he/she said that he/she had been asked to come back later because of a family meeting, The housekeeper scheduled the client's room last to clean that day. The housekeeper stated they arrived back to the client's room at 3:00 pm and did the housekeeping. The housekeeper stated they talked with the client about going to a Halloween party. The client said he/she was going to the Halloween gathering and that he/she wanted to meet the housekeeper’s children. The client had even decorated his/her walker for the Halloween party. The party started at 5:30 pm and ended at 7:30 pm. The housekeeper said the client was walking around and talking without any difficulty. The house cleaning service was done at 3:40 pm. When the housekeeper was leaving, the client was standing in the itchen. The client told the housekeeper, “see you later.” The housekeeper stated they did not see the client at the Halloween party. During an interview with a receptionist, he/she said that the daily "I'm ok" check program did not consist of a written policy or procedure at the time this incident took place. Since then, a new policy had been instituted. The receptionist stated, in the past, each day list of clients was printed off. The receptionist stated, if a receptionist saw a client or if a staff member told the receptionist that a client had been seen, a check mark was placed by the client's name. The receptionist stated, if a client had pushed their pendant system that counted as being "ok". The receptionist stated if a client had not been seen by 10:00 am, they were eventually called. The receptionist stated, if the client did not answer, a staff member was sent to the client's room to assure that client was safe and well. The receptionist said there were times that not all the clients had been checked on because of other responsibilities being performed. The receptionist stated the task of daily "I'm ok" checks were the responsibility of the daytime receptionist. The receptionist stated if all the clients did not get checked on after a phone call, it usually did not get done. The receptionist said phone messages are not left when an "I'm ok" call is made because clients don't listen to phone messages. The interview with the receptionist continued with him/her saying that to the best of his/her knowledge, the client had called the front desk on October 26th inquiring if a package had been delivered. The receptionist also said that the client's family member arrived around 3:00 pm to visit the client. The receptionist stated the family member had stopped at the front desk and asked the receptionist about his/ her pet. The receptionist said the family member typically did not sign in as a guest were supposed to do. The receptionist stated in his/her time working at the facility, there was no memory of having to call the client to do an "ok check". The receptionist stated the most common way to confirm if the client was ok was through aides or the client's family member. The receptionist said there was a camera in the lobby, but it Page 30f8Facility Name: The Commons on Marice Report Number: HL20662013 either did not work or was not wired. A review of the client's phone records show that between October 23rd and 26th, 2017, no calls were made to or from the client's land-line phone to the facility's front desk. In fact, phone records show that the client did not answer several calls received from other family members. During an interview with senior leadership, he/she said that after hearing about the incident of finding the client, an internal review process was conducted and that a new system for doing daily "I'm ok" checks was implemented, senior leadership stated a page of the daily "ok checks" had been discovered missing and that a receptionist had received a written warning because of it. senior leadership stated there was no system in place to document what time packages were taken from the front desk area to the client's rooms. Senior leadership stated they did attend the Halloween gathering at the facility and did not see the client. During an interview with a nurse manager, he/she said that "I'm ok" checks were completed by the front desk, and if client had not been seen by 11:00 am, phone calls to clients were made. The nurse manager stated the client received services for assistance with his/her feeding tube as needed, vital signs, and weight checks were done once a month. The nurse manager stated that a nurse completed an annual assessment. The nurse manager stated it was uncommon for boxes to sit in front of client's doors. Minnesota Vulnerable Adults Act (Minnesota Statutes, section 626.557) Under the Minnesota Vulnerable Adults Act (Minnesota Statutes, section 626.557): Abuse 1 Neglect 1 Financial Exploitation BH Substantiated 1 Not Substantiated [1 Inconelusive based on the following information: Click Here and Type Mitigating Factors: The "mitigating factors" in Minnesota Statutes, section 626.557, subdivision 9c (c) were considered and it was determined that the [] Individuals) and/or 2] Facility is responsible for the Abuse ®& Neglect [] Financial Exploitation. This determination was based on the following: The facility was aware of the client's history of falls, use of a walker, past diagnosis of seizures and vulnerability to falling. The facility had a daily "I'm ok" check program to ensure the safety and well being of the clients. The daily "I'm ok" check program was not conducted for two days on the client and he/she was found deceased. ‘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 Page 4of 8Facility Name: The Commons on Marice Report Number: HL20662013 for possible disqualification in accordance with the provisions of the background study requirements under Minnesota 245C. Compliance! State Statutes for Home Care Providers (MN Statutes section 144.43 - 144A.483) - Compliance Not Met The requirements under State Statutes for Home Care Providers (MN Statutes, section 144A.43 - 144.483) were not met, State licensing orders were issued: J Yes [No (State licensing orders will be available on the MDH website.) State Statutes for Vulnerable Adults Act (MN Statutes, section 626.557) - Compliance Not Met The requirements under State Statutes for Vulnerable Adults Act (MN Statutes, section 626.557) were not met. State licensing orders were issued: [XJ Yes. + [] No (State licensing orders will be available on the MDH website.) State Statutes Chapters 144 & 144A ~ Compliance Not Met - Compliance Not Met The requirements under State Statues for Chapters 144 &144A were not met. State licensing orders were issued: [J Yes [] No (State licensing orders will be available on the MDH website.) Compliance Notes: Definitions: | eee : Minnesota Statutes, section 626.5572, subdivision 17 - Neglect “Neglect” means: (a) 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. (b) The absence or likelihood of absence of care or services, including but not limited to, food, clothing, shelter, health care, or supervision necessary to maintain the physical and mental health of the vulnerable adult which a reasonable person would deem essential to obtain or maintain the vulnerable Page 5 of 8Facility Name: The Commons on Marice Report Number: HL20662013 adult's health, safety, or comfort considering the physical or mental capacity or dysfunction of the vulnerable adult. Minnesota Statutes, section 626.5572, subi n 19 - Substan "substantiated" means a preponderance of the evidence shows that an act that meets the definition of maltreatment occurred. ‘The Investigation included the following: : ‘i j Document Review: The following records were reviewed during the investigation: Medical Records Care Guide Nurses Notes Assessments Treatment Sheets Care Plan Records Facility Incident Reports Service Plan BREA RBReeae ‘Other pertinent medical records: 4 ee ee [| Medical Examiner Records Death Certificat [Police Report BH Other, specify: ‘Additional facility records: 5 Staff Time Sheets, Schedules, etc. Facility Internal Investigation Reports Call Light Audits ® & w w Personnel Records/Background Check, ete. Facility In-service Records [Facility Policies and Procedures Number of additional resident(s) reviewed: Zero Were residents selected based on the allegation(s}? Yes ONo @WN/A Page 6 ofFacility Name: The Commons on Marice Specify: Report Number: HL20662013 Were resident(s) identified in the allegation(s) present in the facility at the time of the investigation? OYes @No ON/A Specify: Deceased Interviews: The following interviews were conducted during the investigation: Interview with reporter(s) @Yes ONo ON/A Specify: If unable to contact reporter, attempts were made on: Date: Time: Date: Time: Date: Time: Interview with family: ® Yes No OvN/A Specify: Did you interview the resident(s) identified in allegation: OYes @No OWN/A Specify: Deceased Did you interview additional residents? @ Yes © ©/No Total number of resident interviews:Six Interview with staff: © Yes ONo ON/A Specify: ‘Tennessen Warnings | i ee. g Tennessen Warning given as required: @Yes Qo Total number of staff interviews Physician Interviewed: QYes @No Nurse Practitioner Interviewed: QyYes @No Physician Assistant Interviewed: QYes @No Interview with Alleged Perpetrator(s): © Yes ONo @N/A_ Speci Attempts to contact: Date: Time Date: Time: Date: Time: If unable to contact was subpoena issued: © Yes, date subpoena was issued ONo Were contacts made with any of the following: (Emergency Personnel [x] Police Officers [x] Medical Examiner [x] Other: <¢j5, Phone Company Page 7 of 8Facility Name: The Commons on Marice Report Number: HL20662013 Observations were conducted related to: Call Light Use of Equipment Cleanliness Safety Issues Facility Tour Bee eee Other: Call light system | ‘Was any involved equipment inspected: Q Yes QNo @N/A ‘Was equipment being operated in safe manner: Q Yes QNo @WN/A Were photographs taken: © Yes Qo Specify: By Medical Examiner's Office cc: Health Regulation Di ion - Licensing & Certification Health Regulation Divi The Office of Ombudsman for Long-Term Care Hennepin Eagan Police Department Dakota County Attorney Eagan City Attorney Page 8 of 8Minnesota Department of H Ith PRINTED: 03/14/2018 FORM APPROVED. ‘STATEMENT OF DEFICIENCIES | (XI) PROVIDER/SUPPLIERICUA | pt) MULTIPLE CONSTRUCTION 3) DATE SURVEY [AND PLAN OF CORRECTION IDENTIFICATION NUMBER ) ULDN (COMPLETED c Ha0662 8.WING 01/29/2018 ‘NAME OF PROVIDER OF SUPPLIER ‘THE COMMONS ON MARICE STREET ADORESS, CITY, STATE, ZIPCODE 1980 MARICE DRIVE EAGAN, MN 55121 2a) ‘SUMMARY STATEMENT OF DEFENCES D ‘PROVIDERS PLAY OF CORRECTION 2a, Prem | GAGHDEFICENGY MUST BEPRECEBED AY FULL | pREFIX (EACHCORRECTIVEACTION SHOULD BE | couPucre TAG | REGULATORY OR LSC IDENTIFYING INFORMATION) Te CAOSS-REFERENCED TO THE APPROPRIATE bare DEFICIENCY) 0.000) Initial Comments 0.000 | *****ATTENTION“A Minnesota Department of Health is documenting the State Licensing HOME CARE PROVIDER LICENSING Correction Orders using federal software, | CORRECTION ORDER Tag numbers have been assigned to | Minnesota State Statutes for Home Care | In accordance with Minnesota Statutes, section Providers. The assigned tag number | 1448.43 to 144.482, this correction order(s) has, appears in the far left column entitled "ID been issued pursuant to a survey. Prefix Tag.” The state Statute number and the corresponding text of the state Statute Determination of whether a violation has been ‘out of compliance is listed in the corrected requires compliance with all “Summary Statement of Deficiencies" requirements provided at the Statute number column. This column also includes the | indicated below. When Minnesota Statute findings which are in violation of the state | contains several items, failure to comply with any requirement after the statement, "This | | of the items will be considered lack of Minnesota requirement is not met as | compliance evidenced by.* Following the surveyors ' findings is the Time Period for Correction. INITIAL COMMENTS: PLEASE DISREGARD THE HEADING OF (On November 21 and 22, 2017, a complaint THE FOURTH COLUMN WHICH investigation was initiated to investigate STATES,"PROVIDER' S PLAN OF complaints #HL20662012, #2066201, and CORRECTION." THIS APPLIES TO #H120662014. At the time of the survey, there FEDERAL DEFICIENCIES ONLY. THIS were 111 clients that were receiving services WILLAPPEAR ON EACH PAGE. Under the comprehensive license. The following correction orders are issued related to complaint THERE IS NO REQUIREMENT TO #H1L20662013. SUBMIT A PLAN OF CORRECTION FOR VIOLATIONS OF MINNESOTA STATE STATUTES. The letter in the left colurnn is used for | tracking purposes and reflects the scope and level issued pursuant to 1441.474 subd. 11 (b) (1) (2) | Subdivision 1. Statement of rights. A person who | receives home care services has these rights: Ninnesota Department of Health LAZORATORY DIRECTORS OR PROVIDERISUPPLIER REPRESENTATIVE’ SIGNATURE me 1x oar STATEFORIT UALOT T connoaton heat Tor6PRINTED: 03/14/2018 FORM APPROVED. Minnesota Department of Health ‘STATEMENT OF DEFIGIENGIES | (Ki) PROVIDERVSUPPLIERIGUA | 0X2) MULTIPLE CONSTRUCTION (0) DATE SURVEY [AND PLAN OF CORRECTION DENTICATIONNUMBER: |. put onG: couptereo ic H20662 wea ——— 01/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADORESS, CITY, STATE, 2° CODE 1980 MARICE DRIVE ‘THE COMMONS ON MARICE EacianT uniesie1 a0 ‘SUMMARY STATEMENT OF DEFICIENCIES pee PROVIDERS PLAN OF CORRECTION 7), Prevx | (GACH DEFICIENCY MUST BE PRECEDED BY FULL PREEX | (EACH CORRECTIVE ACTION SHOULD BE conptere Tae REGULATORY OR LSC IDENTIFYING INFORMATION) ha (CROSS. REFERENCED TO THE APPROPRIATE DATE | DEFICIENCY) 0325] Continued From page 1 (14) the right to be free from physical and verbal | abuse, neglect, financial explotation, and all | forms of maltreatment covered under the Vulnerable ‘Adults Act and the Maltreatment of Minors Act; This MN Requirement is not met as evidenced by: Based on interview and document review, the licensee failed to protect one of one clients (C1) reviewed to be free from maltreatment when the facility faled to perform a “dally 'm ok" check on | the client on October 25 and October 26, 2017. | The client was last seen at 3:00 p.m. on October 24, 2017 and was found deceased in a recliner in | hor room on October 26, 2017 at 6:20 p.m. by a family member. it is unknown when the client's date and time of death occurred but had the daily | “lm ok check" been completed the client may have been found and help could have been called. This is a Level 3 violation (a violation that harmed a client's health or safety, not including serious injury, Impairment, or death, or a violation that has the potential to lead to Serious injury, impairment, or death and an isolated scope (when one ora limited number of clients are affected or one or a limited number of staff are involved or that a situation has occurred only | occasionally). The findings include: C's medical record was reviewed. C1's service agreement, dated October 26, 2017, indicated C1 was receiving services from the comprehensive home care provider for assistance as needed with connecting and unconnecting a feeding bag, [vital signs and weight check, and an annual 0325 imesota Department of Fealth STATE FORM = uatcnt Hcaninutionshest 2 f6 |Minnesota Department of Health PRINTED: 09/14/2018 FORM APPROVED ‘STATENENT OF DEFICIENCIES | (Ki) PROVIDERISUPPLIERIGLIA [AND PLAN OF CORRECTION IDENTIFICATION NUMBERS H20662 (0a) MULTIPLE CONSTRUCTION A. BUILDING 8. Wing (oa) DATE SURVEY ‘COMPLETED c 01/29/2018 NAME OF PROVIDER OR SUPPLIER ‘THE COMMONS ON MARICE ‘STREET ADORESS, CITY, STATE, ZIP CODE 1380 MARICE DRIVE EAGAN, MN 55121 or Pree. Tas. ‘SUMMARY STATEWENT OF DEFICENCES (GACH DEFICIENCY WUST BE PRECEDED By FULL REGULATORY OR USC IDENTIFYING INFORMATION) ‘DEFICENCY). ome PROVIDERS PLAN OF CORRECTION 28) PREF (EACH CORRECTIVE ACTION SHOULD BE conptere Tae (CHOSS REFERENCED TO THE APPROPRIATE DATE 0325 Continued From page 2 assessment. C1 had a resident handbook, issued on July 26, 2018 at the time of signing the residency agreement stated in part, "a daily 'm ok program is completed once a day. The program is a measure used to assure your safety and well being on a dally basis. There is a check-in button located on the wall in your bedroom. When you wake up in the morning, we ask that you push the check mark button to notify the front desk. if you have not pushed the button by 10:00 am, the front desk wil call you to make sure that everything is all right." Adocument titled, "Vulnerability assessment/Abuse prevention plan’, initially dated April 24, 2017, indicated C1 was vulnerable to falls and frequent bruising with a history of falls, vulnerable to not ambulating safely and that C1 uses a walker. The vulnerability | assessment/abuse prevention plan was signed by a registered nurse on July 14, 2017 and October 9, 2017 indicated no changes. ‘Adocument titled, "Home Care Assessment", | dated November 18, 2016, indicated C1 had a | history of falls, was forgetful, had seizures and | dizziness. Adocument marked as a "90 day comprehensive assessment", dated October 9, 2017, indicated a registered nurse reviewed the vulnerabilly, falls, and medication assessments. Adocument titled, "Numerical Resident List’, dated October 25, 2017, indicated C1 had not been checked on, noted by the absence of a check mark in the comments box. 0325 fiasota Deparinent Of Heath STATE FORM om vuatont Ieantnuaton shoot 28 |Minnesota Department of Health PRINTED: 09/14/2018 FORM APPROVED ‘A document titled, "Numerical Resident List’, dated October 26, 2017, indicated C1 had been checked on and was ok, noted by a check mark in the comments box. document titled, "Corrective Action Notice", dated November 9, 2017, indicated that a staff member (0) received a written warning for a process breakdown and inconsistencies discovered concerning the "I'm ok" checks during the period of October 24-26. The document indicated October 24th log sheet was completely missing from the files, October 25th log sheet | indicated that C1 was not checked on, and the | licensee's internal investigation determined that | the October 26th log was inaccurately recorded | for c1. | number: 2017-00010075", dated January 10, | 2018 indicated all calls made to and from C's land-line phone from October 23, 2017 through October 27, 2017. The document indicated thet C1 did not call the licensee, nor did the licensee call C1 During an interview with C1's family member (FM)-C on November 22, 2017 at 3:18 pm, he/she said on October 24, 2016 around 2:15 pm he/she left C1's room and C1 was ambulating and at his/her baseline. On October 26, 2017, around 6:15 pm, FM-C came to visit C1 and found newspapers dated October Sth and October 6th, along with several packages in front of C1's door. FM-C went in to Cts room and discovered C1 unresponsive. FM-C said C1 was obviously dead. FM-C called the front desk but said they did not know what to do, 80 he/she called the hospice triage line. FM-C said that when she walked into the licensee's building STATEMENT OF DEFICIENCIES | (Xi) PROMDENSUPPUEROUA | Da) MULTIPLE CONSTRUGTON a ONE SURVEY ‘mio Puan OF CORRECTION roenmipcaTion uw | Reon one, SouPcere Cc H20662 8 WING. 01/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CT, STATE, 2° CODE 1980 MARICE DRIVE THE COMMONS ON MARICE ean eee ron SUMMARY STATEUENT OF DEROENOES | PROVBERS RAN OF CORREGTION pm eS | (eAGOBRCENGY MUST Be PRECEDED By FULL nrc GACHCORRECTWE AcTINSHOULDEE | coMetere Tho” | REGULATORY OM Se ENTIFYIvG NFORNATION ee CAOSEREPERENGED TOME ARPROmMATE | DATE DenIENCN) | 0.325 Continued From page 3 0325 innasota Department of Health STATE FORM om vuatctt Hreannusion sheet 4 of 8PRINTED: 03/14/2018 FORM APPROVED Minnesota Department of Health STATEMENT OF DEFICIENCIES | Xt) PROVIDERISUPPLIERIGUA | D@ MULTIPLE CONSTRUCTION [oa DATE SURVEY [AND PLAN OF CORRECTION IDENTIFICATION NUMBER anne ‘COMPLETED ic) H20662 8. WING. 01/29/2018 NAME OF PROVIDER OR SUPPLIER ‘STREET ADDRESS, CIY, STATE, 2 CODE 1380 MARICE DRIVE ‘THE COMMONS ON MARICE aan festay oa | ‘SUMMARY STATEMENT OF DEFICIENCIES 2. PROVIDERS PLAN OF CORRECTION. oe Sheri | (GACH DEFICIENCY MUST BE PRECEDED BY FULL PREF. {EACH CORRECTIVE ACTION SHOULO BE conPtere Tae REGULATORY OF USC IDENTIFYING INFORMATION) TAG (CHOSE-REPERENCED TO THE APPROPRIATE DATE | DEFICIENCY) 0.325] Continued From page 4 0.925 | | hafshe did not sign in or stop at tak to a | receptionist. FM-C had not been to visit Ct | earlier in the day. | During an interview wih a receptionist (D) on | November 22, 2017 at 9:41 am, he/she said the | receptionist held the responsibilty for doing daily | ‘I'm ok" checks. Clients were marked as ok if | they were seen, an aide said he/she saw a client, | the client called or pushed their ok button, or a | spouse or external healthcare service saw a | client. if client did not fitin one of those | categories, the client would be called. Ifthe client | did not answer, an aide would be asked to go cchack on the client. The receptionist (0) said that the receptionist held many responsiblties and sometimes not all clients got checked on because only the day shift receptionist conducts the "I'm ‘ok" checks. If by 3:00 pm a client had not been checked on, it just didn't get done that day. The receptionist (D) said that to the best of his/her recollection, on October 26, 2017, C1 had called the front desk inquiring if some packages had been delivered. C1 was marked as ok. The receptionist (D) also said that FM-C had stopped by the receptionist desk which would have been Prior to 3:00 pm During an interview with the executive director (ED)-B on November 22, 2017 at 1:37 pm, he/she said that the director of nursing had notified him/her of the incident and that he/she had conducted an internal investigation. As @ result of that investigation, a staff member had received a written warning regarding inconsistencies found in the dally “Im ok" check rogram. The daily "I'm ok* check program had been revised and all employees and clients had received education on the new process. inmesota Deparment of Healt STATE FORM om unter: Honinutionshest 5.016PRINTED: 09/14/2018 FORM APPROVED Minnesota Department of Health STATEMENT OF DEFICENGIES | (Xi) PROVIDENSUPPLERIGLIR] (2 MULTIPLE CONSTRUCTION (oa) GATE SURVEY [AND PLAN OF CORRECTION IDENTICATION NUMBER. | Pou owe coubteteD c eae B.WING : 1/29/2018 NAME OF PROVIDER OR SUPPLIER ‘STREET ADDRESS, CITY, STATE, 2 CODE 1980 MARICE DRIVE ‘THE COMMONS ON MARICE o EAGAN, MN 55121 rn) "GUNMARY STATEMENT OF DEFCENGIES 10 PROVIDERS PLAN OF CORRECTION 5) Pret | AGH DEFICIENCY MUST BE PRECEDED BY FULL PRED ACHCORRECTNVE AGTION SHOULD BE — | coMPLETE Tae AEGULATORY O8 LSC IDENTIFYING INFORMATION) THe CHOSSAEFERENCED FO THE APPROPRIATE | “OKTE DERIGIENCY) 0.328] Continued From page 5 oss | At the time of the incident, the licensee did not have a policy on the daily "'m ok" check program. | Time Period of Correction: Twenty-One (21) days | iniosata Deparivent OT Hea STATE FORM co ater Heontinaton seat Gof 8m DEPARTMENT OF HEALTH Protecting, Maintaining ondimprovingtheHeaith of All Minnesotans Certified Mail Number: 70150640000458710004 March 14, 2018 David Salmon, Administrator The Commons On Marice 1380 Marice Drive Eagan, MN 55121. RE: Complaint Number HL20662012, HL20662013, HL20662014 Dear Mr. Salmon: Acomplaint investigation (#HL20662012, HL20662013, HL20662014) of the Home Care Provider named above was completed on January 29, 2018, for the purpose of assessing compliance with state licensing regulations. At the time of the investigation, the investigator from the Minnesota Department of Health, Office of Health Facility Complaints, noted one or more violations of these regulations. These state licensing orders are issued in accordance with Minnesota Statutes Sections 1444.43 to 144A.482. State licensing orders are delineated on the attached State Form. The Minnesota Department of Health is documenting the State Licensing Correction Orders using federal software. Tag numbers have been assigned to Minnesota state statutes for Home Care Providers. 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." ‘Awritten plan for correction of licensing orders is not required. Per Minnesota State Statute 144.474 Subd. 8(c), the home care provider must document in the provider's records any action taken to comply with the correction order. A copy of this document of the home care provider's action may be requested at future surveys. Alicensed home care provider may request a correction order reconsideration regarding any correction order issued to the provider. The reconsideration must be in writing and received within 15 calendar days. Reconsiderations should be addressed to: Renae Dressel, Health Program Rep. Sr Home Care Assisted Living Program Minnesota Department of Health P.O, Box 3879 85 East Seventh Place‘The Commons On Marice March 14, 2018 Page 2 St. Paul, MN 55101 It is your responsibility to share the information contained in this letter and the results of the visit with the President of your organization's Governing Body. If you have any questions, please contact me Sincerely, fete = Mike Kaehler Health Regulations Division Supervisor Office of Health Facility Complaints 85 East Seventh Place, Suite 220 P.O. Box 64970 St. Paul, MN. 55164-0970 Telephone: (651) 201-4181 Fax: (651) 281-9796 MK Enclosure ce: Home Health Care Assisted Living File Dakota County Adult Protection Office of Ombudsman MN Department of Human Services {an equal opportunity employer.