Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County It is alleged that a resident was neglected by staff when the resident had a change in condition. The resident Ada 413 Benedictine Care Community x NEGLECT-HEALTH CARE 8/10/2017 3/1/2018 died during the night. x Norman It is alleged that a resident was neglected when staff/alleged perpetrator failed to follow the client's care Ada 413 Benedictine Care Community x NEGLECT-FALLS 6/26,27/2017 11/2/2017 plan during a transfer. The resident had a fall and sustained a left femur fracture. x Norman

It is alleged that a resident was neglected when s/he had a change in condition and the facility did not 03/29,30,31/2 adequately assess him/her. The resident requested to go to the hospital and the facility denied the request. Ada 413 Benedictine Care Community x NEGLECT-HEALTH CARE 016 9/6/2016 The following day the resident was hospitalized with shock, kidney failure and internal bleeding. x Norman

It is alleged that a resident was neglected when facility staff failed to update resident care plan per nursing 03/29,30,31/2 assessments. Resident was assessed to be a burn risk for hot liquids, needing cooled down liquids, and this Ada 413 Benedictine Care Community x NURSING CARE 016 7/25/2016 was not reflected in his/her care plan. Resident spilled his/her coffee and sustained 1st degree burns. x Norman It is alleged that a resident was abused by two men when they entered the resident's room during the night Adams 754 Adams Health Care Center x ABUSE-SEXUAL 3/10/2017 4/11/2017 shift, tied the resident to the bed with a rope and raped the resident. x Mower

It is alleged that a resident was abused by a staff, alleged perpetrator (AP) when the AP treated the resident Adrian 405 Adrian Care Center x ABUSE-EMOTIONAL-STAFF 8/31/2015 7/21/2017 in a humiliating manner, writing on the resident's forehead with a permanent marker. x Nobles

It is alleged that two residents were neglected when staff did not appropriately secure the residents in the NEGLECT-FALLS DUE TO EQUIPMENT FAILURE, facility bus and the residents fell out of their wheelchairs and sustained injuries. In addition, staff is not being Adrian 405 Adrian Care Center x INAPPROPRIATE USE OF EQUIPMENT 4/29/2015 7/22/2015 trained on driving the bus or securing residents in the bus. x Nobles

It is alleged that a client was neglected when the client was not assessed for a change in condition when the client was in pain. In addition, it is alleged that medications were not reordered in a timely manner leaving NEGLECT-HEALTH CARE MEDICATION the client without medications for up to eleven days. In addition, it is alleged there were multiple medication Afton 27465 Afton Care Senior Homes ADMINISTRATION LACK OF TRAINING 1/29/2015 6/29/2015 errors and staff are not being trained to administer medications. x Washington

It is alleged that a client was neglected when s/he was not assessed for a change of condition when the plan NEGLECT-HEALTH CARE MEDICATION of care was not followed, resulting in vomiting and dehydration. In addition, it is alleged that one client's Afton 27465 Afton Care Senior Homes ADMINISTRATION 1/29/2015 5/15/2015 medication were being used for all clients and medications are being disposed of improperly. x Washington It is alleged that a client was neglected when the client fell down and sustained a brain bleed. Staff did not immediately assess the client after her/his fall and did not send the client to the hospital until several hours Afton 27465 Afton Care Senior Homes NEGLECT - HEALTH CARE 5/28/2015 6/18/2015 later. The client passed away at the hospital. x Washington

11/14/2014 It is alleged a client was neglected when staff failed to assess a client's change in condition. The client was and transported to the emergency department and found to be in renal failure. The client had a bladder infection Afton 27465 Afton Care Senior Homes x NEGLECT - HEALTH CARE 11/17/2014 10/30/2015 and was dehydrated. The client's family has not been kept up to date on the client's condition. x Washington It is alleged that a client was exploited when several of their medications including narcotics were replaced Aitkin 2 Aitken Health Services x ABUSE-EXPLOITATION-DRUG DIVERSION 1/3/2017 8/18/2017 with different medications. x Aitken

Aitkin 23660 Golden Horizons x NEGLECT-FALLS, HEALTH CARE NURSING CARE 9/13/2016 10/25/2016 It is alleged that a client was neglected when the client fell on multiple occasions and was injured. x Aitken It is alleged that a client was emotionally abused when the alleged perpetrator restrained the client to room Aitkin 23660 Golden Horizons x ABUSE-EMOTIONAL-STAFF PATIENT RIGHTS 2/22/2017 6/19/2017 by putting chair against the door x Aitken It is alleged that a client was neglected when staff failed to provide care leaving the client in soiled clothing Aitkin 23660 Golden Horizons NEGLECT-HEALTH CARE 5/27/2015 7/21/2015 for several hours. x Aitken It is alleged that residents' were financially exploited when a staff, alleged perpetrator (AP) took the Albany 634 Mother of Mercy Campus of Care x EXPLOITATION - DRUG DIVERSION 6/8,9/2015 7/17/2015 residents' pain medication for his/her own personal use. x Stearns

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 1 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County It is alleged that client #1, client #2 and client #3 were financially exploited when the alleged perpetrator (AP) Albany 20265 Mother of Mercy Senior Living x EXPLOITATION BY DRUG DIVERSION 9/25/2017 2/15/2018 took the client's narcotic medications for their own personal use. x Stearns It is alleged that the facility failed to provide adequate supervision to two clients when one client was found Albany 20265 Mother of Mercy Senior Living x NEGLECT-SUPERVISION NURSING CARE 8/8/2016 4/24/2017 touching another client inappropriately on several occasions. x Stearns It is alleged that a client was financially exploited when a staff alleged perpetrator (AP) took money from the Albert Lea 20016 St John's Community Care x ABUSE-EXPLOITATION-STAFF 12/28/2017 1/8/2018 client. x Freeborn It is alleged that a client was financially exploited when a staff member/alleged perpetrator solicited the Alexandria 21247 Edgewood Alexandria Senior Liv x ABUSE-EXPLOITATION-STAFF 12-Apr-17 9/25/2017 client Isotonix, who sold the product. x Douglas It is alleged that clients #1, #2, #3, and #4 were financially exploited when the alleged perpetrator took the Alexandria 28201 Grand Arbor x ABUSE-EXPLOITATION-STAFF 1/4/2017 3/3/2017 client's money x Douglas It is alleged that clients #1, #2, #3, and #4 were financially exploited when the alleged perpetrator took the Alexandria 28201 Grand Arbor x ABUSE-EXPLOITATION-STAFF 1/4/2017 3/3/2017 client's money x Douglas It is alleged that a resident was neglected when s/he fell and was burned by the baseboard heater in the Alexandria 113 Knute Nelson x NEGLECT-FALLS 4/22/2016 3/10/2017 resident's room. x Douglas It is alleged that a resident was financially exploited when a staff, alleged perpetrator (AP), took the resident's medications for his/her own use. The AP confessed to facility management to taking the Alexandria 113 Knute Nelson x EXPLOITATION - DRUG DIVERSION 2/8/2016 2/8/2016 medications. x Douglas

It is alleged that a resident was neglected when alleged perpetrator failed to follow resident's care plan Alexandria 113 Knute Nelson x NEGLECT-SUPERVISION 2/8/2018 3/5/2018 during a transfer that resulted in a fall. The resident was sent to the emergency room and CT scan was done. x Douglas NEGLECT OF SUPERVISION RESIDENT TO It is alleged that clients were neglected when the facility failed to supervise them and Client #2 climbed into Alexandria 21280 Prairie Senior Cottages of Ale x RESIDENT 10/20/2017 3/1/2018 bed with Client #1 and touched Client #1's breasts without his/her consent. x Douglas It is alleged that client #1 was neglected when staff failed to provide adequate supervision when client #2 Alexandria 1684 Prairiewood Home NEGLECT OF SUPERVISION 7/21/2016 7/18/2017 sexually touched client #1. x Douglas It is alleged that a client was abused the SP yelled at the client and pried the client's legs apart to do cares. ABUSE-PHYSICAL,EMOTIONAL-STAFF PATIENT The AP told the client to go to the client's room then the AP locked the door by jamming a butter knife in the Alexandria 1684 Prairiewood Home RIGHTS 5/26/2016 1/26/2017 molding to prevent the client from getting out of the room. x Douglas ABUSE-EXPLOITATION-DRUG DIVERSION DRUG It is alleged that a client was financially exploited when the alleged perpetrator (AP) took the client's Alexandria 21855 Vista Prairie at Windmill Pond x DIVERSION 9/7/2016 1/23/2017 medication. x Douglas It is alleged that a client was abused when facility staff verbally abused, laughed at, and called the client Andover 29442 Arbor Oaks Senior Living LLC x ABUSE-EMOTIONAL-STAFF 5/10/2017 12/14/2017 names. x Anoka It is alleged that a client was abused when facility staff verbally abused, laughed at, and called the client Andover 29442 Arbor Oaks Senior Living LLC x ABUSE-EMOTIONAL-STAFF 5/10/2017 12/14/2017 names. x Anoka It is alleged that two clients were neglected when staff did not provide adequate supervision and clients Andover 29442 Arbor Oaks Senior Living LLC x NEGLECT-SUPERVISION 8/11/2016 4/24/2017 were found naked with each other. x Anoka It is alleged that a client was neglected when s/he had a fall and it contributed to his/her death five days Andover 29442 Arbor Oaks Senior Living LLC x NEGLECT OF HEALTH CARE-FALLS 8/7/2015 2/9/2016 later. x Anoka It is alleged that a client was inadequately supervised when the client requested protection. The client would Andover 29442 Arbor Oaks Senior Living LLC x NEGLECT OF SUPERVISION 4/20/2017 5/24/2017 not specify further. x Anoka Feb 19-20 Based on a preponderance of evidence, facility failed to follow physician's orders for Couamidin, blood Annandale 951 Annandale Care Center x NEGLECT - MEDICATION ERRORS 2016 5/1/2017 thinner,for 15 days, patient died as a result from complications. x WRIGHT

It is alleged that a client was neglected when staff failed to provide personal cares and toileting assistance Annandale 20856 Centennial Villa Assisted Living x NEGLECT-HEALTH CARE 7/20/2015 2/23/2016 leaving the client in the bathroom for two days resulting in the client reporting pain, bruising, and bleeding. x Wright It is alleged that a client was neglected when staff failed to ensure the client's oxygen tank was filled Annandale 20856 Centennial Villa Assisted Living x NEGLECT OF HEALTH CARE 12/12/2016 12/4/2017 properly. The client had an unresponsive episode due to empty oxygen tank. x Wright

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 2 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County It is alleged that a resident was exploited when the alleged perpetrator took his/her medication from the Anoka 00893 Anoka Rehab & Living Center x EXPLOITATION BY DRUG DIVERSION 11/20/2017 3/9/2018 narcotic box. x Anoka It is alleged that a resident was exploited when the alleged perpetrator took his/her medication from the Anoka 00893 Anoka Rehab & Living Center x EXPLOITATION BY DRUG DIVERSION 11/20/2017 3/9/2018 narcotic box. x Anoka 10/25/2016 and 12/30/2016 It is alleged that a resident was neglected when s/he developed two pressure sores while residing at the Anoka 893 Anoka Rehab & Living Center x NEGLECT OF HEALTH CARE-DECUBITI NURSING 10/26/2016 facility. x Anoka Anoka 893 Anoka Rehab & Living Center x NEGLECT-FALLS NURSING CARE 8/16/2016 10/25/2016 It is alleged that a resident was neglected when s/he had fall resulting in a brain hemorrhage. x Anoka

It is alleged that several residents (Resident 1, 2, and 3) were neglected when they all had falls and the Anoka 893 Anoka Rehab & Living Center x NEGLECT-FALLS 9/2/2015 12/21/2015 facility failed to adequately assess the clients for fall risks and did not put fall interventions in place. x Anoka It is alleged that a resident was neglected when s/he had a fall resulting in injuries, including subdural Anoka 893 Anoka Rehab and Living Ctr x NEGLECT OF HEALTH CARE NURSING CARE 7/29/2016 10/10/2016 hematoma, broken nose and one of his/her eyes swollen shut. x Anoka PATIENT RIGHTS EXPLOITATIN BY DRUG It is alleged that a client was exploited when the alleged perpetrator took narcotic medication from the APPLE VALLEY 25804 APPLE VALLEY VILLA X DIVERSION 1/27/2017 4/6/2017 client's apartment. X Dakota It is alleged that a client was neglected when the alleged perpetrator did not follow the care plan and the NEGLECT OF HEALTH CARE NEGLECT OF client fell, hitting his/her head. The client was not assessed until she became unresponsive. The client died of APPLE VALLEY 25804 APPLE VALLEY VILLA X HEALTH CARE-FALLS 6/24/2015 7/20/2015 a subdural hematoma. X Dakota NEGLECT OF HEALTH CARE - FALLS, HEALTH It is alleged that a resident was neglected when the staff failed to safely transfer a resident using a lift. The APPLE VALLEY 979 AUGUSTANA HCC OF APPLE VALLEY X CARE 6/8/2016 1/17/2017 resident fell and was hospitalized with a right femur fracture. X Dakota It is alleged that a resident was financially exploited when the staff/alleged perpetrator made multiple APPLE VALLEY 979 AUGUSTANA HCC OF APPLE VALLEY X EXPLOITATION BY STAFF 9/21/2015 11/20/2015 unauthorized charges to the resident's credit card. X Dakota

ABUSE-SEXUAL NEGLECT-FAILURE TO REPORT APPLE VALLEY 979 AUGUSTANA HCC OF APPLE VALLEY X ABUSE-SEXUAL 1/8/2018 1/8/2018 It is alleged that a resident was sexually abused when the alleged perpetrator penetrated the resident. X Dakota It is alleged that a resident was neglected when the staff failed to provide wound care treatment to the APPLE VALLEY 979 AUGUSTANA HCC OF APPLE VALLEY X NEGLECT-HEALTH CARE 4/13/2017 8/7/2017 resident's legs and blisters on the resident's legs got worse. X Dakota NEGLECT-SUPERVISION-RESIDENT TO It is alleged that neglect of supervision occurred when resident #1 was in the sunroom and resident #2 was APPLE VALLEY 979 AUGUSTANA HCC OF APPLE VALLEY X RESIDENT 4/13/2017 8/3/2017 inappropriately touching resident #1. X Dakota

It is alleged that a resident was neglected when facility staff could not determine how the resident got a APPLE VALLEY 979 AUGUSTANA HCC OF APPLE VALLEY X NEGLECT-HEALTH CARE 4/13/2017 8/1/2017 bruised left eye and a bump on the head. The resident's room smelled of urine and the bedding was wet. X Dakota

It is alleged that a resident was neglected when the facility failed to provide adequate supervision, resulting NEGLECT-HEALTH CARE VIOLATION OF ACT- in a resident's fall and G.I. bleed. The resident died as a result of complications from an upper G.I. APPLE VALLEY 979 AUGUSTANA HCC OF APPLE VALLEY X FAILURE TO REPORT 1/12/2017 5/15/2017 hemorrhage and aspiration pneumonia. It is alleged the facility did not notify the family. X Dakota NEGLECT-SUPERVISION-RESIDENT TO It is alleged that neglect of supervision occurred when the facility failed to supervise, resulting in resident-to- APPLE VALLEY 979 AUGUSTANA HCC OF APPLE VALLEY X RESIDENT 3/6/2017 3/17/2017 resident altercations. One resident became frightened. X Dakota NEGLECT-MEDICATION ERRORS MEDICATION It is alleged that a resident was neglected when an employee administered the wrong dose of morphine to APPLE VALLEY 979 AUGUSTANA HCC OF APPLE VALLEY X ERROR 3/6/2017 3/13/2017 the resident: 200 mg instead of 2.5 mg. X Dakota It is alleged that a resident was neglected when a staff member failed to follow the resident's care plan for APPLE VALLEY 979 AUGUSTANA HCC OF APPLE VALLEY X NEGLECT OF HEALTH CARE 11/23/2015 1/11/2016 transferred and the resident sustained a right humerus fracture. X Dakota It is alleged that a client was neglected when a staff member failed to follow physician's orders and the APPLE VALLEY 979 AUGUSTANA HCC OF APPLE VALLEY X NEGLECT-MEDICATIONS 6/25/2015 7/20/2015 patient did not receive cancer medication for 10 days. X Dakota It is alleged that the resident was neglected when staff failed to follow the resident's care plan, resulting in a Arden Hills 975 Presbyterian Homes of Arden Hills x NEGLECT-HEALTH CARE 6/28/2017 12/19/2017 fall, and a fractured left femur. x Ramsey

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 3 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County It is alleged that a resident was neglected when the alleged perpetrator failed to follow the resident's care plan and transferred the resident without the use of a mechanical stand lift. The resident had a fall with a Arden Hills 975 Presbyterian Homes of Arden Hills x NEGLECT-HEALTH CARE, FALLS 3/20/2017 10/9/2017 fractured/depressed area of the right knee. x Ramsey It is alleged that a resident was neglected when the resident aspirated on his/her own vomit due to Arden Hills 20898 Presbyterian Homes of Arden Hills x NEGLECT OF HEALTH CARE 3/20/2017 9/22/2017 inadequate nursing care. The resident was diagnosed with pneumonia. x Ramsey It is alleged that a resident was neglected when facility staff failed to keep resident safe and s/he sustained Arden Hills 20898 Presbyterian Homes of Arden Hills x NEGLECT HEALTH CARE-FALLS 4/29/2016 4/3/2017 multiple facial fractures after driving electric wheelchair down a stairwell. x Ramsey It is alleged that a resident was neglected when facility staff failed to keep resident safe and s/he sustained Arden Hills 20898 Presbyterian Homes of Arden Hills x NEGLECT-SUPERVISION 4/29/2016 8/25/2016 multiple facial fractures after driving electric wheelchair down a stairwell. x Ramsey

Arden Hills 975 Presbyterian Homes of Arden Hills x RAPE BY STAFF RAPE BY OTHER 3/3/2017 12/22/2017 It is alleged that a resident was sexually assaulted by an alleged perpetrator (AP) during the night. x Ramsey It is alleged that a resident was abused when a staff member, alleged perpetrator, inappropriately touched Arden Hills 975 Presbyterian Homes of Arden Hills x SEXUAL ABUSE 8/14/2017 12/22/2017 the resident. x Ramsey It is alleged that a resident was abused when a staff member, alleged perpetrator, inappropriately touched Arden Hills 975 Presbyterian Homes of Arden Hills x ABUSE-SEXUAL 8/14/2017 12/22/2017 the resident. x Ramsey

NEGLECT-FALLS, FALLS DUE TO EQUIPMENT 4/11/2017 It is alleged that a resident was neglected when s/he had a fall from a mechanical lift due to a leg strap Arden Hills 975 Presbyterian Homes of Arden Hills x FAILURE; INAPPROPRIATE USE OF EQUIPMENT 12/13/2016 coming off during transfer from a bed to a chair. x Ramsey 01/20/2015 NEGLECT-FALLS DUE TO EQUIPMENT FAILURE, and It is alleged that a resident was neglected when she fell from a mechanical lift and passed away 20 minutes Arden Hills 975 Presbyterian Homes of Arden Hills x INAPPROPRIATE USE OF EQUIPMENT 01/21/2015 3/20/2015 later. x Ramsey It is alleged that a resident was financially exploited when a staff, alleged perpetrator (AP) used the Arlington 617 Good Samaritan Society Arlington x NEGLECT OF SUPERVISION 3/24/2016 6/6/2016 resident's credit card. x Sibley

It is alleged that a client was emotionally abused when the alleged perpetrator AP # 1 inappropriately instructed the client to urinate on the floor. In addition, it is alleged that the client's privacy was violated Atwater 1110 Atwater ICF-IID ABUSE-MENTAL-STAFF PATIENT RIGHTS 3/1/2017 4/24/2017 when AP #2 made an inappropriate video of AP #1's interactions with the client. x Kandiyohi It is alleged that a resident was neglected when s/he fell out of a mechanical lift and sustained a broken Aurora 21353 ESSENTIA HEALTH NORTHERN PINES x NEGLECT-HEALTH CARE 2/4/2016 12/8/2016 femur. The resident died a few months later. x St. Louis It is alleged that a resident was neglected when s/he was being transferred with a mechanical lift and the lift malfunctioned. The resident fell and sustained several broken bones. The resident died one week after the NEGLECT-HEALTH CARE, FALLS DUE TO EQUIP fall. It addition, the resident had pneumonia and the facility did not provide adequate assessment and Aurora 21353 ESSENTIA HEALTH NORTHERN PINES x FAILURE, INAPPROPRIATE USE OF EQUIPMENT 12/29/2015 5/27/2016 treatment for the pneumonia. x St. Louis It is alleged that a resident was financially exploited when staff used the resident's money for his/her own Aurora 604 ESSENTIA HEALTH NORTHERN PINES x EXPLOITATION BY OTHER 11/12/2015 3/10/2016 personal use. This totaled over $7,000 before being uncovered. x St. Louis It is alleged that two clients were financially exploited when the alleged perpetrator (AP) took the client's Austin 20189 Cedars of Austin x ABUSE-EXPLOITATION-OTHER 10/24/2106 1/3/2017 jewelry. x Mower It is alleged that two clients were financially exploited when the alleged perpetrator (AP) took the client's Austin 20189 Cedars of Austin x ABUSE-EXPLOITATION-STAFF 10/24/2106 1/3/2017 jewelry. x Mower It is alleged that Client #1 and Client #2 were neglected when staff failed to supervise them, and Client #2 Austin 20189 Cedars of Austin x ABUSE-SEXUAL 3/29/2017 6/11/2017 put Client #1's hand down his pants to touch his penis. x Mower It is alleged that a client was financially exploited when a staff alleged perpetrator (AP) took the client's money for her/his own personal use. The document has been re-scanned to the MDH website. The Austin 20189 Cedars of Austin x EXPLOITATION BY STAFF 9/21/2015 12/24/2015 compliance revisit was completed on 02/29/2016. x Mower

It is alleged that a client was neglected when staff failed to provide the client with any assistance for almost Austin 20189 Cedars of Austin x NEGLECT-HEALTH CARE,FALLS 4/6/2015 9/18/2015 six hours. The resident fell out of his chair and paramedics found him/her in soiled clothing. x Mower

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 4 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County It is alleged that a resident was neglected when the facility did not assess and monitor the resident after the resident sustained a fall. The facility transferred the resident to the hospital the following day. The hospital Austin 967 Good Sam Society Comforcare x NEGLECT-FALLS 2/14/2017 10/9/2017 determined the resident sustained a back fracture. x Mower

It is alleged that a client was neglected when s/he had a fall. The client had progressively worse pain after Austin 20449 KSMS Our House LLC x NEGLECT-HEALTH CARE NURSING CARE 9/28/2016 2/13/2017 the fall and it was discovered ten days later that the client had a tibia fracture. x Mower

It is alleged that a client was neglected when s/he presented to the hospital with an elevated temperature, a Austin 20449 KSMS Our House LLC x NEGLECT-DECUBITI 9/28/2016 2/13/2017 leg severely bruised with blisters, and a large ulcerated sore on his/her tailbone that was infected. x Mower It is alleged that a client was abused by an alleged perpetrator (AP) when the AP kissed the client multiple Austin 20449 KSMS Our House LLC x ABUSE-SEXUAL 8/8/2017 12/22/2017 times. x Mower It is alleged that a client was abused by an alleged perpetrator (AP) when the AP kissed the client multiple Austin 20449 KSMS Our House LLC x ABUSE-SEXUAL 8/9/2017 12/22/2017 times. x Mower

It is alleged that residents' were neglected when the facility failed to provide supervision that resulted in an NEGLECT OF SUPERVISION-RESIDENT TO altercation between two residents. Resident #1 was attacked by Resident #2 in his/her room. Resident #1 Austin 20449 KSMS Our House LLC x RESIDENT 6/21,22/2017 11/21/2017 was taken to the hospital due to bruising/bleeding that would not stop. x Mower

It is alleged that residents' were neglected when the facility failed to provide supervision that resulted in an NEGLECT OF SUPERVISION-RESIDENT TO altercation between two residents. Resident #1 was attacked by Resident #2 in his/her room. Resident #1 Austin 20449 KSMS Our House LLC x RESIDENT 6/21,22/2017 11/21/2017 was taken to the hospital due to bruising/bleeding that would not stop. x Mower It is alleged that a client has been neglected when he/she has had several falls when the facility is too short staffed to provide assistance to the client in a timely manner. In addition, the client had a change in condition and the facility failed to assess or send the client into the hospital to be assessed when he/she had NEGLECT OF HEALTH CARE-FALLS NEGLECT OF suffered a stroke. This document has been re-scanned to the MDH website. The compliance revisit was Austin 20978 St Marks Heritage Community x HEALTH CARE 7/7/2015 9/29/2015 completed on 12/16/2015. x Mower It is alleged that a resident was neglected when s/he was given physician's orders to remain non-weight bearing for six weeks and the facility is having the resident transfer with one staff. In addition, it is alleged that the resident's catheter care has not been completed and the resident is now having bloody urine and Austin 394 St Marks Lutheran Home x NEGLECT-HEALTH CARE 12/2/2015 9/26/2016 lower back pain. x Mower

It is alleged that a resident was neglected when a staff, alleged perpetrator (AP) failed to remove old Austin 394 St Marks Lutheran Home x NEGLECT - MEDICATIONS 11/3/2014 6/11/2015 Fentanyl patches before placing new Fentanyl patches on the resident resulting in death due to overdose. x Mower UNEXPLAINT INJURY UNEXPLAINED It is alleged that a resident was neglected when s/he presented to the emergency room with unknown Austin 394 St Marks Lutheran Home x INJURY/FRACTURE 7/26/2016 8/3/2016 bruising and multiple fractures covering his/her body. x Mower

UNEXPLAINED INJURY UNEXPLAINED It is alleged that a resident was neglected when s/he was found with multiple bruising covering his/her body. Austin 394 St Marks Lutheran Home x INJURY/FRACTURE 7/26/2016 8/3/2016 The resident was sent to the emergency room diagnosed with multiple fractures and bruising. x Mower UNEXPLAINED INJURY UNEXPLAINED It is alleged that a resident was found with unknown bruising and multiple fractures covering his/her body. Austin 394 St Marks Lutheran Home x INJURY/FRACTURE 7/26/2016 8/3/2016 S/he was transferred to ED for further evaluation. x Mower

It is alleged that a resident was neglected when the staff failed to assess the resident and provide emergency BAGLEY 974 CORNERSTONE NSG & REHAB CENTER X NEGLECT-HEALTH CARE 3/18/2015 9/29/2015 medical services when the resident had a 45-minute seizure and a high fever. X Clearwater

It is alleged that a client was neglected when the alleged perpetrator failed to notify emergeny services in a timely manner after the client complained of chest, jaw and arm pain. When emergency services arrive, staff BAGLEY 26540 CORNERSTONE RESIDENCE OF BAGLEY X NEGLECT OF HEALTH CARE 12/30/2014 6/23/2015 instructed them not to transport the client to a hospital. X Clearwater

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 5 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County

It is alleged that a client was abused when alleged perpetrator #1 restrained the client in the bathroom and propped a chair under the doorknob preventing the client from getting out. Alleged perpetrator #2 BAGLEY 1012 HG121001 ABUSE-RESTRAINTS 9/19/2016 1/12/2017 restrained the client in the bathroom by putting a foot against the door. X Clearwater It is alleged that a client was abused when alleged perpetrator #1 restrained the client in the bathroom and propped a chair under the doorknob preventing the client from getting out. Alleged perpetrator #2 BAGLEY 1012 HG121002 RESTRAINTS 9/19/2016 1/12/2017 restrained the client in the bathroom by putting X Clearwater It is alleged that a client was neglected when staff failed to provide adequate nutrician resulting in the client BAGLEY 21640 THE GARDEN PLACE ASSISTED LIVING X NEGLECT-HEALTH CARE 3/18/2015 6/3/2015 becoming dehydrated and hospitalized three times. X Clearwater It is alleged that a client was neglected when staff, alleged perpetrators, failed to provide supervision when NEGLECT-SUPERVISION staff left the building and clients unattended and there was a physical altercation with two clients resulting BAGLEY 21540 THE GARDEN PLACE ASSISTED LIVING X 3/18/2015 5/28/2015 in injuries. X Clearwater It is alleged that a resident was financially exploited when the alleged Perpetrator (AP) took the resident's Barnsville 968 Valley Care and Rehab LLC x EXPLOITATION BY STAFF 2/12/2016 2/12/2016 checks and credit cards for his/her own use. x Clay

10/29/2014 It is alleged that a resident was abused when a staff, alleged perpetrator (AP), intentionally bent the and resident's fingers back attempting to remove a cord from the resident's hand. The resident has now become Barrett 153 Barrett Care Center Inc x ABUSE-PHYSICAL-STAFF 10/30/2014 3/31/2015 hysterical when asked about the incident and is afraid of everyone in scrubs. x Grant It is alleged that a resident was financially exploited when the alleged perpetrator (AP) took the resident's Battle Lake 146 Good Samaritan Society Battle Lake x ABUSE-EXPLOITATION-STAFF 8/15/2017 1/4/2018 narcotic medication. x Otter Tail It is alleged that a resident was neglected when alleged perpetrators (AP #1 and AP #2) transferred the resident with a mechanical lift. The bottom loop of the sling disconnected from the lift falling off during a Battle Lake 146 Good Samaritan Society Battle Lake x NEGLECT FALLS DUE TO EQUIPMENT 3/29/2017 8/11/2017 transfer. The resident fell to the floor. x Otter Tail Lake of It is alleged that a resident was neglected when the resident's care plan was not followed and the resident the Baudette 21104 LAKEWOOD CARE CENTER x NEGLECT-FALLS 12/19-20/2017 3/8/2018 fell and sustained a hip fracture. x Woods

It is alleged that a resident was abused when s/he was found with multiple bruising ranging from large hand prints to tennis ball size bruising covering the resident's body. Also, the resident has multiple sores on NEGLECT-HEALTH CARE ABUSE-PHYSICAL- his/her feet that are black in color. In addition, the resident was neglected when staff failed to properly Belgrade 626 Belgrade Nursing Home x STAFF 8/11/2015 12/10/2015 monitor and assist with the resident's oxygen tank and s/he was found unresponsive. x Stearns It is alleged that clients were financially exploited when the alleged perpetrator (AP) took multiple narcotic medications for his/her own use. This document has been re-scanned to the MDH website. The compliance Belle Plaine 26037 Kingsway Home Care x EXPLOITATIN BY DRUG DIVERSION 9/1/2015 12/24/2015 revisit was completed on 3/7/2016. x Scott It is alleged that a resident was neglected when staff/alleged perpetrators (AP's) failed to use the proper NEGLECT-FALLS DUE TO EQUIP sling during a mechanical lift transfer. The resident fell off the sling and the resident's head hit the floor Belle Plaine 605 Lutheran Home x FAILURE/INAPPROPRIATE USE OF EQUIP 6/22.23/2017 11/22/2017 causing a subdural hematoma. x Scott

It is alleged that a resident was neglected when facility staff failed to implement an adequate care plan to Belle Plaine 605 Lutheran Home x NEGLECT-HEALTH CARE-FALLS 3/29/2016 4/20/2017 prevent the resident from falling. The resident had a fall which resulted in a left hip fracture. x Scott

It is alleged that a resident was neglected when s/he fell and staff did not provide adequate assessment and treatment after the fall. The family voiced concerns to the facility about the resident and the facility did not Belle Plaine 605 Lutheran Home x NEGLECT-HEALTH CARE 8/18/2015 9/17/2015 respond. The resident died of a subdural hematoma five days later. x Scott

It is alleged that a client was abused by an alleged perpetrator (AP) when the AP threatened and pulled the Belle Plaine 1682 The Lutheran Home Hope Res ABUSE-PHYSICAL, EMOTIONAL 2/17/2017 1/22/2018 client from a chair when the client refused to stand up. The client sustained two broken toes. x Scott

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 6 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County 12/15/2016 and It is alleged that two residents were financially exploited when the alleged perpetrator (AP) took multiple Belview 543 Parkview Home x ABUSE-EXPLOITATION-STAFF 12/19/2016 9/11/2017 tablets of their opioid pain medication. x Redwood 12/15/2016 NEGLECT-MEDICATION ERRORS, HEALTH CARE and It is alleged that a resident was neglected when the resident did not receive his/her furosemide medication Belview 543 Parkview Home x MEDICATION ERROR 12/19/2016 3/8/2017 for three days. x Redwood

NEGLECT OF HEALTH CARE NEGLECT OF It is alleged that a resident was neglected when s/he lost 70 pounds in a year. The resident's pain is not Belview 543 Parkview Home x HEALTH CARE-FALLS 6/4/2015 6/19/2015 controlled. The resident is a fall risk with recent falls and facility failed to monitor falls and risk assessment. x Redwood 3/29, It is alleged that a client was neglected when staff failed to provide adequate supervision. Client eloped from Bemidji 20075 GOLDPINE HOME x NEGLECT-SUPERVISION 3/30/2017 5/8/17 facility via wheelchair onto freeway and fell off wheelchair face down. x Beltrami It is alleged that resident was neglected when s/he was discharged home from the facility without having homecare services in place and was found home alone the next day lying soiled. The resident was Bemidji 17 HAVENWOOD CARE CENTER x NEGLECT-HEALTH CARE 5/11/2015 6/29/15 hospitalized. x Beltrami It is alleged that a client was abuse when s/he wanted to go outside and the alleged perpetrator (AP) did not Bemidji 21190 MEADOWLAND ELDER x ABUSE-RESTRAINTS 2/16/16 allow the client to do so x Beltrami

It is alleged a resident was neglected when staff failed to adequately supervise a resident who needed Benson 930 Golden Livingcenter Meadow Ln x NEGLECT-HEALTH CARE NURSING CARE 10/21/2016 1/30/2017 assistance with meals. The resident sustained a burn with blisters which required medical attention. x Swift

It is alleged that a resident was neglected when s/he arrived at the emergency room unresponsive, clothing and undergarments soaked in urine, and eyes mattered shut. In addition, the resident's catheter had crusted drainage around the insertion site. The resident had two open sores on his/her buttocks and heel protector Benson 930 Golden Livingcenter Meadow Ln x NEGLECT-HEALTH CARE 5/23/2016 4/21/2017 boots soaked with drainage and open blisters. x Swift

It is alleged that a resident was neglected, when staff failed to provide adequate care and the resident presented to the hospital with a draining wound on both heels with no dressing and large amounts of pus in the resident's perianal area. Staff neglected to perform adequate personal cares, as the resident had dried Benson 930 Golden Livingcenter Meadow Ln x NEGLECT-HEALTH CARE 6/3/2015 4/28/2016 BM in her/his pants and crusted drainage on her/his skin. x Swift It is alleged that a resident was neglected when the resident experienced a choking episode and was not Benson 930 Golden Livingcenter Meadow Ln x NEGLECT-HEALTH CARE 12/8/2015 4/11/2016 given adequate treatment. The resident expired shortly after choking. x Swift It is alleged that residents are being neglected due to staffing shortage. Residents are not receiving proper Benson 930 Golden Livingcenter Meadow Ln x NEGLECT-HEALTH CARE 9/2,3/2015 10/28/2015 personal cares, nutrition, medical services and adequate supervision. Swift

It is alleged that a client was abused when a staff, alleged perpetrator, sexually abused the client. IN Bird Island GLESENERS ASSISTED LIVING SERV SEXUAL ABUSE 3/30/2016 3/30/2016 addition, it is alleged that the staff used illegal substances while working at the facility. x Renville

NEGLECT-DECUBITI MEDICATION It is alleged that a client was neglected when s/he presented at the hospital with two new pressure ulcers. It Biwabik 3739 NEW JOURNEY RESIDENCE x ADMINISTRATION 5/18-19/2016 5/26/2016 is also alleged that the client is receiving incorrect dosages of his/her medication. x St. Louis NEGLECT-SUPERVISION-RESIDENT TO Blaine 26857 Blaine White Pine x RESIDENT 10/13/2017 2/27/2018 It is that neglect of supervision when Client #1 was inappropriately touched by Client #2 x Anoka It is alleged that a client was neglected when facility staff left client for seven hours in his/her soiled Blaine 26857 Blaine White Pine x NEGLECT-HEALTH CARE 12/4/2017 12/27/2017 incontinence product. x Anoka It is alleged that a client was neglected when his/her dairy (?) plan for pureed food was not followed and the resident aspirated non-pureed food, developed pneumonia, and was hospitalized. In addition, the client 6/16/2016 developed a pressure ulcer and the facility failed to ensure the client received physician ordered physical Blaine 31648 Blaine WPII LLC x NEGLECT-HEALTH CARE, NUTRITION 12/2/2015 therapy and speech therapy. x Anoka

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 7 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County Blaine 757 Camilia Rose Care Center LLC x RAPE BY STAFF 8/16/2017 2/21/2018 It is alleged that a resident was abused when alleged perpetrator sexually assaulted resident. x Anoka

It is alleged that clients were neglected when staff did not change clients. This led to a number of clients with 04/10/2017 red, raw skin. Facility staff did not follow up regarding a client who had a swollen foot and a broken toe until NEGLECT-HEALTH CARE ABUSE-PHYSICAL- and the client hit a staff member. It is alleged that clients were abused when staff pushed and hit the clients. Blaine 32456 Edgemont Place x STAFF 04/11/2017 5/22/2017 Facility administration staff were notified but did not follow up. x Anoka 04/10/2017 and 5/22/2017 It is alleged that Client #1 was neglected when Client #2 grabbed Client #1 and pulled him/her, causing Client Blaine 32456 Edgemont Place x ABUSE-PHYSICAL-STAFF 04/11/2017 #1 to fall on the floor. Client #1 sustained bruises as a result of the fall. x Anoka It is alleged that a client was abused when a staff person pulled the client from a bed by pulling on the Blaine 32456 Edgemont Place Alzheimer's SPE x ABUSE-PHYSICAL-STAFF 8/31/2017 9/14/2017 client's arm. The client sustained a rug burn. x Anoka

Blaine 29941 Edgewood Blaine Senior LVG SEXUAL ABUSE 5/20/2015 11/20/2015 It is alleged that a client was abused when staff, alleged perpetrator (AP) touched the client inappropriately. x Anoka It is alleged that a client was abused when staff, alleged perpetrator (AP) touched the client inappropriately Blaine 29941 Edgewood Blaine Senior LVG SEXUAL ABUSE 5/20/2015 11/20/2015 on two occasions. x Anoka Blaine 29941 Edgewood Blaine, LLC x ABUSE-EXPLOITATION-STAFF 4/20/2016 7/13/2016 It is alleged that client was exploited when a staff took the clients money. x Anoka It is alleged that a client was neglected when the alleged perpetrator (AP) failed to monitor the client's blood Blaine 29621 Synergy Home Care Northeast Metro x NEGLECT OF HEALTH CARE 12/20/2017 2/13/2018 sugars in accordance with his/her care plan, resulting in a head on collision. x Anoka Client was exploited when AP took the client's narcotic medication for their own personal use. Medications Bloomington 28789 Ebenezer Home Care X ABUSE-EXPLOITATION-DRUG DIVERSION 9/25/2017 1/22/2016 were kept in the client's room in a locked box. X Hennepin It is alleged that a resident was neglected when s/he fell out of his/her wheelchair and sustained a hip Bloomington 806 Friendship VLGE of Bloomington x Neglect of Health Care Nursing Care 9/15/2016 11/16/2016 fracture x Hennepin

It is alleged that a resident was neglected when he/she developed a fever and called 911 and was admitted with an infection. Physical therapy is not providing safety interventions ordered by the physician resulting in Bloomington 169 Golden Living Center Bloomington x Neglect-Health Care Nursing Care 8/25/2016 3/6/2017 injuries during a fall. Diabetes is not monitored resulting in low blood sugar levels. x Hennepin It is alleged that a resident was neglected when facility staff did not follow the physician's wound care orders Bloomington 169 Golden Living Center Bloomington x Neglect-Health Care 9/1/2016 9/1/2016 for the resident and the resident's wound worsened. x Hennepin It is alleged that a resident was neglected when staff failed to ensure the resident received enough fluid in Bloomington 169 Golden Living Center Bloomington x Neglect-Health Care 4/15/2015 3/17/2016 his/her g-tube and the resident became severely dehydrated x Hennepin It is alleged that a resident was neglected when the resident eloped from the facility and was not found until the next day by the police department. The resident was taken and admitted to the hospital for multiple Bloomington 169 Golden Living Center Bloomington x Neglect-Supervision 9/28/2015 1/20/2016 bodily injuries. x Hennepin Bloomington 227 Martin Luther Care Center x Exploitation by Drug Diversion 5/1/2014 4/3/2015 It is alleged that the alleged perpetrator took resident's pain medications. x Hennepin It is alleged that a resident was neglected when the facility failed to provide adequate supervision to the Bloomington 227 MARTIN LUTHER CARE CENTER x NEGLECT OF HEALTH CARE 6/13-14/2017 3/19/2018 resident. The resident fell out of bed and refractured her/his hip. x Hennepin It is alleged that a resident was neglected when the facility failed to seek medical help after the resident fell Bloomington 227 MARTIN LUTHER CARE CENTER x FALLS DUE TO EQUIPMENT FAILURE 6/13-14/2017 3/13/2018 out of the mechanical lift and complained of pain to bilateral legs. x Hennepin It is alleged that a resident was physically and emotionally abused when the alleged perpetrator forcefully changed the resident's brief against his/ her wishes. Due to the forceful change, the alleged perpetrator left Bloomington 227 MARTIN LUTHER CARE CENTER x ABUSE-PHYSICAL, EMOTIONAL-STAFF 11/6/2017 11/6/2017 a bruise on the resident's left hand. x Hennepin It is alleged that a residence was neglected when a facility failed to provide proper wound care to the Bloomington 227 MARTIN LUTHER CARE CENTER x NEGLECT-HEALTH CARE 4/4/2017 6/5/2017 resident's decubiti. x Hennepin It is alleged that a resident was financially exploited when a staff, alleged perpetrator, took home the Bloomington 227 MARTIN LUTHER CARE CENTER x EXPLOITATION - DRUG DIVERSION 4/29/2015 7/8/2015 resident's narcotics for his/her own use. x Hennepin

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 8 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County It is alleged that a resident was neglected when the resident developed two pressure ulcers related to inadequate repositioning. In addition, the resident was later hospitalized for surgical debridement of one of Bloomington 189 PRESB HOMES OF BLOOMINGTON x NEGLECT-DECUBITI August 11 2014 4/14/2015 the ulcers. x Hennepin It is alleged that a client was financially exploited when the alleged perpetrator (AP) stole clients checks and Bloomington 25662 PRNSC x Abuse-Exploitation-Other 9/18/2017 10/5/2017 deposited in a Bank ATM. The amount of money stolen was $1,700 x Hennepin It is alleged that the client was neglected when he/she developed pressure ulcers while at the licensee. In addition, it is alleged that the facility, did not adequately manage his/her diabetes. The client had very high Bloomington 25662 PRNSC x NEGLECT-HEALTH CARE 2/12/2016 4/15/2016 blood readings for a month and was hospitalized. x Hennepin May 22 & 23 It is alleged that the client was sexually assaulted by the alleged perpetrator (AP) when the client and AP 08/01/2016 Bloomington 3633 PROFESSIONAL RESOURCE NETWORK OTHER PENETRATION BY OTHER 2016 engaged in sexual activity. x Hennepin

It is alleged that the resident was neglected when the resident developed a fever and called 911 and was admitted with an infection. Physical therapy is not providing safety interventions ordered by the physician Bloomington 169 THE ESTATES AT BLOOMINGTON x NEGLECT-HEALTH CARE NURSING CARE 8/25, 26, 29/2016 3/6/2017 resulting in injuries during a fall. Diabetes is not monitored resulting in low blood sugar levels. x Hennepin It is alleged that the resident was neglected when the facility did not follow the physician's wound care Bloomington 169 THE ESTATES AT BLOOMINGTON x NEGLECT-HEALTH CARE 6/8/2016 9/1/2016 orders for the resident and the resident's wound worsened. x Hennepin It is alleged that resident was neglected when staff failed to ensure the resident received enough fluid in Bloomington 169 THE ESTATES AT BLOOMINGTON x NEGLECT-HEALTH CARE 4/15/2015 3/17/2016 his/her g-tube and the resident became severely dehydrated. x Hennepin It is alleged that the resident was neglected when the resident eloped from the facility and was not found until the next day by the police department. The resident was taken to the hospital and admitted for multiple bodily injuries. In addition, the resident is insulin dependent and had gone for an extended period of Bloomington 169 THE ESTATES AT BLOOMINGTON x NEGLECT-SUPERVISION 9/8/2015 1/20/2016 time without medications. x Hennepin 28128 WEALSHIRE OF BLOOMINGTON Bloomington x EMOTIONAL ABUSE BY STAFF 7/13/2015 12/15/2015 It is alleged that a staff , alleged perpetrator (AP) verbally and physically abused several clients x Hennepin NEGLECT-SUPERVISION-RESIDENT TO It is alleged that neglect of supervision occurred when a client put his hands up a female client's shirt and Brainerd 23750 EDGEWOOD BRAINERD SENIOR LIVING X RESIDENT 8/1/2017 8/1/2017 touched her breasts. X Crow Wing It is alleged that a resident was neglected when the resident was found unresponsive and staff did not follow medical procedures according to the care plan. The care plan showed contradictory information, delaying Brainerd 87 GOOD SAM SOCIETY BETHANY X NEGLECT-HEALTH CARE 2/18/2015 6/4/2015 lifesaving measures and the resident died. X Crow Wing NEGLECT-HEALTH CARE, MEDICATIONS,DEHYDRATION, PAIN It is alleged that a resident was neglected when his/her medical needs were not attended to in a timely Brainerd 87 GOOD SAM SOCIETY BETHANY X MANAGEMENT NURSING CARE 2/1/2017 4/21/2017 manner ultimately resulting in the resident's death in an unnecessarily painful manner. X Crow Wing

Brainerd 87 GOOD SAM SOCIETY BETHANY X NONE LISTED 3/16/2017 10/9/2017 It is alleged that a resident was abused when the alleged perpetrator touched the resident inappropriately. X Crow Wing It is alleged the resident was neglected when the alleged perpetrator failed to follow the resident's care plan. Brainerd 87 GOOD SAM SOCIETY BETHANY X NEGLECT HEALTH CARE-FALLS 7/7/2016 5/4/2017 The resident fell and suffered a right leg tibia and fibula fracture. X Crow Wing

Brainerd 956 GOOD SAM SOCIETY WOODLAND X ABUSE-PHYSICAL-STAFF 8/17/2017 11/20/2017 It is alleged that a resident was abused when a staff member/alleged perpetrator was rough with care. X Crow Wing

Brainerd 956 GOOD SAM SOCIETY WOODLAND X ABUSE-PHYSICAL-STAFF 8/17/2017 11/20/2017 It is alleged that a resident was abused when a staff member/alleged perpetrator was rough with care. X Crow Wing

Brainerd 956 GOOD SAM SOCIETY WOODLAND X ABUSE-PHYSICAL-STAFF 8/17/2017 11/20/2017 It is alleged that a resident was abused when a staff member/alleged perpetrator was rough with care. X Crow Wing It is alleged that a client was neglected when staff failed to adequately supervise him/her and the client shot Brainerd 20129 GOOD SAMARITAN SOCIETY BETHANY X NEGLECT-SUPERVISION 5/8/2015 6/10/2015 himself/herself in the head. X Crow Wing abuse-exploitation-staff neglect-health care It was alleged a client was financially exploited and was not provided adequate nursing care by unnamed but neglect-failure to report nursing care multiple staff/alleged perpetrators. Client expired on Thursday and staff did not realize that client had died Brooklyn Center 30405 ALLIANCE HOME HEALTH CARE INC x unlicensed personnel 4/24/2017 7/7/2017 until Monday, and the 911 was notified. x Hennepin

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 9 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County

It is alleged that a client who was vent dependent was neglected when staff failed to ensure s/he was receiving oxygen and the client developed a high fever, had high levels of secretions and had low oxygen stats. In addition, staff failed to ensure the resident received his/her prescribed medication, one of which Brooklyn Center 27873 American Best Home Care x Neglect-Health Care, Medications 9/3/2015 1/22/2016 was used to lower, his/her secretions. The client was hospitalized. x Brooklyn Center Resident was left alone for hours. The VA was outside when the AP returned did not assist VA back into the apartment. The AP fell asleep in the VA's apartment , was then incoherent with slurred speech. Alcohol NEGLECT OF HEALTH CARE NEGLECT OF bottles were found. The AP didn't provide medication or food to resident all day. The VA got locked out of Brooklyn Center 27873 American Best Home Care SUPERVISION 7/28/2017 12/31/2017 the apartment while the AP slept. X Brooklyn Center NEGLECT OF HEALTH CARE NEGLECT OF Brooklyn Center 27873 American Best Home Care SUPERVISION 7/28/2017 12/13/2017 Not sure why two different reports X Brooklyn Center It is alleged that a client was financially exploited when the alleged perpetrator (AP) took the client's money Brooklyn Center 1021 Brooklyn Center Outreach Home Abuse-Exploitation-Staff 10/21/2015 12/4/2015 for his personal use x Hennepin

Resident was neglected when staff failed to provide adequate personal skin care checks. Resident was admitted to the hospital for infected wounds to both feet. Resident required treatment with antibiotics and debridement of the left toe. Resident returned to the facility after two day's with orders for dressing changes Brooklyn Center 29083 Earle Brown Terrace X NEGLECT OF HEALTH CARE 9/28,29/2017 6/22/2017 to the left toe. Staff provided care to the resident but were not aware of the open wounds. X Brooklyn Center It is alleged that client was neglected when he/she was having increased behaviors and the facility staff failed to provide adequate supervision. The client began having self injuring behaviors and injured the back Brooklyn Center 26335 First Choice Nursing & Home Care x NEGLECT-SUPERVISION 12/14/2015 3/31/2016 of his/her head. The client was hospitalized. x Brooklyn Center

It is alleged that a resident was neglected when facility staff administered the resident's antibiotics daily Brooklyn Center 226 Maranatha Care Center x Neglect-Medication Errors 7/26/2017 9/7/2017 instead of every other day. The resident's condition declined and was send to the emergency room. x Brooklyn Center

Brooklyn Center 226 MARANATHA CARE CENTER x ABUSE-SEXUAL 5/26/2016 8/9/2016 It is alleged that a resident was sexually assaulted by a male while at the facility x Brooklyn Center It is alleged that a client was neglected when s/he presented to the hospital with wounds to his/her Brooklyn Park 25432 Caring Nurses LLC x Unexplained Injury Neglect-Health Care 9/22/2016 2/9/2017 abdomen and groin x Hennepin it is alleged that a resident was neglected when the facility administered medications to the client which had previously been ordered to be discontinued, and the client experienced an altered mental status and became Brooklyn Park 25432 Caring Nurses LLC x Neglect-Health Care, Medications 1/24/2017 12/8/2017 unresponsive x Hennepin It is alleged that a client was abused when client complained of getting beat up and previously having a Brooklyn Park 25432 Caring Nurses LLC x Physical abuse by staff Nursing Care 4/6/2017 7/28/2017 bruise on his/her arm x Hennepin

It is alleged that a client was financially exploited when credit cards and money went missing from the client's room. It is also alleged the client was sexually abused when the alleged perpetrator (AP) got into the Neglect of Health Care Exploitation by other client's bed and touched the client's breast. It is alleged that a client was neglected when facility staff failed Brooklyn Park 25432 Caring Nurses LLC x touching/fondling by other 4/5/2017 6/26/2017 to provide adequate sanitation for the client's bathroom. x Hennepin it is alleged that a client was neglected when the facility did not provide appropriate care when s/he experienced hallucinations and erratic behavioral disorders. Client's daughter called 911 and an ambulance showed up but staff refused to let EMS into the facility. In addition, it is also alleged that the client was neglected when the facility did not provide him/her food and water on time. The client was found with Brooklyn Park 25432 Caring Nurses LLC x Neglect-Health Care, Failure to Notify Physician 11/17/2016 6/21/2017 swollen legs and rash x Hennepin

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 10 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County

it is alleged that a client was neglected when staff failed to administer the correct amount of oxygen and are not following physician's orders to wean the client off oxygen. In addition, the staff are not adequately completing medication administration records or health progress notes. There are concerns that the client Brooklyn Park 25432 Caring Nurses LLC x Neglect Health Care 12/4/2015 1/14/2016 has been declining due to an inadequate level of care. x Hennepin it is alleged that a client was neglected when staff failed to provide adequate supervision when the client Abuse-Physical-Staff Neglect-Health Care, was reported to be suicidal, leaving the client outside in inclement weather and refusing to assist the client Brooklyn Park 27640 Caring Nurses LLC Supervision 6/9/2015 9/23/2015 inside the facility. x Hennepin

it is alleged that a client was neglected when staff failed to adequately assess the client after a fall. The client Brooklyn Park 27640 Caring Nurses LLC x Neglect-Falls, health Care 2/17/2015 4/13/2015 was admitted to the hospital with fractured vertebrae, fractured fingers and a head contusion. x Hennepin

Brooklyn Park 25432 Caring Nurses LLC X ABUSE-SEXUAL 8/8,9/2017 9/25/2017 Client was abused when the AP sexually assaulted the client. X Hennepin

Client was abused when the AP sexually assaulted the client. Ape was not interviewed did not have a Brooklyn Park 29431 Empowerment Healthcare SEXUAL ABUSE 5/18/2015 7/22/2015 working telephone number. A subpoena was sent to the AP and the AP did not appear. X Hennepin It is alleged that a client was abused when staff/alleged perpetrator (AP) watched pornography on a cell PATIENT RIGHTS TOUCHING/FONDLING BY phone while the AP provided perineal care to the client. The AP also shaved the client's pubic area on Brooklyn Park 1273 Homeward Bound Brooklyn Park STAFF 12/27/2017 3/13/2018 another occasion. x Hennepin It is alleged that a client was abused when staff/alleged perpetrator (AP) watched pornography on a cell TOUCHING/FONDLING BY STAFF PATIENT phone while the AP provided perineal care to the client. The AP also shaved the client's pubic area on Brooklyn Park 1273 Homeward Bound Brooklyn Park RIGHTS 12/27/2017 3/13/2018 another occasion. x Hennepin TOUCHING/FONDLING BY STAFF VERBAL It is alleged that a client was abused when the staff/alleged perpetrator (AP) held the client's penis and made Brooklyn Park 1273 HOMEWARD BOUND BROOKLYN PARK REMARKS BY STAFF 12/27/2017 3/13/2018 inappropriate comments. x Hennepin TOUCHING/FONDLING BY STAFF VERBAL It is alleged that a client was abused when the staff/alleged perpetrator (AP) held the client's penis and made Brooklyn Park 1273 HOMEWARD BOUND BROOKLYN PARK REMARKS BY STAFF 12/27/2017 3/13/2018 inappropriate comments. x Hennepin It is alleged that clients were financially exploited by an unknown staff person when the clients' money was Brooklyn Park 1273 Homeward Bound Brooklyn Park Abuse-Exploitation-Other 2/14/2017 5/3/2017 stolen from a locked file cabinet inside a locked office. x Hennepin

It is alleged that client #1 and client #2 were neglected when staff failed to provide adequate supervision and NEGLECT-SUPERVISION-RESIDENT TO client #2 forced client #1 to perform a sex act. Client #1 has a history of attempting to sexually assault other Brooklyn Park 1258 LIVING WELL EDGEWOOD RESIDENT SEXUAL ABUSE 7/9/2015 8/10/2015 clients, and the facility has failed to prevent this from occurring. x Hennepin

It is alleged that a client was neglected when the licensee staff noticed significant drainage from his/her catheter, and did not notify the facility nurse. The licensee failed to further assess and treat this. The client Brooklyn Park 27951 MARANATHA PLACE x NEGLECT-HEALTH CARE 10/5/2015 1/4/2016 was hospitalized with a Urinary Tract Infection and an infection in his/her catheter. x Hennepin 4/9/2015 & It is alleged that client #1, client #2, client #3 and client #4 were financially exploited when the alleged Brooklyn Park 27951 MARANATHA PLACE x EXPLOITATION BY DRUG DIVERSION 4/10/2015 8/25/2015 perpetrator took the clients pain medication for his/her own use. x Hennepin It is alleged that a client was neglected when the facility failed to provide adequate cares and repositioning. December 3 & Also, the client had bruises in several places on his/her body. In addition, the client needs total care and Brooklyn Park 25418 OLIDIA CARE INC x NEGLECT-HEALTH CARE 4 2015 2/1/2016 oftentimes staff are sleeping while on duty. x Hennepin

It is alleged that a resident was neglected when staff failed to answer her call light in a timely manner, the 7/4/2015 resident fell and the staff failed to assess and provide adequate care after the fall. The fall resulted in a fractured pelvis and wrist. In addition the resident was required to use a wheelchair only, even after the Brooklyn Park 27752 SAINT THERESE AT OXBOW LAKE x NEGLECT-HEALTH CARE 3/16/2015 resident expressed a desire to use her walker. This resulted in the resident becoming weaker. x Hennepin

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 11 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County

It is alleged that a client was abused and neglected when the client presented with bruising to the right arm 12/29/2017 from shoulder to elbow. The client states the facility staff pulls on the client's arms when assisting the client ABUSE-PHYSICAL-STAFF' NEGLECT-HEALTH May 31, 2017 out of the bed or chair. In addition it takes facility 20-25 minutes to answer the call lights and the client is left Brooklyn Park 29078 WATERFORD MANOR x CARE June 1, 2017 on the toilet for a very long time. The facility also failed to walk the client according to a schedule. x Hennepin It is alleged that the client was neglected when the staff failed to follow his/her care plan. The client was to have feeding with specialized diet. The client had excess food in his/her lungs. The client passed away due to pneumonia and dehydration. Also, the client did not receive medications as prescribed. In addition, the Brooklyn Park 29078 WATERFORD MANOR x NEGLECT OF HEALTH CARE 12/12/2016 7/24/2017 client lost 25 lbs. in two months. x Hennepin It is alleged that client was sexually assaulted by two staff. The client was taken to the emergency Brooklyn Park 29078 WATERFORD MANOR x ABUSE-SEXUAL 1/6/2016 2/24/2016 department and was reported to be traumatized and suicidal due to the assault. x Hennepin

It is alleged that a client was neglected when staff failed to adequately assess and provide timely medical care when the client had swelling in his/her feet and legs. The client was transported to the emergency room for evaluation and was admitted to the hospital. In addition, the client's call light was not answered in a Brooklyn Park 29078 WATERFORD MANOR x NEGLECT-FALLS, HEALTH CARE 4/27/2016 8/19/2015 timely manner, resulting in the client self-transferring and falling. x Hennepin Buffalo 29351 Gentle Touch Health Initiative x NEGLECT-MEDICATIONS 2/15/2017 3/28/2017 It is alleged that a client was neglected. The client was overmedicated. x Wright It is alleged that Client #1, Client #2, and Client #3 were financially exploited when their narcotic medications Buffalo 29351 Gentle Touch Health Initiative x ABUSE-EXPLOITATION-DRUG DIVERSION 10/23/2017 2/14/2018 went missing from a locked cabinet. x Wright

It is alleged that a client was neglected when staff did not adequately assess the client's supervision needs. The client walked to town, fell in the street, and was found by a member of the community. In addition, the Buffalo 29353 Gentle Touch Health Initiative LLC NEGLECT-HEALTH CARE, SUPERVISION 6/9/2015 9/11/2015 client was cold and not dressed appropriately for the weather. x Wright It is alleged that a resident was neglected when staff did not administer two doses of seizure medication to the resident. The resident suffered two seizures on the second day. The facility transferred the resident to Buffalo 714 Lake Ridge Care Center of Buffalo x MEDICATION ERRORS 3/2/2017 9/20/2017 the hospital. x Wright

It is alleged that a resident was neglected when s/he did not receive his/her pain medications as scheduled Buffalo 714 Lake Ridge Care Center of Buffalo x NEGLECT-PAIN MANAGEMENT, MEDICATIONS 11/12/2015 10/10/2016 after knee replacement surgery. The resident was hospitalized due to lack of pain control. x Wright It is alleged that a resident was sexually abused by an unknown alleged perpetrator (AP). It is alleged that the Buffalo 714 Lake Ridge Care Center of Buffalo x ABUSE-SEXUAL 6/22/2017 11/14/2017 AP touched the resident's perineal area. x Wright It is alleged that a client was financially exploited when an unknown staff, alleged perpetrator (AP), took five Buffalo 25448 Park Terrace Assisted Living x ABUSE-EXPLOITATION-DRUG DIVERSION 7/10/2017 9/16/2017 tablets of 5 milligram (mg) oxycodone from the client for personal use. x Wright It is alleged that a client was financially exploited when an unknown staff, alleged perpetrator (AP), took two Buffalo 25448 Park Terrace Assisted Living x ABUSE-EXPLOITATION-DRUG DIVERSION 7/10/2017 9/16/2017 tablets of Norco from the client for personal use. x Wright 01/24/2017 and It is alleged that a resident was neglected when a wound on the buttocks was not covered with a dressing Buffalo 3190 Prairie River Home Care NEGLECT-DECUBITI 01/25/2017 4/24/2017 and the wound became infected. x Wright 07/20/2015 Abuse occurred when a staff, alleged perpetrator (AP) took photos of a patient while the patient was naked. and The AP touched the patient inappropriately during personal cares and the patient has expressed fear of the Buffalo 3190 Prairie River Home Care NEGLECT-HEALTH CARE 07/21/2015 9/8/2015 AP. x Wright

It is alleged that a client was neglected when a staff, AP, inserted a catheter incorrectly and the client Buffalo 3190 Prairie River Home Care SEXUAL ABUSE ABUSE-EMOTIONAL-STAFF 2/25/2015 4/9/2015 suffered sepsis, bladder trauma, and a urinary tract infection (UTI). The patient is currently hospitalized. x Wright It is alleged that a patient was neglected when scheduled staff did not show up to provide necessary Buffalo 3190 Prairie River Home Care NURSING CARE 2/28/2017 5/16/2017 healthcare for two days when the client requires care seven days a week. x Wright

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 12 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County It is alleged that a client was neglected when staff did not respond appropriately when the client had a Buffalo 3190 Prairie River Home Care NEGLECT-HEALTH CARE 11/2/2016 3/9/2017 medical emergency. The client died three days later. x Wright 01/26/2016 It is alleged that a client was neglected when facility nurses failed to ensure his/her medications were set-up and as prescribed. The client subsequently did not receive medications and was hospitalized with heart Buffalo 3190 Prairie River Home Care NEGLECT-HEALTH CARE, MEDICATIONS 01/27/2016 11/7/2016 problems. x Wright It was alleged that a client was financially exploited when the perpetrator took the client's oxycodone for Buffalo 3190 Prairie River Home Care Inc. EXPLOITATION BY DRUG DIVERSION March 27 2017 6/27/2017 his/her own use. x WRIGHT June 17-18, It was alleged that a client #1 was financially exploited when the perpetrator took the client's Rolex watch Buffalo 3190 Prairie River Home Care Inc. ABUSE-EXPLOITATION-STAFF 2015 12/4/2015 and $600.00 for his/her own use. x WRIGHT It was alleged that a patient was financially exploited when a perpetrator took the client's money for his/her Buffalo 3190 Prairie River Home Care Inc. ABUSE-EXPLOITATION-STAFF 11/17/2015 11/27/2015 own use. x WRIGHT

09/06/2017 It is alleged that a client was neglected when facility staff failed to provide adequate medical care and and assessment of the client's catheter and urinary symptoms. It is alleged that the client has had multiple Buffalo 1487 REM South Central Services Buffalo NEGLECT-HEALTH CARE 09/07/2017 11/6/2017 emergency department visits due to bladder infections and clogged urinary catheter. x Wright

It is alleged that a resident was emotionally abused when the alleged perpetrator put a crown and a sash on Buffalo Lake 550 BUFFALO LAKE HEALTHCARE CTR x EMOTIONAL ABUSE BY STAFF 10/23/2017 2/9/2018 the resident while in the bathroom called the resident, the "King of the Throne". x Renville It is alleged that a resident was neglected when the facility failed to follow the resident's care plan, and s/he Buhl 23242 CORNERSTONE VILLA x NEGLECT-HEALTH CARE, FALLS 5/31-6/1/2016 12/21/2016 had a fall resulting in facial fractures. The resident passed away two days later. x St. Louis It is alleged that a resident was abused when the staff/alleged perpetrator slapped the resident in the face. The resident's face was initially reddened but later resolved. Review of the facility video showed the staff BURNSVILLE 29326 AUGUSTANA EMERALD CREST BURNSV X ABUSE-PHYSICAL-STAFF PATIENT RIGHTS 1/4/2017 9/12/2017 slapped the resident. X Dakota It is alleged that a resident was abused when the staff/alleged perpetrator slapped the resident in the face. The resident's face was initially reddened but later resolved. Review of the facility video showed the staff BURNSVILLE 29326 AUGUSTANA EMERALD CREST BURNSV X ABUSE-PHYSICAL-STAFF PATIENT RIGHTS 1/4/2017 9/12/2017 slapped the resident. X Dakota

It is alleged the facility staff failed to provide supervision to a client who left the facility and was not discovered to be missing until 7 hours later. The client was supposed to have two-hour checks, but they were BURNSVILLE 23238 AUGUSTANA REGENT AT BURNSVILLE X NEGLECT-SUPERVISION 8/8/2016 9/14/2017 not completed. The client was found deceased in a pond near the facility. X Dakota It is alleged that a client was neglected when facility staff failed to assess a swollen leg, which turned out to BURNSVILLE 23238 AUGUSTANA REGENT AT BURNSVILLE X UNEXPLAINED INJURY/FRACTURE 12/12/2017 1/10/2018 be a fracture. X Dakota

BURNSVILLE 756 EBENEZER RIDGES GERIATRIC CC X NEGLECT-MEDICATIONS 11/5/2015 5/16/2016 It is alleged that a resident was neglected when staff administered the wrong doses of medications. X Dakota

BURNSVILLE 756 EBENEZER RIDGES GERIATRIC CC X NEGLECT-HEALTH CARE 9/15/2015 10/14/2015 It is alleged that a resident was neglected when staff failed to change incontinence pads on a timely basis. X Dakota It is alleged that a client was neglected when staff failed to provide pain management and medical attention BURNSVILLE 756 EBENEZER RIDGES GERIATRIC CC X NEGLECT-HEALTH CARE, FALLS 6/11/2015 10/29/2015 after several falls. Also, clothing was soaked in urine. X Dakota

BURNSVILLE 756 EBENEZER RIDGES GERIATRIC CC X NEGLECT-HEALTH CARE NEGLECT-FALLS 2/27/2015 9/14/2015 It is alleged that a resident was neglected when staff failed to provide timely assistance following a fall. X Dakota It is alleged that a client was neglected when the facility did not adequately supervise the client and the BURNSVILLE 29079 THE RIVERS X NEGLECT OF HEALTH CARE-FALLS 3/9/2017 5/18/2017 client fell. X Dakota It is alleged a resident was sexually abused when the resident was sent to the ER for wounds on her leg and BURNSVILLE 29079 THE RIVERS X OTHER PENETRATION BY OTHER 3/9/2017 6/10/2017 vaginal bleeding + bruises and redness to the vaginal area. X Dakota It is alleged that four clients were financially exploited when the alleged perpetrator took the clients' money, BURNSVILLE 21703 VISITING ANGELS X ABUSE-EXPLOITATION-STAFF 3/2/2016 4/25/2016 jewelry and credit cards for his/her own use. X Dakota

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 13 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County It is alleged that four clients were financially exploited when the alleged perpetrator took the clients' money, BURNSVILLE 21703 VISITING ANGELS X ABUSE-EXPLOITATION-STAFF 3/2/2016 4/25/2016 jewelry and credit cards for his/her own use. X Dakota It is alleged that a client was neglected when staff failed to provide an adequate assessment after s/he had a Cambridge 20709 GPC Commons x NEGLECT OF HEALTH CARE-FALLS 10/29/2015 1/12/2016 fall and suffered a brain bleed and passed away. x Isanti

It is alleged that a resident was neglected, when facility staff failed to provide safe temepratures of Cambridge 292 Gracepointe Cross Gables East x NEGLECT-HEALTH CARE 5/24/2016 8/1/2016 food/drink. The resident developed blisters when s/he spilled their hot coffee. x Isanti

It is alleged that a resident was neglected when staff failed to provide adequate repositioning and personal Cambridge 292 Gracepointe Cross Gables East x NEGLECT-HEALTH CARE 3/24/2015 7/22/2015 cares, and the resident was admitted to the hospital with skin breakdown and open wounds. x Isanti

It is alleged that a resident was neglected when s/he developed a Stage II pressure ulcer on his/her left heel. Cambridge 292 Gracepointe Cross Gables East x NEGLECT OF HEALTH CARE NURSING CARE 1/5/2017 5/22/2017 In addition, staff did not ensure the resident was provided proper daily hygiene. x Isanti

It is alleged that a resident has been neglected when staff failed to reposition the resident and the resident has developed skin breakdown. In addition, the resident needs assistance with personal cares, eating, etc.; the facility has not changed the resident's care plan and is not assisting the resident with these things. The Cambridge 294 Gracepointe Cross Gables West x NEGLECT-HEALTH CARE 7/28/2015 9/2/2016 resident reports feeling scared that s/he won't be taken care of properly by the facility. x Isanti 06/06/2016 It is alleged that a resident was neglected when an alleged perpetrator left resident sitting at bedside and unattended. Resident had a fall and sustained cervical fracture, subarachnoid hemorrhage, and acute Cambridge 294 Gracepointe Cross Gables West x NEGLECT-HEALTH CARE-FALLS 06/07/2016 7/12/2016 subdural hematoma. Resident passed away two days later. x Isanti It is alleged that a patient was abused when a staff, alleged perpetrator (AP) hit the client and called him/her names. In addition, the client has been losing weight because the AP takes away the client's food when s/he Canby 1081 REM Southwest Services Canby A ABUSE-PHYSICAL, EMOTIONAL-STAFF 9/2/2015 5/16/2016 becomes agitated. x Yellow Medicine It is alleged that Resident #1 was neglected when the alleged perpetrator (AP) did not help the resident when the resident had a fall. In addition, the AP failed to assess and monitor the resident after the fall and failed to notify the resident's physician, family and administration regarding the incident. It is alleged that Resident #2 was emotionally abused when the alleged perpetrator went into the resident's room and called Cannon Falls 758 Angels Care Center x EMOTIONAL ABUSE BY STAFF 2/10/2017 9/18/2017 him/her a "bitch." x Goodhue It is alleged that a resident was neglected when a staff, alleged perpetrator (AP) failed to properly assess the Cannon Falls 758 Angels Care Center x NEGLECT-HEALTH CARE 2/10/2017 9/18/2017 resident after a fall to complete fall documentation. x Goodhue It is alleged that a resident was neglected when the resident tipped his/her electric wheelchair over outside Cannon Falls 758 Angels Care Center x NEGLECT OF SUPERVISION 6/15/2017 8/11/2017 of the facility. The resident sustained multiple broken bones. x Goodhue It is alleged that a resident was neglected when facility staff did not provide adequate emergency medical Cannon Falls 758 Angels Care Center x NEGLECT-FALLS NEGLECT-FAILURE TO REPORT 7/5/2017 8/11/2017 care following a fall with a major injury. x Goodhue 06/20/2016 and It was alleged that a resident was neglected when s/he was found with a lit cigarette in his/her room and Cannon Falls 758 Angels Care Center x NEGLECT-SUPERVISION 06/21/2016 9/12/2016 his/her bed was one fire. x Goodhue

It is alleged that a resident was neglected when staff failed to treat the resident's skin condition. The resident developed blisters that had broken open and a yeast infection in his/her groin area and under skin folds. The Cannon Falls 758 Angels Care Center x NEGLECT-HEALTH CARE 5/6/2015 7/15/2015 resident was admitted to the hospital with cellulitis. x Goodhue

It is alleged that a resident was neglected when s/he obtained and choked on a regular-texture sandwich. Cannon Falls 758 The Gardens at Cannon Falls x NEGLECT-SUPERVISION 11/20/2015 1/22/2016 The resident was not supposed to eat regular-texture foods. The resident died enroute to the hospital. x Goodhue

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 14 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County It is alleged that Resident #1 was neglected when the alleged perpetrator (AP) did not help the resident when the resident had a fall. In addition, the AP failed to assess and monitor the resident after the fall and failed to notify the resident's physician, family and administration regarding the incident. It is alleged that Resident #2 was emotionally abused when the alleged perpetrator went into the resident's room and called Cannon Falls 758 The Gardens at Cannon Falls x EMOTIONAL ABUSE BY STAFF 2/10/2017 9/18/2017 him/her a "bitch." x Goodhue It is alleged that a resident was neglected when a staff, alleged perpetrator (AP) failed to properly assess the Cannon Falls 758 The Gardens at Cannon Falls x NEGLECT-HEALTH CARE 2/10/2017 9/18/2017 resident after a fall to complete fall documentation. x Goodhue It is alleged that a resident was neglected when the resident tipped his/her electric wheelchair over outside Cannon Falls 758 The Gardens at Cannon Falls x NEGLECT OF SUPERVISION 6/15/2017 8/11/2017 of the facility. The resident sustained multiple broken bones. x Goodhue It is alleged that a resident was neglected when facility staff did not provide adequate emergency medical Cannon Falls 758 The Gardens at Cannon Falls x NEGLECT-FALLS NEGLECT-FAILURE TO REPORT 7/5/2017 8/11/2017 care following a fall with a major injury. x Goodhue 06/20/2016 and It was alleged that a resident was neglected when s/he was found with a lit cigarette in his/her room and Cannon Falls 758 The Gardens at Cannon Falls x NEGLECT-SUPERVISION 06/21/2016 9/12/2016 his/her bed was one fire. x Goodhue

It is alleged that a resident was neglected when s/he developed pressure ulcers on both heels and facility Cannon Falls 758 The Gardens at Cannon Falls x NEGLECT-DECUBITI 8/25/2015 9/11/2015 staff did not notice the ulcers. The resident was hospitalized and the ulcers were discovered by hospital staff. x Goodhue It is alleged that a resident was negledted when the facility did not adequately supervise Resident #1 and NEGLECT-SUPERVISION-RESIDENT TO Resident #2 when Resident #2 hit Resident #1 on the head. The facility transferred Resident #1 to the Carlton 49 Augustana Mercy Care Center x RESIDENT 11/29/2017 2/5/2018 hospital x Carlton It is alleged that a resident was negledcted when the resident fell and hit his/her head and was not adequately evaluated. Thje resident was later transported to the ER and diagnosed with a boken cheekbone Carlton 49 Augustana Mercy Care Center x NEGLECT OF HEALTH CARE FALLS 6/10/2014 4/28/2015 and a brain bleed. x Carlton It is alleged that a resident was neglected when she slipped out of a lift and sustained bruising and a right Carlton 21170 Interfaith Care Center x NEGLECT HEATLH CARE-FALLS 5/18/2016 9/2/2016 humerus fracture. x Carlton It is alleged that a resident was neglected when facility staff failed to follow physician orders for wound care. 7/15/2016 Carlton 21170 Interfaith Care Center x NEGLECT OF HEALTH CARE 5/2/2016 Incorrect dressing was place on resident's wound causing it to worse. x Carlton It is alleged that a resident was neglected when the facility staff failed to flush the resident's peg tube with NEGLECT-HEALTH CARE water after each medication dose. The resident becam dehydrated and developed elevated sodium levels. Carlton 21170 Interfaith Care Center x 8/20/2015 12/2/2015 The resident was hospitalized for six days. x Carlton It is alleged that a resident was neglected when staff failed to adequately assess the resident when s/he was Carlton 21170 Interfaith Care Center x NEGLECT-HEALTH CARE 4/1/2015 9/30/2015 retaining fluid, complainint of paint, and failed to access x Carlton NEGLECT-FALLS, FALLS DUE TO EQUIP. FAILURE. INAPPROPRIATE USE OF EQUIP. It is alleged that a resident was neglected when the sling on the EZ stand lift came off the hooks resulting in Carlton 21170 Interfaith Care Center x SAFETY HAZARDS 1/17/2017 5/10/2017 the resident dropping to the floor. x Carlton

Two clients were financially exploited when the AP took the client's medications for personal use. AP did not Champlin 22095 Brookdale Champlin ABUSE-EXPLOITATION-DRUG DIVERSION 9/11/2017 12/19/2017 follow the facility medication destruction policy. The medications were discovered missing three weeks later. X Hennepin

Facility staff found the client in distress, lowered the client to the floor. Facility transferred the client to the hospital where the client was found to have multiple fractures. Facility incident reports and staff interviews did not include any evidence of the client sustaining a fall. The family included they had concerns of the care of the facility. Family was unaware of any incidents or falls. They questioned the origin or the fractures. Champlin 22095 Brookdale Champlin NEGLECT-UNEXPLAINED INJURY/FRACTURE 8/31/2017 12/19/2017 Client was placed into hospice and dies at the hospital. X Hennepin Champlin 22095 Brookdale Champlin ABUSE-EXPLOITATION-DRUG DIVERSION 9/11/2017 9/17/2017 Two different reports about the same allegation X Hennepin It is alleged that a client was financially exploited when alleged perpetrator (AP) took a controlled substance, Champlin 25047 Champlin GW LLC x Exploitation By Drug Diversion 7/13/2017 9/24/2017 opioid medication from the client x Hennepin

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 15 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County It is alleged that a resident was exploited when staff took 14 tablets of a controlled medication belonging to Champlin 25047 Champlin GW LLC x Exploitation By Drug Diversion 7/13/2017 9/24/2017 a resident over multiple days x Hennepin It is alleged that a client was exploited when the alleged perpetrator took 30 tablets of Oxycodone in client's Champlin 25047 Champlin GW LLC x ABUSE-EXPLOITATION-DRUG DIVERSION 7/13/2017 9/24/2017 possession for personal use. x Hennepin

It is alleged that a client was neglected when the client had a fall with injury, receiving 40 stitches. The Chaska 24271 Auburn Courts X NEGLECT-FALLS,HEALTH CARE 9/18/2015 4/1/2016 facility also failed to assess the client's change in condition, which included two broken wrists and a UTI. X Carver

It is alleged that a client was neglected when the resident wandered into the laundry room and was burned Chaska 335 Auburn Manor X NEGLECT-HEALTH CARE 1/4/2017 4/14/2017 by hot water. The hospital determined the resident sustained second degree burns and died the next day. X Carver

It is alleged that a client was neglected when the resident wandered into the laundry room and was burned Chaska 335 Auburn Manor X NEGLECT-SUPERVISION NURSING CARE 1/4/2017 4/4/2017 by hot water. The hospital determined the resident sustained second degree burns and died the next day. X Carver

It is alleged that a client was neglected when the resident wandered into the laundry room and was burned Chaska 335 Auburn Manor X NEGLECT-SUPERVISION NURSING CARE 1/4/2017 4/4/2017 by hot water. The hospital determined the resident sustained second degree burns and died the next day. X Carver It is alleged that a resident was neglected when the alleged perpetrator failed to provide adequate supervision and left the resident unattended in a hallway, resulting in a fall with C1 fracture and Chaska 335 Auburn Manor X NEGLECT-FALLS NURSING CARE 10/25/16 11/14/2016 subarachnoid hemorrhage. The resident passed away due to the fracture and fall. X Carver It is alleged that a resident was neglected when staff provided timely medical care and assessment when the resident presented with a fever, cough, jaundice and lethargy. The resident was sent to the ER with Chaska 335 Auburn Manor X NEGLECT-HEALTH CARE 4/28/2015 4/14/2016 pneumonia, sepsis and severe dehydration. X Carver

ABUSE-PHYSICAL-STAFF ABUSE-SEXUAL Is is alleged that a resident was abused when stafe/alleged perpetrator grabbed the resident and Chaska 335 Auburn Manor X PATIENT 10/25/2016 4/14/2016 inappropriately touched the patient. The patient has no injuroies and a history of hallucinations. X Carver It is alleged that a resident was abused when the alleged perpetrator inappropriately touched the resident Chaska 335 Auburn Manor X 4/5/2017 10/4/2017 and was rough when assisting the resident to the toilet. X Carver

Chaska 20816 Hidden Creek Assisted Living X NEGLECT-HEALTH CARE, FALLS 7/28/2015 8/5/2015 It is alleged that a resident was neglected when he developed bed sores after laying in bed all day. X Carver ABUSE-EMOTIONAL-STAFF NEGLECT-HEALTH It is alleged that clients are being neglected when alleged perpetrators are intoxicated while working and Chaska 20816 Hidden Creek Assisted Living X CARE 7/28/2015 8/5/2015 leaving beer in the facilty refrigerator. X Carver

It is alleged that a client was neglected when the client did not receive wound care, resulting in a change in Chaska 20816 Hidden Creek Assisted Living X NEGLECT-HEALTH CARE INFECTION CONTROL 3/9/2015 8/4/2015 condition. It is also alleged that multiple clients are sick due to a mice infestation. X Carver It is alleged that the resident was neglected when staff/alleged perpetrator left the resident outside. The Chatfield 750 Chosen Valley Care Center x NEGLECT-SUPERVISION 12/27/2016 6/28/2017 outside temperature was 11 degrees. The resident had circulatory impairment. x Fillmore It is alleged that the facility failed to provide adequate supervision when the resident's foot rested on a Chisholm 904 Heritage Manor x NEGLECT-SUPERVISION SAFETY HAZARDS 3/2/2016 7/12/2016 heater and was burned. The resident was hospitalized and is expected to die. x St. Louis It is alleged that a client was emotionally and physically abused by staff alleged perpetrator (AP) when AP grabbed VA's walker and pushed VA, causing him/her to fall backwards resulting in large bruises on the back of the arms as well as a large bump on the back of the head. Urgent care visit findings resulted in possible slight concussion and bruising. VA claims a different VA was moved out of the facility due to aggressive AP. Chisholm 27162 ASPEN GROVE ASSISTED LIVING x ABUSE-PHYSICAL, EMOTIONAL 5/20-31/2017 11/1/2017 VA fears being in facility. x St. Louis

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 16 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County

It is alleged that client was neglected when staff did not adequately assess his/her anxiety and failed to administer as needed medication for anxiety when the client was visibly agitated, had erratic mood and was 11/30- frequently tearful. Also the client did not received pain medication that the client's physician ordered for Chisholm 27162 ASPEN GROVE ASSISTED LIVING x NEGLECT-HEALTH CARE 12/1/2016 12/7/2016 fourteen days. The client had been reporting that s/he had high levels of pain during that time period. x St. Louis

It is alleged that a client was neglected when she was left in bed for two days without personal cares being completed and s/he did not receive her medications. The client was found with urine soaked hair and Chisholm 27162 ASPEN GROVE ASSISTED LIVING x NEGLECT-HEALTH CARE 10/13/2015 6/10/2016 clothing and the bed was saturated in urine. The client reported feeling scared. x St. Louis It is alleged that a client was neglected when s/he was locked out of the facility for over 30 minutes. The Chisholm 27162 ASPEN GROVE ASSISTED LIVING x NEGLECT-SUPERVISION 1/21-22/2016 4/12/2016 client was sent to the emergency room and suffered blisters on his/her hands. x St. Louis

It is alleged that a client was abused when the staff was rough leaving bruises. Staff have taken the client's assistive living devices away because the client was "being bad." In addition, it is alleged that the client is not ABUSE-PHYSICAL-STAFF NEGLECT-HEALTH receiving adequate assistance when the call light is put on and this has resulted in incontinence. Staff also Chisholm 27162 ASPEN GROVE ASSISTED LIVING x CARE 10/22/2015 1/27/2016 leave the client sitting on a couch for several hours while assisting all of the other client's to bed. x St. Louis It is alleged that the facility failed to provide adequate supervision when the resident's foot rested on a Chisholm 904 Heritage Manor x NEGLECT-SUPERVISION SAFETY HAZARDS 7/12/2016 7/12/2016 heater and was burned. The resident was hospitalized and is expected to die. x St. Louis It is alleged that a resident was neglected when facility staff failed to provide adequate supervision resulting in the resident eloping from the facility and being found by the police at an intersection. Resident eloped Chisholm 904 Heritage Manor x NEGLECT-SUPERVISION 4/10/2017 11/06/2017 with his/her husband who was severely confused. x St. Louis It is alleged that a resident was abused when the alleged perpetrator (AP) yelled at and swore at the Chisholm 904 Heritage Manor x ABUSE-EMOTIONAL-STAFF 4/19-20/2017 5/20/2016 resident. The residents are fearful of the AP. x St. Louis It is alleged that a resident was neglected when s/he had a dislocated hip and the facility did not assess the resident's change in condition. Staff had the resident continue rehab even through the resident complained Chisholm 904 Heritage Manor x NEGLECT-HEALTH CARE 5/12/2015 12/21/2015 of pain. The resident was sent to the hospital. x St. Louis It is alleged that a client was neglected when s/he developed five new unstageable pressure ulcers at the Chisholm 20199 HILLCREST TERRACE OF CHISHOLM x NEGLECT DECUBITI 6/28-29/2016 08/02/2016 facility. x St. Louis EGLECT-SUPERVISION-RESIDENT TO RESIDENT It is alleged that a client (Client #1) was neglected when the facility failed to provide adequate supervision Chisholm 20199 HILLCREST TERRACE OF CHISHOLM x NEGLECT-FAILURE TO REPORT 12/7/2017 12/19/2017 when Client #2 touched Client #1 inappropriately. x St. Louis

It is alleged that a client was abused when the alleged perpetrator (AP) grabbed the client's arm very hard, Chisholm 20199 HILLCREST TERRACE OF CHISHOLM x PHYSICAL ABUSE BY STAFF 8/14-15/2017 11/6/2017 which made a large bruise on the client's left arm. The client felt threatened by the AP. x St. Louis It is alleged that neglect occurred when the client didn't receive medication for over a month, resulting in the Chisholm 20199 HILLCREST TERRACE OF CHISHOLM x NEGLECT OF HEALTH CARE-MEDICTIONS 5/21-6/1/2017 7/28/2017 client attempting suicide. x St. Louis It is alleged that a client was abused when staff, alleged perpetrators (AP#1) and (AP#2), would speak to him/her in a threatening manner, withhold eating utensils, removed his/her phone, and not provide Chisholm 20199 HILLCREST TERRACE OF CHISHOLM x ABUSE-EMOTIONAL-STAFF PATIENT RIGHTS 3/31-4/1/2016 5/9/2016 housekeeping and cares for several weeks. x St. Louis

It is alleged that a client was neglected when staff failed to provide him/her with a diabetic diet, were not administering the client's sliding scale insulin, and the client had readings as high as 598. In addition, the Chisholm 20199 HILLCREST TERRACE OF CHISHOLM x NEGLECT-HEALTH CARE 7/1-2/2015 2/3/2016 staff used the client's glucose meter to test other clients' blood glucose levels. x St. Louis It is alleged that a client was neglected when s/he developed a pressure sore while at the facility. In addition, Chisholm 20199 HILLCREST TERRACE OF CHISHOLM x NEGLECT-HEALTH CARE NURSING CARE 11/14-15/2016 7/24/2017 the client was found to have very poor hygiene. x St. Louis It is alleged that a resident was abused when the alleged perpetrator restrained the resident's hands causing Clara City 61 Clara City Care Center x PHYSICAL ABUSE BY STAFF 11/1/2017 11/22/2017 pain to the resident. x Chippewa

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 17 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County

NEGLECT OF HEALTH CARE FALLS DUE TO It is alleged that a resident was neglected when staff / AP failed to follow the resident's care plan of two EQUIP. FAILURE, INAPPROPRIATE USE OF person assist with a mechanical lift transfer. The resident was hooked up to the mechanical lift and the Clara City 61 Clara City Care Center x EQUIPMENT 5/3/2017 7/17/2017 brakes were not locked which led to the resident sliding off and falling to the ground. x Chippewa It is alleged that a resident was neglected when the AP applied a hot pack that was too warm to the NEGLECT OF HEALTH CARE Clara City 61 Clara City Care Center x 5/2/2017 12/7/2016 resident's shoulder causing redness and blisters. x Chippewa It is alleged that neglect occurred when the alleged perpetrator failed to follow the resident's care plan for toileting and transferred the resident into the bathroom instead of using the commode. The resident Clarkfield 842 Clarkfield Care Center x NEGLECT-HEALTH CARE 5/25/2016 9/16/2016 sustained a skin tear and bruise to the left hand. x Yellow Medicine It is alleged that a resident was financially exploited when a staff member, alleged perpetrator, took the CLEARBROOK 78 GOOD SAM SOCIETY CLEARBROOK X ABUSE-EXPLOITATION-STAFF 1/31/2017 4/4/2017 resident's lottery tickets and cashed them at a local gas station. X Clearwater 11/14/2017 and It is alleged that abuse occurred when the client developed bruises of unknown origin on the body and made Cloquet 21672 New Perspective - Cloquet and BA x PHYSICAL ABUSE BY STAFF RAPE BY OTHER 11/15/2017 12/15/2018 concerning statements such as someone has hurt her and believing she may be pregnant. x Carlton

It is alleged that a client was neglected when staff failed to monitor the client's nutrition with the client resulting in weight loss; also, staff did not monitor the client's fluid intake resulting in the client being Cohasset 26859 Autumn Lane x NEGLECT-HEALTH CARE 4/2/2015 2/17/2016 hospitalized for severe dehydration. The staff failed to follow physician's discharge orders. x Itasca

It is alleged that a client was neglected when staff failed to adequately manage the resident's diabetes. The client received insulin and his/her blood sugar dropped to 35 and staff shoved cake in his/her mouth and his/her airway became partially blocked. The client was hospitalized. In addition, another client was Cokato 20830 Brookridge x NEGLECT OF HEALTH CARE 8/18/2015 12/8/2015 hospitalized with blood sugars over 300 and the staff had not checked his/her blood sugar levels. x Wright It is alleged that a resident was neglected when s/he had a change in condition and the facility failed to adequately assess the resident. The resident was found to be unresponsive by family and was hospitalized. Cold Spring 624 Assumption Home x NEGLECT-HEALTH CARE 6/22/2016 7/11/2016 The resident died ten days later. x Stearns It is alleged that a client was neglected when the facility failed to provide emergency response on time, Columbia Heights 20750 Crest View Home Care x NEGLECT-HEALTH CARE, SUPERVISION 2/10/2017 3/10/2017 resulting in a fall, bleeding nose, broken left arm, and black eye. x Anoka 02/25/2016 and 5/2/2016 It is alleged that a client was neglected when facility staff failed to assess for complications from prescribed Columbia Heights 20750 Crest View Home Care x NEGLECT-HEALTH CARE 02/26/2016 medication. Client was taking Coumadin and was hospitalized for high lab levels associated with medication. x Anoka 09/24/2015 NEGLECT OF SUPERVISION NEGLECT OF and It is alleged that a client was neglected when the facility failed to provide adequate supervision and the client Columbia Heights 20750 Crest View Home Care x SUPERVISION-RESIDENT TO RESIDENT 09/25/2015 10/27/2015 was sexually inappropriate with other clients. x Anoka

NEGLECT-HEALTH CARE NURSING CARE It is alleged that the resident was neglected when the resident's incontinence brief was not changed. Staff Columbia Heights 5 Crest View Lutheran Home x 2/1/2018 3/2/2018 don't help the resident eat, do not walk him/her, or manage the resident's pain. x Anoka Columbia Heights 5 Crest View Lutheran Home x ABUSE-SEXUAL 3/30/2017 6/11/2017 It is alleged that a resident was sexually abused. x Anoka

PHYSICAL ABUSE BY STAFF PATIENT RIGHTS Columbia Heights 5 Crest View Lutheran Home x 11/10/2016 11/28/2016 It is alleged that a resident was abused when a staff member/alleged perpetrator (AP) slapped the resident. x Anoka It is alleged that a resident was neglected when s/he was found unresponsive by family and was hospitalized NEGLECT-HEALTH CARE Columbia Heights 5 Crest View Lutheran Home x 7/21/2016 10/6/2016 with dehydration and low hemoglobin. x Anoka 05/23/2016, 05/24/2016 and It is alleged that a resident was neglected when s/he had lost 20 lbs. in one month. In addition, the client has Columbia Heights 5 Crest View Lutheran Home x NEGLECT-HEALTH CARE 05/25/2016 7/20/2016 many bruises on his/her arm and face. x Anoka

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 18 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County It is alleged that a resident was neglected when s/he waited for two hours for his/her call light to be 11/24/2015 answered and nursing assistance to be provided. In addition, it is alleged that staff were performing his/her and perineal cares incorrectly after a bowel movement. The resident reported feeling unsafe and ultimately Columbia Heights 5 Crest View Lutheran Home x NEGLECT-HEALTH CARE 11/25/2015 1/19/2016 passed away. x Anoka 11/24/2015 and It is alleged that a resident was neglected when adequate cares were not provided and the resident passed Columbia Heights 5 Crest View Lutheran Home x NEGLECT-HEALTH CARE 11/25/2015 1/19/2016 away. x Anoka

It is alleged that a resident was abused when alleged perpetrator (AP) hit resident in the chest causing a Columbia Heights 5 Crest View Lutheran Home x ABUSE-PHYSICAL-STAFF 10/30/2017 1/8/2018 bruise. x Anoka It is alleged that a client was neglected when staff failed to administer prescribed medications for pnemonia. 26853 NEGLECT-HEALTH CARE, MEDICATIONS The client had a change in condition when s/he was assessed and foud to be deteriorating. The client was Columbia Heights ighthouse of Colombia Heights x MEDICATION ADMNISTRATION 9/27/2016 11/8/2016 later hospitalized and passed away. x Anoka

26853 Columbia Heights ighthouse of Colombia Heights x NEGLECT-PAIN MANAGEMENT 6/22/2015 6/22/2015 It is alleged that a client was neglected when s/he was left without pain medication for nine days. x Anoka It is alleged that a client was neglected when staff failed to administer prescribed medications for pnemonia. NEGLECT-HEALTH CARE, MEDICATIONS The client had a change in condition when s/he was assessed and foud to be deteriorating. The client was MEDICATION ADMNISTRATION Columbia Heights 26853 New Perspective - CH x 9/27/2016 11/8/2016 later hospitalized and passed away. x Anoka

6/22/2015 Columbia Heights 26853 New Perspective - CH x NEGLECT-PAIN MANAGEMENT 12/1/2014 It is alleged that a client was neglected when s/he was left without pain medication for nine days. x Anoka It is alleged that a client was neglected when another client inappropriately touched the client's breast while Columbia Heights 26853 New Perspective - Columbia Heights x ABUSE-SEXUAL 4/24/2017 6/30/2017 s/he was sleeping in a chair in the common area. x Anoka It is alleged that a client was abused when a staff/alleged perpetrator (AP) climbed into the client's bed and Columbia Heights 26853 New Perspective - Columbia Heights x ABUSE-SEXUAL 4/24/2017 6/30/2017 kissed the client. x Anoka

It is alleged that a client was neglected when staff did not assess and monitor the client when the client sustained falls over a period of a few days. The agency found the client with a decreased level of consciousness and transferred the client to the hospital. The hospital admitted the client due to severe stroke and urinary tract infection. It is alleged that the client was abused by an unknown alleged perpetrator Columbia Heights 26853 New Perspective - Columbia Heights x NEGLECT-HEALTH CARE ABUSE-SEXUAL 4/24/2017 6/28/2017 (AP) due to multiple bruises on the client's body. This included bruising around the rectum. x Anoka It is alleged that a client was abused when a staff/alleged perpetrator (AP) kissed and inappropriately Columbia Heights 26853 New Perspective - Columbia Heights x ABUSE-SEXUAL 4/24/2017 6/28/2017 touched the client. x Anoka

NEGLECT OF HEALTH CARE NEGLECT OF It is alleged that a resident was neglected when the facility did not adequate assess and supervise the Cook 586 COOK COMMUNITY HOSP C&NC x SUPERVISION 1/8/2018 2/16/2018 resident. Staff found the resident with a self-inflicted cut on the wrist and a pool of blood on the floor. x St. Louis The facility failed to provide adequate supervision to a resident when the resident attempted suicide by Cook 586 COOK COMMUNITY HOSP C&NC x NEGLECT-SUPERVISION 7/12/14/2016 5/10/2017 wrapping the call light around his/her neck. x St. Louis 08/22/2017 NEGLECT-FAILURE TO DO CPR NEGLECT- and It is alleged that a resident was neglected when facility staff failed to provide adequate emergency medical Coon Rapids 757 Camilia Rose Care Center LLC x HEALTH CARE NEGLECT-FAILURE TO REPORT 08/23/2017 12/29/2017 services when the resident appeared to be choking during lunch. x Anoka 04/26/2016 and It is alleged that a resident was neglected when a staff member, alleged perpetrator (AP), failed to follow the Coon Rapids 757 Camilia Rose Care Center LLC x NEGLECT-HEALTH CARE 04/27/2016 11/29/2016 resident's care plan resulting in an injury. x Anoka

Coon Rapids 757 Camilia Rose Care Center LLC x RAPE BY STAFF 8/16/2017 12/19/2017 It is alleged that a resident was abused when alleged perpetrator sexually assaulted a resident. x Anoka Coon Rapids 1141 Camilia Rose Group Home NEGLECT-HEALTH CARE 5/10/2016 8/5/2016 It is alleged that a client was neglected when he/she had two falls requiring stitches. x Anoka

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 19 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County It is alleged that Client #1 was neglected when the facility did not adequately supervise the client. Another Coon Rapids 1141 CAMILIA ROSE GROUP HOME NEGLECT OF SUPERVISION/RES TO RES 10/20/2017 3/7/2018 client, Client #2, with 1:1 supervision, inappropriately touched Client #1. x Anoka

It is alleged that a client was neglected when the facility did not provide 24 hour staffing. The client broke into a medication cabinet after staff left the facility for the night. The client took multiple medications in a Coon Rapids 26510 HAPPY HEARTS HOME HEALTH AGENC x NEGLECT-SUPERVISION 2/27/2018 4/20/2017 suicide attempt. Staff found the client the following morning and transferred the client to the hospital. x Anoka It is alleged that a client was neglected when staff did not adequately supervise the client. Staff found the Coon Rapids 26510 Happy Hearts Home Health Agency x NEGLECT-SUPERVISION 3/29/2017 8/3/2017 client hanged in the client's bedroom. The client died. x Anoka It is alleged that the alleged perpetrator (AP) financially exploited a client by taking the client's financial information without the client's consent and by failing to give the client a check which was sent to the Coon Rapids 26510 Happy Hearts Home Health Agency x ABUSE-EXPLOITATION-STAFF 2/27/2017 4/25/2017 facility. x Anoka It is alleged that the alleged perpetrator (AP) financially exploited a client by depositing the client's money Coon Rapids 26510 Happy Hearts Home Health Agency x ABUSE-EXPLOITATION-STAFF 2/27/2017 4/20/2017 into his/her own account and by billing for services which were not provided. x Anoka It is alleged that a patient was financially exploited when the alleged perpetrator (AP) took the patient's Coon Rapids 3136 Mary T Home Health EXPLOITATION BY DRUG DIVERSION 9/8/2017 1/18/2018 medications for his/her own personal use. x Anoka

It is alleged that a resident was abused and neglected when on several occasions, multiple bruises and finger PHYSICAL ABUSE BY STAFF NEGLECT OF marks were found on resident's arm. In addition, staff did not administer blood sugar medication on time Coon Rapids 10 Park River Estates Care Center x HEA;LTH CARE NEGLECT-MEDICATIONS 3/28/2017 1/24/2018 and as prescribed, resulting in the resident's blood sugar being very high and s/he had convulsion. x Anoka 06/13/2017 and It is alleged that the resident was neglected when facility staff failed to provide emergency medical services Coon Rapids 10 Park River Estates Care Center x NEGLECT OF HEALTH CARE - FALLS 06/14/2017 10/5/2017 when the resident had a fall and was in pain. x Anoka 12/14/2015 and It is alleged that a resident was neglected when staff failed to provide adequate wound care and medication Coon Rapids 10 Park River Estates Care Center x NEGLECT-HEALTH CARE 12/15/2015 11/15/2016 administration and subsequently s/he had multiple surgeries in one month due to infection. x Anoka It is alleged that a client was neglected when the facility did not adequately assess or supervise the client. 1/31/2018 The client sustained reddened areas on both of the client's arms (3 inches by 8 inches) and on buttocks areas Coon Rapids 1591 REM MN Community Services INC Kumquat NEGLECT OF SUPERVISION 6/15/2017 (6 inches wide) and across the entire buttocks. x Anoka It is alleged that a client was neglected when the facility staff failed to consistently weight the client, assess the client's skin, and assess the client for changes in condition. The client was found to have an ulcer on PATIENT RIGHTS NEGLECT OF HEALTH CARE his/her buttocks. The client was transferred to the hospital where it was determined the client had sepsis, Coon Rapids 1591 REM MN Community Services INC Kumquat NEGLECT OF HEALTH CARE-DECUBITI 12/5/2016 10/23/2017 pneumonia, and a urinary tract infection. x Anoka It is alleged a client was neglected when staff members administered sleeping pills to the client which the client did not need, refused to administer cream medication, and refused to assist the client with putting on Coon Rapids 25728 Select Senior Living of Coon R x PATIENT RIGHTS NEGLECT OF HEALTH CARE 11/27/2017 2/26/2018 his/her shoes. x Anoka

NEGLECT OF HEALTH CARE NEGLECT OF It is alleged that a resident was neglected when staff failed to assist a resident with bathing and answering Coon Rapids 25728 Select Senior Living of Coon R x HEALTH CARE-FALLS 5/18/2017 9/14/2017 his call light for over three hours. Resident slipped when transferring self from tub and hit his head. x Anoka

It is alleged that a client was neglected when staff did not provide adequate supervision and the client was found at another facility after having been outside in below zero temperatures not adequately dressed for the weather. This document has been re-scanned to the MDH website. The report has been revised after Coon Rapids 25728 Select Senior Living of Coon R x NEGLECT-SUPERVISION 2/24/2015 12/1/2015 additional information was received August 31, 2015. x Anoka

02/03/2016 It is alleged that a client was neglected when staff failed to follow medication administration and blood and pressure monitoring as ordered by the physician for multiple days. The client subsequently fell and his Coon Rapids 25728 Select Senior Living Of Coon Rapids x NEGLECT-HEALTH CARE, MEDICATIONS 02/04/2016 5/31/2016 his/her head. In addition, staff have not provided adequate personal cares. x Anoka

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 20 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County

It is alleged that a client was neglected when staff administered the client's medications and administered another client's medication to him/her. Staff were not aware of the error until hours later after the client Cottage Grove 26133 Cottage Grove White Pine x NEGLECT - HEALTH CARE 7/22/2015 1/14/2016 complained of stomach pain. Client was then hospitalized for two days. x Washington

Cottage Grove 27918 Cottage Grove WP II LLC x NEGLECT OF HEALTH CARE-DECUBITI 6/3/2016 8/23/2016 It is alleged that a client was neglected when s/he developed a stage four pressure ulcer while at the facility. x Washington It is alleged that a client was abused when a staff, alleged perpetrator (AP), was rough with the client. The Cottage Grove 27490 Royal Age Assisted Living x ABUSE - PHYSICAL - STAFF 12/3/2015 2/18/2016 client was crying and fearful of the AP. x Washington

02/11/2016 It is alleged that a client was physically abused when the alleged perpetrator (AP) restrained the client's and hands behind the wheelchair, pinning the client's arms. In addition, the client was emotionally abused when Cottage Grove 25202 Triple Angels Healthcare Company x ABUSE-PHYSICAL-EMOTIONAL-STAFF 02/12/2016 12/30/2016 the AP left the client in the bathroom without assistance, although the client was yelling for help. x Washington It is alleged that a client was neglected when s/he was dropped from a lift due to equipment failure and NEGLECT-FALLS DUE TO EQUIP FAILURE, suffered skin tears and bruising. Later, the same day, a different mechanical lift failed and the client suffered Cromwell 26451 Villa Court INAPPROPRIATE USE OF EQUIP 1/21/2016 1/21/2016 an additional skin tear. x Carlton It is alleged that a client was neglected when the client was admitted to the hospital with a pressure ulcer Cromwell 26451 Villa Court NEGLECT-HEALTH CARE NEGLECT-DECUBITI 3/26/2015 11/3/2015 and eye infection that appeared not to have been treated. x Carlton It is alleged that a resident was neglected when staff failed to adequately supervise the resident. Staff was aware of a malfunctioning secure door a day prior to the resident leaving the facility through the malfunctioning door. The resident was found after dark on a busy highway a half mile away from the facility Crookston 470 Riverview Hospital & HSG Home x NEGLECT-SUPERVISION 1/6/2015 6/30/2015 wearing no coat, hat, or gloves. x Polk It is alleged that a resident was neglected when staff failed to adequately supervise the resident. Staff was aware of a malfunctioning secure door a day prior to the resident leaving the facility through the malfunctioning door. The resident was found after dark on a busy highway a half mile away from the facility Crookston 470 Riverview Hospital & HSG Home x NEGLECT-SUPERVISION 1/6/2015 6/30/2015 wearing no coat, hat, or gloves. x Polk

11/28/2016 It is alleged that a resident was abused by staff/alleged perpetrator when the AP was witnessed to pick up and the resident, throw the resident onto the bed, hit, kick, punch, and call the resident names. The resident Crookston 815 Villa St Vincent x ABUSE-PHYSICAL-STAFF PATIENT RIGHTS 11/29/2016 5/1/2017 complained of pain and fear. The resident received minor injuries. x Polk

11/28/2016 It is alleged that a resident was abused by staff/alleged perpetrator when the AP was witnessed to pick up and the resident, throw the resident onto the bed, hit, kick, punch, and call the resident names. The resident Crookston 815 Villa St Vincent x ABUSE-PHYSICAL-STAFF PATIENT RIGHTS 11/29/2016 5/1/2017 complained of pain and fear. The resident received minor injuries. x Polk

11/28/2016 It is alleged that a resident was abused by staff/alleged perpetrator when the AP was witnessed to pick up and the resident, throw the resident onto the bed, hit, kick, punch, and call the resident names. The resident Crookston 815 Villa St Vincent x ABUSE-PHYSICAL-STAFF PATIENT RIGHTS 11/29/2016 5/1/2017 complained of pain and fear. The resident received minor injuries. x Polk

11/28/2016 It is alleged that a resident was abused by staff/alleged perpetrator when the AP was witnessed to pick up and the resident, throw the resident onto the bed, hit, kick, punch, and call the resident names. The resident Crookston 815 Villa St Vincent x ABUSE-PHYSICAL-STAFF PATIENT RIGHTS 11/29/2016 5/1/2017 complained of pain and fear. The resident received minor injuries. x Polk

It is alleged that a resident was neglected when staff failed to provide adequate medical care when the 11/10/2014 resident complained of shortness of breath several times during the evening. The resident expired that and evening and staff failed to initiate cardio-pulmonary resuscitation (CPR). In addition, staff are not treating Crookston 815 Villa St Vincent x NEGLECT-HEALTH CARE NEGLECT-DECUBITI 11/14/2014 6/15/2015 resident #2's (R2) pressure ulcers and not bathing R3 for more than three weeks. x Polk

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 21 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County

It is alleged that a resident was neglected when staff failed to provide adequate medical care when the 11/10/2014 resident complained of shortness of breath several times during the evening. The resident expired that and evening and staff failed to initiate cardio-pulmonary resuscitation (CPR). In addition, staff are not treating Crookston 815 Villa St Vincent x NEGLECT-HEALTH CARE NEGLECT-DECUBITI 11/14/2014 6/15/2015 resident #2's (R2) pressure ulcers and not bathing R3 for more than three weeks. x Polk Crosby 91 CUYUNA REGIONAL MEDICAL CENTER X NEGLECT-FALLS 12/22/2016 5/1/2017 It is alleged that a resident fell out of a mechanical lift and suffered a head injury. X Crow Wing

It is alleged that a resident was neglected when he/she was left smoking unsupervised, which did not follow Crosby 91 CUYUNA REGIONAL MEDICAL CENTER X NEGLECT-SUPERVISION 11/10/2015 3/16/2016 the care plan. The resident was found with his/her coat/blanket on fire and covered in ash. X Crow Wing It is alleged that a client was abused when a staff member/alleged perpetrator yelled at the client in the Crosby 20479 HEARTWOOD X ABUSE-EMOTIONAL-STAFF PATIENT RIGHTS 10/17/2017 10/17/2017 dining room. X Crow Wing It is alleged that a client was neglected when the client was injured during a transfer onto the bath chair with Cross Lake 26009 GOLDEN HORIZONS OF CROSSLAKE X NEGLECT-HEALTH CARE 12/21/2015 1/19/2016 staff assistance. X Crow Wing It is alleged that a client was neglected when the staff failed to provide adequate personal cares when the client was left in the same clothing covered in feces and urine for five days, developing bed sores and a Cross Lake 26009 GOLDEN HORIZONS OF CROSSLAKE X NEGLECT-HEALTH CARE, FALLS 2/4/2015 7/20/2015 urinary tract infection. The client also had five falls in one month. X Crow Wing

It is alleged that a client was neglected when staff did not follow the client's care plan and failed to provide Crystal 24012 Amazing Love LLC x Neglect of Supervision 12/7/2015 6/6/2016 adequate supervision. The client went missing and has been missing for 26 days. X Hennepin It is alleged that a client was abused when staff/alleged perpetrator (AP), entered the clients room and had Crystal 24012 Amazing Love LLC x Rape by Staff 10/4/2017 2/9/2018 sexual contact with the client x Hennepin It is alleged that a client (Client #1)was neglected when the facility did not adequately supervise the clients and client #1 and client #2 had sexual relations. The facility transferred client #1 to the hospital for an Crystal 24012 Amazing Love LLC x Neglect-Supervision-Resident to Resident 10/4/2017 2/9/2018 unrelated incident x Hennepin

It is alleged that a client was abused when the alleged perpetrator (AP) pushed the client into the restroom Physical abuse by staff Emotional Abuse by and forced the client to shower. In addition, the client was incontinent, but the AP forced the client to go to Crystal 24012 Amazing Love LLC x Staff 4/21/2017 5/2/2017 restroom every two hours. The incidents happened on several occasions. x Hennepin

It is alleged that two clients were neglected when staff failed to provide adequate supervision when client #2 Crystal 24012 Amazing Love LLC x Neglect-Supervision-Resident to Resident 8/8/2016 9/9/2016 threw boiling water on client #1. Client #1 was hospitalized with 1st and 2nd degree burns. x Hennepin it is alleged that a resident was abused when alleged perpetrator was rough with resident during personal Crystal 255 Centennial Gardens x Abuse-Physical-Staff 10/6/2017 2/7/2018 cares and hit resident x Hennepin it is alleged that Resident #1 was neglected when staff failed to provide adequate supervision. Resident #1 Crystal 255 Centennial Gardens x Neglect-Supervision-Resident to Resident 2/27/2017 5/30/2017 was hit by Resident #2 resulting in serious injury x Hennepin It is alleged that a resident was neglected when s/he developed a large, open ulcer on the resident's perineal area and facility staff were not aware. In addition, the facility failed to adequately assess the resident for a change in condition when the resident had a fever, slurred speech, and labored breathing for several days. Crystal 255 Centennial Gardens x Neglect-Health Care Nursing Care 7/27/2016 5/25/2017 The resident was hospitalized. x Hennepin It is alleged that a resident was neglected when staff failed to monitor resident's blood sugar levels for two Crystal 255 Centennial Gardens x Neglect of health Care-Falls 7/27/2016 5/2/2017 days and the resident suffered falls. x Hennepin

Crystal 255 Centennial Gardens x Abuse-Sexual 4/17/2017 5/1/2017 it is alleged that a resident was abused when staff/alleged perpetrator inappropriately touched the resident. x Hennepin it is alleged that a resident was neglected when staff failed to provide adequate supervision when he/she climbed out of a second story window at the facility and fell to the ground. The resident fractured his/her hip Crystal 255 Centennial Gardens x Neglect of Supervision 4/25/2016 7/5/2016 and is hospitalized. x Hennepin

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 22 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County It is alleged that a resident was neglected when s/h had a change in condition, including symptoms of difficulty breathing. The resident's spouse asked the facility to have the resident sent to facility and the Crystal 255 Centennial Gardens x NEGLECT-HEALTH CARE 4/5/2016 6/29/2016 facility refused. The resident died a few hours later. x Hennepin

It is alleged that a resident's pain is not adequately addressed. The resident's call light is not in reach and not answered timely when in reach. The resident doesn't receive the necessary toileting assistance resulting in incontinence. The resident's toenails are not trimmed and activity preferences not met. The resident doesn't receive his/her evening snack and beverages. This resident's visiting hours are restricted and grievances are Crystal 255 Centennial Gardens x PATIENT RIGHTS 2/8/2016 4/11/2016 not followed up on. The resident is being retaliated against. x Hennepin it is alleged that a resident was neglected when staff did not ensure the resident's oxygen was turned on or set at the appropriate level. The resident's family would frequently find him/her having labored breathing or Crystal 255 Centennial Gardens x Neglect Health Care 7/31/2015 10/5/2015 gasping for breath. The resident passed away. x Hennepin

Client was abused when a AP verbally and physically abused the client. Staff witnessed client scratched AP's vehicle with the client's key's. AP went and took client's key's from around the neck. Client stated that AP Crystal 1625 Cip City Lights ABUSE-PHYSICAL, EMOTIONAL-STAFF 2/18/2016 2/18/2017 slapped client across the face, knocked off the client's glasses and swore at the client. No injury was noted. X Hennepin EXPLOITATION BY STAFF EXPLOITATION BY It is alleged that client was financially exploited by alleged perpetrator when he/she used the clients credit Crystal 29082 HEATHERS MANOR x OTHER 5/2/2016 5/2/2016 cards in the amount of $1,200-$1,500. x Hennepin It is alleged that a client was neglected by facility staff. Abuse occurred when the client was hit by staff in the arm, resulting in a bruise and also being handled roughly. Neglect occurred when staff failed to answer the clients call light in a timely manner. Client is fearful regarding how bad things could get if client doesn't get Crystal 29082 Heathers Manor x Neglect of Health Care Physical Abuse by Staff 10/23/2017 1/16/2018 help. x Hennepin

It is alleged that clients (Client #1 and Client #2) are not receiving adequate supervision. The clients have left Crystal 29409 N & V Helpful Heart Care INC x Nursing Care Neglect-Supervision 4/4/2016 4/4/2016 the facility without staff being aware. In addition, the clients are not receiving the correct medications. x Hennepin

It is alleged that a client was financially exploited when an employee, the Alleged Perpetrator (AP), used the Crystal 1562 Outreach Rice Creek Abuse-Exploitation-Staff 3/27/2015 11/25/2015 client's finances over a 12-15 month period for his/her own personal use, totaling $769.31 x Hennepin

Crystal 29409 N & V HELPFUL HEART CARE INC x ABUSE PHYSICAL STAFF August 17 2017 9/26/2017 It is alleged that the client was abused when the alleged perpetrator punched the client in the chest x Hennepin ABUSE PHYSICAL October It is alleged that the client was abused when staff punched him/her and slapped him/her in the face. The Crystal 29409 N & V HELPFUL HEART CARE INC x 28,2015 12/28/2015 client has multiple bruises all over his/her face and arms and is fearful. x Hennepin

Crystal 29409 N & V HELPFUL HEART CARE INC x ABUSE-SEXUAL 6/1/2015 6/11/2015 It is alleged that the client was abused when a staff, alleged perpetrator, touched the client inappropriately. x Hennepin It is alleged that a resident was neglected when facility staff failed to follow the resident's care plan resulting Dawson 326 Johnson Memorial Hospital & Home x NEGLECT OF HEALTH CARE - FALLS 1/7/2016 11/18/2016 in a fall. The resident was hospitalized with a fractured hip. x Lac Qui Parle It is alleged that a resident was neglected when the facility did not adequately supervise the resident. The NEGLECT-SUPERVISION, Health Care Patient resident walked onto a frozen lake in inclement weather without proper clothing. Law enforcement found Deephaven 234 Lake Minnetonka Care Center x Rights 12/21/2016 8/28/2017 the resident who expressed suicidal ideation. x Hennepin It is alleged that a client was neglected when the alleged perpetrator (AP) failed to provide adequate nursing care. AP was rude to resident and did not help resident to put on stockings which s/he needed for cellulitis. Resident is wheel-chair bound, has dementia and is unable to put the stockings on his/herself. In addition, NEGLECT-HEALTH CARE ABUSE-EMOTIONAL- the AP failed to supervise resident's medication intake, resulting in a pill found on the table by the resident's Delano 933 The Estates at Delano LLC x STAFF 3/9/2017 9/25/2017 bed. x Wright It is alleged that Resident #1 and Resident #2 were neglected when staff failed to provide adequate supervision to both residents. Resident #1 pulled Resident #2 out of his/her bed, and s/he had scalp Delano 933 The Estates at Delano LLC x NEGLECT-SUPERVISION 9/20/2016 6/12/2017 contusion. x Wright

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 23 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County VERBAL REMARKS BY STAFF EMOTIONAL It is alleged that a client #1 and a client #2 were abused verbally, physically and sexually when a staff ABUSE BY STAFF PHYSICAL ABUSES BY STAFF member made inappropriate sexual comments to client #1. It is also alleged the facility failed to provide hot Delano 26590 The Legacy of Delano LLC x PHYSICAL PLANT MAINTENANCE 4/17/2017 11/7/2017 water for bathing. It is alleged client #2 had a bruise on the forearm. x Wright In addition, it is alleged that resident rights were violated when staff did not help the resident to go socialize with others. Resident was frustrated, feels s/he was not important enough, and was being isolated in his/her room. It is also alleged that the resident was not offered an alternative food when s/he did not want Detroit Lake 22058 EMMANUEL COMMUNITY x NEGLECT-HEALTH VARE, FALLS 5/1, 5/2/2017 6/19/17 lunch/dinner. x Becker It is alleged that a resident was neglected when the facility staff did not assist the resident with eating. The Detroit Lake 21056 Golden Manor Corporation x NEGLECT-HEALTH CARE 10/7/15 8/19/2016 resident lost weight. Staff left the resident on the toilet for two hours. x Becker It is alleged that a resident was neglected when alleged perpetrator (AP) #1 and AP 2 used a mechanical lift inappropriately resulting in a fall. The resident subsequently hit his/her head and was diagnosed with a Detroit Lakes 13 Emmanual Nursing Home x FASLLS DUE TO EUIIPMENT FAILURE 10/17/2017 3/2/2018 concussion. x Becker It is an allegation of drug diversion based on the following: The alleged perpetrator (AP) took narcotic medications from Client #1 and Client #2's medication cart. There was no documentation in the narcotic Dilworth 24327 Serenity Assisted Living x ABUSE-EXPLOITATION-DRUG DIVERSION 8/21/2017 1/19/2017 book. x Clay It is alleged that a client was financially exploited when a staff member cashed the client's checks for Duluth 23296 HOME INSTEAD SENIOR CARE x ABUSE-EXPLOITATION-STAFF 8/17/2017 9/14/2017 personal use without the client's knowledge. x St. Louis NEGLECT OF SUPERVISION-RESIDENT TO It is alleged client #1 was neglected when staff failed to provide adequate supervision that resulted in client Duluth 21125 RES TREATMENT & DETOX CTR RESIDENT 12/5/2017 2/9/2018 #2 and client #3 performing anal penetration on client #1. x St. Louis ABUSE-TOUCHING/FONDLING-STAFF NEGLECT- It is alleged that the resident was abused when the alleged perpetrator touched the resident inappropriately Duluth 593 THE NORTH SHORE ESTATES LLC x FAILURE TO REPORT 8/30-31/2017 12/27/2017 during incontinent care. x St. Louis It is alleged that a resident was neglected when resident had a fall from a lift and sustained a right hip Duluth 593 THE NORTH SHORE ESTATES LLC x NEGLECT HEALTH CARE-FALLS 6/20/2016 10/18/2016 fracture. x St. Louis

ABUSE-PHYSICAL-OTHER NEGLECT- It is alleged that neglect of supervision occurred, resulting in a physical altercation between two clients. One Duluth 20151 WESLEY RESIDENCE OF DULUTH x SUPERVISION-RESIDENT TO RESIDENT 1/17-18/2017 05/08/2017 client punched the other client several times to the head with a closed fist, and bit the other client. x St. Louis It is alleged that a client was neglected by an unnamed staff/alleged perpetrator (AP) when the client was found four block away from the facility by a concerned citizen. The client was not dressed appropriately for the 14 degree weather. S/he was were a coat but only had slippers on his/her feet. S/he appeared to have fallen out of his/her wheelchair at some point. The citizen transported the client to his/her destination, then Duluth 20151 WESLEY RESIDENCE OF DULUTH x NEGLECT-SUPERVISION 6/14-15/2017 6/28/2017 back to the facility. x St. Louis

NEGLECT-SUPERVISION-RESIDENT TO It is alleged neglect of supervision occurred, resulting in a client being emotionally abused by another client. Duluth 20151 WESLEY RESIDENCE OF DULUTH x RESIDENT ABUSE-EMOTIONAL-OTHER 1/17-18/2017 5/8/2017 Client #2 yelled at other clients which triggered Client #1's prior traumatic experiences. x St. Louis It is alleged that a client was financially exploited when the alleged perpetrator (AP) took an envelope full of Duluth 338 Accra Home Health - Duluth EXPLOITATION BY STAFF 2/11/2016 2/2/2017 money out of the client's walker. x St. Louis It is alleged that a client was financially exploited when the alleged perpetrator (AP) took an envelope full of Duluth 3338 ACCRA HOME HEALTH-DULUTH EXPLOITATION BY STAFF 2/11/2016 2/2/2017 money out of the client's walker. x St. Louis EMOTIONAL ABUSE BY STAFF FAILURE TO It is alleged that a resident was abused when the alleged perpetrator (AP) spoke to and touched the resident Duluth 581 AFTENRO HOME x REPORT 11/1/2017 12/14/2017 in a threatening manner. x St. Louis

NEGLECT OF HEALTH CARE NEGLECT OF It is alleged that a resident was neglected when s/he did not receive nine doses of medications, and was Duluth 589 Bayshore Residence & Rehab Ctr x HEALTH CARE-MEDICATION 10/12/2015 1/19/2016 hospitalized. x St. Louis

It is alleged that a resident was neglected when a staff had a significant medication transcription error for Duluth 589 BAYSHORE RESIDENCE & REHAB CTR x NEGLECT - MEDICATIONS 10/12/2015 1/19/2016 the residen'ts Coumadin orders and s/he did not receive medications according to physician's orders. x St. Louis

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 24 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County It is alleged that a resident was neglected when staff did not do proper assessment for fall risk and did not update the care plan. The resident fell out of his/her wheelchair, sustained a cerebral hemorrhage and Duluth 589 BAYSHORE RESIDENCE & REHAB CTR x NEGLECT-HEALTH CARE 2/3-4/2015 5/4/2015 subsequently died. x St. Louis It is alleged that a resident was neglected when staff failed to provide adequate wound cares after s/he had vascular surgery. The resident went in for a check-up post surgery and will now need above the knee Duluth 589 BAYSHORE RESIDENCE & REHAB CTR x NEGLECT-HEALTH CARE 12/3-4/2015 11/08/2016 amputation due to worsening wounds. x St. Louis It is alleged that a resident was neglected when the staff did not fill the resident's oxygen tank. The resident's tracheotomy needed to be replaced. The resident was transferred to the hospital. The resident's oxygen level Duluth 589 BAYSHORE RESIDENCE & REHAB CTR x NURSING CARE NEGLECT OF HEALTH CARE 1/5/2017 07/07/2017 was very low. x St. Louis It is alleged that a resident was neglected when staff did not provide adequate personal cares, leaving the resident in a urine-soaked brief with dried feces for a full day, resulting in the resident not being able to complete dialysis treatment. In addition, the resident was sent out of the facility without proper attire, Duluth 589 BAYSHORE RESIDENCE & REHAB CTR x NEGLECT-HEALTH CARE 12/4/2015 03/23/2015 resulting in skin being exposed to the cold weather. x St. Louis

Duluth 589 Bayshore Residence & Rehab Ctr x SEXUAL ABUSE 10/23,24/2017 3/5/2018 It is alleged that a resident was abused when the alleged perpetrator inappropriately kissed the resident. x St. Louis

It is alleged that a patient was neglected when facility staff failed to provide adequate personal and medical care resulting in hospitalization for a urinary tract infection. It is alleged that the resident's catheter was Duluth 589 BAYSHORE RESIDENCE & REHAB CTR x NEGLECT-HEALTH CARE 9/19/2017 1/31/2018 capped for approximately four days and resident was not able to urinate. x St. Louis It is alleged that a resident was neglected when the facility power was disconnected. The resident was Duluth 589 BAYSHORE RESIDENCE & REHAB CTR x NEGLECT-HEATLH CARE 8/9-10/2017 1/30/2018 affected due to use of a tube feeding. x St. Louis

It is alleged that a patient was neglected when facility staff failed to provide adequate personal and medical care resulting in hospitalization for a urinary tract infection. It is alleged that the resident's catheter was Duluth 589 BAYSHORE RESIDENCE & REHAB CTR x NEGLECT-HEALTH CARE 12/19/2017 12/19/2017 capped for approximately four days and resident was not able to urinate. x St. Louis It is alleged that a resident was neglected when the alleged perpetrator failed to follow the resident's care Duluth 589 BAYSHORE RESIDENCE & REHAB CTR x NEGLECT OF HEALTH CARE - FALLS 10/23-24/2017 12/15/2017 plan and the resident had a fall resulting in a femur fracture. x St. Louis

It is alleged that a resident was neglected when s/he had a change in condition, including chills, coughing, fever and nausea for three days before the resident was hospitalized. Once hospitalized, the resident was Duluth 589 BAYSHORE RESIDENCE & REHAB CTR x NEGLECT-HEALTH CARE 3/15/2016 6/12/2017 diagnosed with pneumonia and a urinary tract infection. The resident died several days later. x St. Louis NEGLECT-HEALTH CARE, DECUBITI NURSING It is alleged that a resident was neglected when the resident was observed to have a stage four pressure Duluth 589 BAYSHORE RESIDENCE & REHAB CTR x CARE 1/23/2017 3/10/2017 ulcer to the right ear. x St. Louis

It is alleged that a resident was neglected when the facility failed to adequately monitor the resident's condition according to physician's orders. This facility failed to take hourly vitals, isolate the resident due to Duluth 861 BENEDICTINE HEALTH CENTER x NEGLECT-HEALTH CARE 6/8-9/2015 11/23/2015 being highly susceptible to infections and failed to administer the proper medications. x St. Louis It is alleged that a resident was emotionally abused when a staff member used inappropriate words with Duluth 861 BENEDICTINE HEALTH CENTER x ABUSE-EMOTIONAL-STAFF 3/9/2017 09/25/2017 him/her. x St. Louis

It is alleged that a resident was neglected when staff/alleged perpetrator failed to schedule a urine analysis as prescribed by physician. The resident had a change in condition, was sent to ER and diagnosed with Duluth 861 BENEDICTINE HEALTH CENTER x NEGLECT OF HEALTH CARE 5/1/2017 11/14/2017 sepsis, hypotension, urinary tract infection, acute and chronic renal failure, hyperkalemia. x St. Louis : It is alleged that a resident was abused when staff/alleged perpetrator placed an indwelling urinary catheter Duluth 861 BENEDICTINE HEALTH CENTER x NEGLECT OF HEALTH CARE 3/9/2017 10/9/2017 without a physician order. This caused the resident pain. x St. Louis It is alleged that a resident was neglect when the staff failed to administer the morning dose of a medication Duluth 598 CHRIS JENSEN HLTH & REHAB CTR x NEGLECT-MEDICATIONS 8/20-21/2015 12/01/2015 used to reduce seizure activity for an entire month. x St. Louis

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 25 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County

It is alleged that a resident was neglected when his/her physical condition significantly declined while the facility/staff did not notify his/her physician or family. In addition, the resident presented at the hospital with Duluth 598 CHRIS JENSEN HLTH & REHAB CTR x NEGLECT-HEALTH CARE UNEXPLAINED INJURY 5/4/2015 07/08/2015 bruising/scratches all over his/her body and was unkempt and unclean. x St. Louis 11/8,9,13/201 It is alleged that a resident was abused and heard calling out when the alleged perpetrator provided the Duluth 598 CHRIS JENSEN HLTH & REHAB CTR x ABUSE-PHYSICAL-SEXUAL 7 02/12/2018 resident cares behind closed doors. x St. Louis It is alleged that a resident was abused when alleged perpetrator spend extended periods of time with 11/8,9,13/201 resident providing care. It is alleged that the resident would call out frequently during these periods. It is 7 alleged that sex toys were seen falling out of alleged perpetrator's pocket and were found on the floor of the Duluth 598 CHRIS JENSEN HLTH & REHAB CTR x ABUSE-PHYSICAL-STAFF, SEXUAL 2/12/2018 shower room. x St. Louis 11/8,9,13/201 7 It is alleged that a resident was abused when alleged perpetrator #1 and alleged perpetrator #2 pushed the Duluth 598 CHRIS JENSEN HLTH & REHAB CTR x ABUSE-PHYSICAL-STAFF NEGLECT-FALLS 2/6/2018 resident in a wheelchair and the resident fell out of the wheelchair resulting in a head injury. x St. Louis ABUSE-SEXUAL NEGLECT-SUPERVISION- Duluth 598 CHRIS JENSEN HLTH & REHAB CTR x RESIDENT TO RESIDENT 1/18/2017 10/20/2017 It is alleged that a resident was sexually assaulted by another unknown resident. x St. Louis Duluth 598 CHRIS JENSEN HLTH & REHAB CTR x ABUSE-SEXUAL NEGLECT-SUPERVISION 1/18/2017 10/20/2017 It is alleged that a resident was sexually assaulted by another unknown resident. x St. Louis It is alleged that a resident was not adequately supervised by staff and the resident eloped. The resident was Duluth 598 CHRIS JENSEN HLTH & REHAB CTR x NEGLECT-SUPERVISION 3/6/2017 5/8/2017 found 30 minutes after noted to be missing. x St. Louis It is alleged that a resident was neglected when the alleged perpetrator failed to follow the care plan during Duluth 598 CHRIS JENSEN HLTH & REHAB CTR x NEGLECT-HEALTH CARE 10/5/2017 12/14/2017 a transfer resulting in a left ankle fracture. x St. Louis

It is alleged that a resident was neglected when facility staff failed to provide adequate medical assessment Duluth 598 CHRIS JENSEN HLTH & REHAB CTR x NEGLECT OF HEALTH CARE 10/18/2017 12/14/2017 and services when the resident developed signs and symptoms of a septic infection. x St. Louis

Duluth 598 CHRIS JENSEN HLTH & REHAB CTR x PHYSICAL ABUSE BY STAFF 5/16/2017 10/4/2017 It is alleged that the abuse occurred when a resident was slapped by an employee, alleged perpetrator. x St. Louis

Diamond Willow Assisted Lving (FULL NEGLECT OF HEALTH CARE-FALLS FALLS DUE It is alleged that a client was neglected when staff transferred the client incorrectly with a mechanical lift and Duluth 24424 CIRCLE SENIOR LIVING INC) x TO EQUIPMENT 11/6/2017 12/27/2017 hit the client's head. The staff when transferring the client with a gait belt fractured the client's rib. x St. Louis Diamond Willow Assisted Lving (FULL ABUSE-PHYSICAL-STAFF NEGLECT-- It is alleged that a client was physically abused when a staff/allleged perpetrator (AP) held the client's arms Duluth 24424 CIRCLE SENIOR LIVING INC) x SUPERVISION 6/8/2017 11/6/2017 down. x St. Louis Diamond Willow Assisted Lving (FULL It is alleged that a client was emotionally abused when the client was afraid of staff and expressed concern Duluth 24424 CIRCLE SENIOR LIVING INC) x EMOTIONAL ABUSE BY STAFF 5/11/2017 7/3/2017 that the staff would hit him/her in the future. x St. Louis

Diamond Willow Assisted Lving (FULL It was alleged that a client was physically abused by staff. Bruising was noticed on his/her hands and wrists. Duluth 24424 CIRCLE SENIOR LIVING INC) x ABUSE-PHYSICAL-STAFF NURSING CARE 3/20-31/2017 6/28/2017 The client stated staff were rough and angry when they tried to lift the client. x St. Louis

Diamond Willow Assisted Lving (FULL It was alleged that a client was physically abused by staff. Bruising was noticed on his/her hands and wrists. Duluth 24424 CIRCLE SENIOR LIVING INC) x PHYSICAL ABUSE BY STAFF 3/20-31/2017 6/28/2017 The client stated staff were rough and angry when they tried to lift the client. x St. Louis

It is alleged that the client was abused when the alleged perpetrator (AP) have been rough while providing Diamond Willow Assisted Lving (FULL personal cares. In addition, the APs have held the client down while changing his/her clothes and have Duluth 24424 CIRCLE SENIOR LIVING INC) x ABUSE-PHYSICAL-STAFF 9/29-30/2016 11/28/2016 restrained him while s/he is bathing. The client screams for help during these cares. x St. Louis

It is alleged that a client was neglected when s/he had a fall and staff failed to adequately assess his/her Diamond Willow Assisted Lving (FULL injuries. The client had injuries to the head and shoulder. In addition, staff failed to provide necessary Duluth 24424 CIRCLE SENIOR LIVING INC) x NEGLECT-HEALTH CARE 8/18-19/2015 5/2/2016 personal cares when the client's catheter bag was found full and it had leaked a large amount of urine. x St. Louis

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 26 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County It is alleged that staff neglected a client whenstaff failed to properly assess the client after s/he had a change Diamond Willow Assisted Lving (FULL in condition and did not provide services in a timely manner. The client was hospitalized and passed aways a Duluth 24424 CIRCLE SENIOR LIVING INC) x NEGLECT-FALLS 12/7/2015 2/8/2016 few hours later. x St. Louis Diamond Willow Assisted Lving (FULL Duluth 24424 CIRCLE SENIOR LIVING INC) NEGLECT-FALLS 7/13-14/2015 10/2/2015 It is alleged that a client was neglected when s/he fell and sustained a fracture. The client died 10 days later. x St. Louis It is alleged that a client was neglected when s/he experienced a fall in the facility which resulted in a hip Duluth 20852 Edgewood Hermantown l Senior L x NEGLECT-FALLS 4/19-20/2017 12/29/2017 fracture. x St. Louis It is alleged that neglect of supervision occurred when one client was shoved by a second client. The first NEGLECT OF HEALTH CARE NEGLECT-HEALTH client suffered injuries. The facility staff did not arrange for further care at the hospital; after a delay in Duluth 20852 Edgewood Hermantown l Senior L x CARE 11/27-28/2017 12/21/2017 treatment, the family transported the client to the hospital. x St. Louis

It is alleged that a resident was abused when the alleged perpetrator (AP) spoke to the resident in a Duluth 21353 EDGEWOOD VISTA VIRGINIA x ABUSE-EMOTIONAL-STAFF 9/17-18/2014 4/27/2015 threatening and intimidating manner. In addition, the resident feared for his/her life and was visibly shaken. x St. Louis It is alleged that the resident was neglected when the alleged perpetrator (staff unknown) did not administer Duluth 865 Franciscan Health Center x MEDICATION ADMINISTRATION 1/3/2018 2/28/2018 Diamox medication as prescribed resulting in hospitalization. x St. Louis It is alleged that several clients were financially exploited when the alleged perpetrator (AP) took the clients' Duluth 24424 FULL CIRCLE SENIOR LIVING INC x EXPLOITATION BY STAFF 8/15-16/2016 1/3/2017 money. x St. Louis It is alleged that several clients were financially exploited when the alleged perpetrator (AP) took the clients' Duluth 24424 FULL CIRCLE SENIOR LIVING INC x EXPLOITATION BY STAFF 8/15-16/2016 1/3/2017 money. x St. Louis It is alleged that several clients were financially exploited when the alleged perpetrator (AP) took the clients' Duluth 24424 FULL CIRCLE SENIOR LIVING INC x EXPLOITATION BY OTHER 8/15-16/2016 1/3/2017 money. x St. Louis It is alleged that a client was financially exploited when the alleged perpetrator (AP) took cash from the Duluth 24424 FULL CIRCLE SENIOR LIVING INC x EXPLOITATION BY STAFF 6/5/2017 08/15/2017 client. x St. Louis ABUSE-EXPLOITTION-STAFF ABUSE- It is alleged that a client was abused when a staff, alleged perpetrator (AP) initiated a sexual relationship Duluth 20837 GARDEN HOUSE ESTATES EMOTIONAL-STAFF 4/9/2015 6/18/2015 with the client. x St. Louis

Duluth 20035 Heritage Haven Inc x NEGLECT OF HEALTH CARE - FALLS 5/3,4,5/2017 12/18/2017 It is alleged that a client was neglected when the client fell multiple times, sustaining multiple injuries. x St. Louis It is alleged that a client was financially exploited when a staff member cashed the client's checks for Duluth 23296 Home Instead Senior Care x ABUSE-EXPLOITATION-STAFF 8/17/2107 9/14/2017 personal use without the client's knowledge. x St. Louis It is alleged that a client was financially exploited by a staff, alleged perpetrator (AP), when several checks Duluth 23296 HOME INSTEAD SENIOR CARE x EXPLOITATION BY STAFF 5/22/2017 06/19/2017 were made out to the AP for $200-$300 each. x St. Louis It is alleged that a client was financially exploited by a staff, alleged perpetrator (AP), when several checks Duluth 23296 HOME INSTEAD SENIOR CARE x ABUSE-EXPLOITATION-STAFF 5/22/2017 6/19/2017 were made out to the AP for $200-$300 each. x St. Louis

It is alleged that a patient was neglected when staff administered the wrong medication and dosages. The patient suffered a fall resulting in a broken ankle due to the side effects. The patient was taken to the Duluth 2828 INTERIM HEALTHCARE NEGLECT-MEDICATIONS 11/19-20/2015 05/25/2016 emergency room where the physician confirmed the patient had been receiving the wrong medications. x St. Louis

It is alleged that a client was neglected when staff/alleged perpetrator (AP) continued to transfer the client Duluth 2828 INTERIM HEALTHCARE NEGLECT-HEALTH CARE 8/21-22/2017 1/22/2018 in a mechanical lift after the client's leg was caught. The client subsequently sustained a fractured tibia. x St. Louis

It is alleged that a client was neglected when the facility failed to respond when s/he was pressing an Duluth 20183 SAINT ANN'S RESIDENCE x NEGLECT-FALLS 1/19-20/2017 4/13/2017 emergency button and as a result, did not receive assistance when s/he fell and broke his/her sternum. x St. Louis It is alleged that a client was abused when facility staff pushed him/her and called him/her names. The client Duluth 3775 SEPTEMBER HOUSE x ABUSE-PHYSICAL,EMOTIONAL-STAFF 2/1/2016 3/8/2016 is fearful of staff. x St. Louis It is alleged that a resident was exploited by staff/alleged perpetrator (AP) when the AP used the resident's Duluth 24120 SPIRIT VALLEY ASSISTED LIVING x ABUSE-EXPLOITATION-DRUG DIVERSION 8/16/2017 10/20/2017 metoprolol and Lisinopril for the AP's personal use. x St. Louis

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 27 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County It is alleged that a resident was neglected when s/he did not receive physician ordered pain medication when the resident was actively dying. In addition, it is alleged that the facility staff failed to do pain checks Duluth 593 ST ELIGIUS HEALTH CENTER x NEGLECT-HEALTH CARE 11/16-17/2015 03/03/2016 every hour during the morning the resident died. x St. Louis It is alleged that a resident was neglected when staff failed to assess the resident's fall risk and staff did not implement a plan of care that prevented falls and the resident had several falls with injuries resulting in Duluth 593 ST ELIGIUS HEALTH CENTER x NEGLECT-HEALTH CARE,FALLS 5/18-20/2015 1/21/2016 multiple emergency room visits. x St. Louis ABUSE-EMOTIONAL-STAFF ABUSE-PHYSICAL- It is alleged that a client has been abused when a staff, alleged perpetrator (AP) was verbally abusive to the Duluth 20834 TRANSITIONAL SENIOR HOUSING x STAFF 6/8/2015 7/28/2015 client and also pulled on the client's arm. x St. Louis

It is alleged that a resident was neglected when the facility did not adequately assess, monitor, or follow up with the physician regarding the resident's diabetic foot ulcer. The resident subsequently required a toe Duluth 602 VIEWCREST HEALTH CENTER x NEGLECT-HEALTH CARE 2/6/2018 03/05/2018 amputation and then surgical removal of the rests of the toes on the same foot. x St. Louis It is alleged that a resident was neglected when staff was pushing the resident in his/her wheelchair and the resident's foot got stuck underneath the chair, causing the resident to fall forward. The resident sustained a Duluth 602 VIEWCREST HEALTH CENTER x NEGLECT-HEALTH CARE 11/12/2015 1/8/2016 knee injury and needed to be hospitalized. x St. Louis It is alleged that a resident was neglected when s/he had a fall and was unable to get staff assistance. The resident's bed alarm was going off but staff did not respond. The resident was hospitalized after this fall with Duluth 602 VIEWCREST HEALTH CENTER x NEGLECT OF HEALTH CARE-FALLS 9/15/2015 1/6/2016 injuries. x St. Louis It is alleged that a resident was neglected when s/he arrived at the hospital with multiple ulcers large in size Duluth 602 VIEWCREST HEALTH CENTER x NEGLECT-HEALTH CARE 6/6/2016 11/4/2016 and infected to the bone. x St. Louis It is alleged that a client was exploited when an unknown amount of money, jewelry, pictures, and video EXPLOITATION BY OTHER Duluth 20151 WESLEY RESIDENCE OF DULUTH x 6/14-15/2017 6/28/2017 were stolen from his/her apartment. x St. Louis It is alleged that a client was financially exploited when a facility staff member/perpetrator used the client's Duluth 20935 Westwood of Duluth x ABUSE-EXPLOITATION-STAFF 10/3,4/2017 12/27/2017 medication for his/her own use. x St. Louis It is alleged that a client was neglected when staff failed to follow fall precautions in the client's care plan, Duluth 20935 WESTWOOD OF DULUTH x NEGLECT-FALLS 10/3-4/2017 12/27/2017 the client fell and had a fracture. x St. Louis ABUSE-EXPLOITATION-OTHER It is alleged that a client was financially exploited when the alleged perpetrator took the client's spouse's EAGAN 2838 ALLIANCE HEALTH SERVICES INC 3/14/2016 7/18/2016 jewelry. X Dakota It is alleged that a client was neglected when s/he had a fall and hit his/her head. The client was not NEGLECT OF HEALTH CARE-FALLS NEGLECT OF adequately assessed after the fall and staff waited two hours after the fall to call for emergency services. The Eagan 26862 Hometown Senior Living x HEALTH CARE 9/18/2015 3/1/2017 client was hospitalized. x Dakota It is alleged that a client was financially exploited when the staff/alleged perpetrator took the client's credit EAGAN 29559 KEYSTONE EAGAN X EXPLOITATION BY STAFF 12/14/2015 2/8/2016 card and made purchases for personal use. X Dakota ABUSE-PHYSICAL-STAFF NEGLECT-HEALTH It is alleged the client was abused when the staff punched the client in the chest and grabbed the client by EAGAN 25523 NEW CHALLENGES INC X CARE, NUTRITION 4/19/2017 5/11/2017 the arm. The client was also neglected of food, sustaining weight loss. X Dakota It is alleged the client was abused when the staff punched the client in the chest and grabbed the client by EAGAN 25523 NEW CHALLENGES INC X ABUSE-PHYSICAL, EMOTIONAL-STAFF 4/19/2017 5/11/2017 the arm. The client was also neglected of food, sustaining weight loss. X Dakota It is alleged that a client was neglected when facility staff failed to provide daily checks according to the Eagan 20662 The Commons on Marcie x NEGLECT-HEALTH CARE 11/21/2017 1/29/2018 service plan. Client passed away and was not discovered for two days. x Dakota It is alleged multiple (16) clients were exploited when their substance controlled medications were stolen. EAGAN 20662 THE COMMONS ON MARICE X ABUSE-EXPLOITATION-DRUG DIVERSION 8/2/2017 9/12/2017 Police said security was inadequate and there was no inventory control in place. X Dakota

NEGLECT-FALLS DUE TO EQUIPMENT EAGAN 20662 THE COMMONS ON MARICE X FAILURE,INAPPROPRIATE USE OF EQUIPMENT 5/6/2016 6/30/2016 It is alleged that a client was neglected when he/she fell out of a Hoyer lift, fracturing a shoulder. X Dakota

It is alleged that a client was financially exploited when the alleged perpetrator used the credit cards for EAGAN 20662 THE COMMONS ON MARICE X ABUSE-EXPLOITATION-STAFF 8/1/2017 9/12/2017 personal use. The perpetrator was fired before he/she could use the credit card. X Dakota

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 28 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County It is alleged a client was neglected when staff failed to plug in and monitor the client's heart pump. The Eden Prairie 24640 Aging Joyfully x NEGLECT-HEALTH CARE 7/15/2016 1/4/2017 client passed away x Hennepin

Client fell and sustained a head injury. No Gait belt was used for transfer. Ten days later client expressed arm pain during transfers. Four days later client declined in ability to transfer mechanical lift was now being used. A large bruise to the upper chest and left arm was observed. Client went to the hospital. No fractures, 7-15,18,19 osteoporosis was found in left shoulder, degenerative spine change no brain bleeding. Evidence of previous Eden Prairie 24640 Aging Joyfully x ABUSE-PHYSICAL-STAFF 2016 8/31/2016 stroke. Client remained in hospital for five days. Discharged to Skilled Nursing Facility. X Hennepin

It is alleged that a resident was neglected when facility staff transferred resident from bed to wheelchair and Eden Prairie 973 Castle Ridge Care Center x NEGLECT-HEALTH CARE, Falls, Failure to report 9/1/2017 1/18/2018 resident fell. It is alleged that resident passed away due to complications from the fall x Hennepin

It is alleged that a resident was neglected when staff failed to provide personal care to the resident for 15 days and the resident developed infections in his/her skin folds. In addition, staff are not providing care for Eden Prairie 973 Castle Ridge Care Center x Neglect Health Care 1/22/2015 4/17/2015 the resident's medical needs and neglecting to arrange needed respiratory therapy. x Hennepin

It is alleged that a resident was sexually abused by an alleged perpetrator (AP) when the resident was Eden Prairie 973 Castle Ridge Care Center x ABUSE-SEXUAL 3/2/2017 2/23/2018 inappropriately touched when the AP checked to see if his/her undergarment was dry. x Hennepin It is alleged that a resident was abused when a staff, alleged perpetrator came into the resident's room and Eden Prairie 973 Castle Ridge Care Center x ABUSE-SEXUAL 3/2/2017 2/23/2018 touched him/her inappropriately. x Hennepin It is alleged that a client was financially exploited when alleged perpetrator took client's credit cards and Edina 26486 Brookdale Edina x Exploitation by other 9/14/2017 10/23/2017 used them for her own person use. x Hennepin

Edina 26486 Brookdale Edina x Abuse-Exploitation-Staff 8/27/2015 It is alleged clients were financially exploited when a staff, alleged perpetrator, took money from clients x Hennepin It is alleged that a resident was neglected when staff failed to provide adequate assistance and supervision resulting in a fall and large skin tear. In addition, staff failed to administer the resident's blood pressure Neglect of Health Care Neglect of Health Care medication when the resident was rushed to the hospital and was found to have a blood pressure of 196 Edina 26486 Brookdale Edina x Medications Nursing Care 9/27/2016 10/23/2017 over 120 x Hennepin It is alleged that a client was neglected when the facility failed to administer the physician ordered supplemental oxygen for three days, and the client developed a relapse of congestive heart failure. The Edina 26486 Brookdale Edina x Neglect of Health Care 9/27/2016 6/26/2017 client died six weeks later. x Hennepin Resident was neglected when they fell out of a Hoyer lift during a transfer. Resident had several injuries, including a subarachnoid hemorrhage, and was hospitalized. The resident was hospitalized and died five Edina 740 Edina care & Rehab Center X NEGLECT-HEALTH CARE 12/11,14/2015 3/6/2017 days later. X Hennepin It was alleged that a client was financially exploited when alleged perpetrator took client's credit cards and Edina 26486 Edina Park Plaza aka Brookdale Edina EXPLOITATION BY OTHER 12/14/2017 10/23/2017 used for her own use. x Hennepin

Edina 26486 Edina Park Plaza aka Brookdale Edina x Abuse-Exploitation-Staff 8/27/2015 It is alleged clients were financially exploited when a staff, alleged perpetrator, took money from clients x Hennepin

It is alleged that a client was neglected when staff failed to properly assess and provide emergency services Edina 20233 Heritage of Edina x Neglect-Health Care, Falls 2/28/2017 10/24/2017 after the client had a fall with injuries and was bleeding. The client was hospitalized with five rib fractures. x Hennepin It is alleged that a client was financially exploited when a staff, alleged perpetrator (AP) took the client's Edina 20233 Heritage of Edina x Abuse-Exploitation-Drug Diversion 11/30/2015 4/18/2016 medication for his/her own use. x Hennepin Edina 20233 HERITAGE of EDINA INC x EXPLOITATION BY STAFF 10/24/2017 11/29/2017 It is alleged that the client was exploited when the staff (AP) took money from the client. x Hennepin It is alleged that the client was abused when the alleged perpetrator slapped and pushed the client's head Edina 28357 HOMEWATCH CAREGIVERS x ABUSE-PHYSICAL July 19,2017 12/29/2017 roughly. x Hennepin

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 29 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County

Edina 30082 Lifesprk LLC x Exploitation by Drug Diversion 1/9/2017 1/9/2017 It is alleged that a client was financially exploited when s/he had approximately 50-56 pills missing x Hennepin It is alleged that a client was financially exploited when the alleged perpetrator (AP) used the client's credit Edina 30082 Lifesprk LLC x Exploitation by Staff 1/29/2016 4/26/2016 cards for his/her own personal use. x Hennepin It is alleged that two clients were financially exploited when an unknown alleged perpetrator (AP) took the Edina 30082 LIFESPRK LLC x EXPLOITATOIN BY DRUG DIVERSION 1/24/2018 3/13/2018 client's medication. x Hennepin It is alleged that a client was neglected when the facility did not adequately assess and monitor the client. The client had multiple pressure ulcers on the coccyx and heels. The facility transferred the client to the Edina 20814 Sunrise Assisted Living of EDI x Neglect-Decubiti 6/6/2017 9/15/2017 hospital. The hospital admitted the client. x Hennepin It is alleged that a patient was financially exploited when the alleged perpetrator (AP) took the patient's Sherburn Elk River 21487 Accurate Home Care LLC ABUSE-EXPLOITATION-DRUG DIVERSION 4/20/2015 6/6/2015 medication for the AP's own use. x e NEGLECT OF SUPERVISION-RESIDENT TO It is alleged that client #1 was neglected when the facility staff failed to provide adequate supervision that Sherburn Elk River 21673 Guardian Angels By The Lake x RESIDENT 9/13/2017 12/29/2017 resulted in client #2 pushing client #1 down resulting in hip fracture. x e

NEGLECT-SUPERVISION-RESIDENT TO It is alleged that the facility did not adequately supervise two residents resulting in an accident where one Sherburn Elk River 21673 Guardian Angels By The Lake x RESIDENT PATIENT RIGHTS 1/27/2016 6/28/2017 resident pushed the other and the resident who was pushed fell and fractured his/her arm. x e It is alleged that residents were financially exploited when a staff alleged perpetrator (AP) took the resident's Sherburn Elk River 1632 MacGregor Place ABUSE-EXPLOITATION-DRUG DIVERSION 9/18/2015 2/14/2016 medications for his/her own use. x e It is alleged that a client was abused when the alleged perpetrator (AP) conducted a search of the client which included placing his/her hands inside the client's pants. In addition, it is alleged the client's rights were ABUSE-EMOTIONAL-STAFF ABUSE-SEXUAL violated when the facility refused to allow the client to return to the facility, without providing appropriate Elko 21486 The Lodge on Natchez x PATIENT RIGHTS 3/1/2017 3/31/2017 discharge notice and planning. x Scott It is alleged that a resident was abused when the alleged perpetrator (AP) took a picture of the resident on Ely 587 BOUNDARY WATERS CARE CENTER x ABUSE-EXPLOITATION-STAFF 1/24-25/2018 02/21/2018 his/her personal phone. x St. Louis It is alleged that a resident was abused when the alleged perpetrator (AP) pushed a recliner up to the resident's bed and placed a call light across the resident's legs and tied the call light to the support bar to Erskine 469 Pioneer Memorial Care Center x ABUSE-RESTRAINTS 9/6/2017 3/1/2018 limit the resident's ability to get out of bed. x Polk It is alleged that a resident was abused when the alleged perpetrator (AP) pushed a recliner up to the resident's bed and placed a call light across the resident's legs and tied the call light to the support bar to Erskine 469 Pioneer Memorial Care Center x ABUSE-RESTRAINTS 9/6/2017 3/1/2018 limit the resident's ability to get out of bed. x Polk It is alleged that a resident was neglected when the facility failed to provide proper nursing care and follow- up resulting in the resident requiring hospitalization with large vulvar abscess, significant tunneling, exposed bone, and anatomic destruction. The resident required two trips to the operating room for surgical Erskine 469 Pioneer Memorial Care Center x NEGLECT-HEALTH CARE 12/9/2016 6/30/2017 debridement and long term wound care. x Polk It is alleged that a resident was neglected when the facility failed to provide proper nursing care and follow- up resulting in the resident requiring hospitalization with large vulvar abscess, significant tunneling, exposed bone, and anatomic destruction. The resident required two trips to the operating room for surgical Erskine 469 Pioneer Memorial Care Center x NEGLECT-HEALTH CARE 12/9/2016 6/30/2017 debridement and long term wound care. x Polk

03/30/2017 It is alleged that a resident was neglected when staff/alleged perpetrator administered the wrong and medications to the resident. The facility transferred the resident to the emergency room where the resident Erskine 20593 The Country Place x MEDICATION ERRORS 03/31/2017 5/15/2017 was monitored and treated with intravenous fluids. The resident was lethargic and slept during the ED visit. x Polk

03/30/2017 It is alleged that a resident was neglected when staff/alleged perpetrator administered the wrong and medications to the resident. The facility transferred the resident to the emergency room where the resident Erskine 20593 The Country Place x MEDICATION ERRORS 03/31/2017 5/15/2017 was monitored and treated with intravenous fluids. The resident was lethargic and slept during the ED visit. x Polk

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 30 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County It is alleged that neglect occurred when the facility didn't administer medications as ordered for five days Erskine 20593 The Country Place x MEDICATION ERRORS 11/17/2017 2/21/2018 resulting in the client requiring admission to the hospital. x Polk It is alleged that neglect occurred when the facility didn't administer medications as ordered for five days Erskine 20593 The Country Place x MEDICATION ERRORS 11/17/2017 2/21/2018 resulting in the client requiring admission to the hospital. x Polk It is alleged that a resident was neglected when facility staff failed to provide adequate supervision. Resident Eveleth 583 ST RAPHAELS HEALTH & REHAB CTR x NEGLECT-SUPERVISION 10/16/2017 12/14/2017 observed using microwave resulting in fire. x St. Louis It is alleged that the facility failed to provide cardiopulmonary ressucitation after a resident choked. The facility staff provided the Heimlich maneuver but did not continue on with rescuscitative efforts. The Eveleth 583 ST RAPHAELS HEALTH & REHAB CTR x NEGLECT-FAILURE TO DO CPR PATIENT RIGHTS 11/17/2016 07/14/2017 resident died. x St. Louis It is alleged that a resident was neglected when the resident developped symptoms of a urinary tract infection, including fever, increased confusion and pain for several days. The resident was eventually hospitalized and diagnosed with UTI, sepsis, kidney infection and pneumonia. The resident died a few weeks Eveleth 583 ST RAPHAELS HEALTH & REHAB CTR x NEGLECT OF HEALTH CARE 8/29-30/2016 5/4/2017 laters. x St. Louis It is alleged that a resident was neglected due to staff not transferring the resident according to his/her care plan causing the resident to have pain and bruising. The resident has become dehydrated due to staff not properly assisting the resident with eating. Staff has not provided adequate personal care for up to two Eveleth 583 ST RAPHAELS HEALTH & REHAB CTR x NEGLECT-HEALTH CARE STAFFING SHORTAGE 4/29/2015 1/29/2016 weeks. x St. Louis It is alleged that a resident was neglected when his/her perineal area was covered with infected sores and the skin was excoriated. In addition, staff failed to assess the resident for a change in condition when the resident had a temperature of 104 degrees Fahrenheit. The resident received inadquate personal cares when Eveleth 583 ST RAPHAELS HEALTH & REHAB CTR x NEGLECT OF HEALTH CARE DECUBITI 7/22-23/2015 7/24/2015 s/he had feces on his/her bottom. x St. Louis It is alleged that a resident was neglected when the facility did not adequately reposition the resident. The Eveleth 588 FITZGERALD NH AND REHAB x NEGLECT-DECUBITI 11/7/2017 12/14/2017 resident developed a Stage 3 pressure ulcer. x St. Louis It is alleged that a resident was abused when the alleged perpetrator (AP) yelled at the client and withheld Eveleth 588 FITZGERALD NH AND REHAB x EMOTIONAL ABUSE BY STAFF 1/9/2018 02/12/2018 items/money from the resident. x St. Louis

It is alleged that the clients are being neglected because the facility does not have adequate staffing to Eveleth 3739 NEW JOURNEY RESIDENCE NEGLECT-HEALTH CARE 7.24.2015 12/24/2015 provide adequate supervision, personal cares, and medication administration to the clients. x St. Louis It is alleged that clients are being neglected because the facility does not have adequate staffing to provide Eveleth 3739 New Journey Residence NEGLECT-HEALTH CARE 12/24/2015 12/24/2015 supervision, personal cares, and medication administration to the clients. x St. Louis

It is alleged that a resident was neglected when staff failed to update the resident's care plan to reduce fall risk after the resident had several falls in one week. In addition, staff failed to assess the resident after a fall Eveleth 3739 NEW JOURNEY RESIDENCE/Salmi Homes Inc. NEGLECT-FALLS, HEALTH CARE 5/19-20/2015 10/12/2015 when the resident suffered several injuries and was not sent to the hospital until the next day. x St. Louis It is alleged that as resident was abused when the alleged perpetrator threatened to confine resident to their Eveleth 583 St Raphaels Health & Rehab Ctr x ABUSE-EMOTIONAL-STAFF 10/16/2017 3/5/2018 room and was verbally abusive. x St. Louis It is alleged that a resident was abused when the alleged perpetrator threatened to confine resident to their Eveleth 583 ST RAPHAELS HEALTH & REHAB CTR x ABUSE-EMOTIONAL-STAFF 10/16/2017 3/5/2018 room and was verbally abusive. x St. Louis It is alleged that a resident was abused when a staff/alleged perpetrator (AP) inappropriately touched Eveleth 583 ST RAPHAELS HEALTH & REHAB CTR x ABUSE-SEXUAL 5/2/2017 11/6/2017 resident's private area. Resident denied any penetration. x St. Louis

Fairbault 25820 Milestone Senior Living X NEGLECT-HEALTH CARE 4/4/2016 4/4/2016 Client lost 25 pounds in 2 months. Hospitalized found to be extremely dehydrated. Died 3 days later. X Rice

Fairbault 571 St Lucas Care Center X FAILURE TO DO CPR NEGLECT OF HEALTH CARE 7/17/2017 2/9/2018 Facility staff failed to provide CPR and client died. X Rice

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 31 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County

It is alleged that a resident was neglected when facility failed to provide appropriate nursing care and failed to notify physician when the resident was found in critical condition, altered mental status, and severely NEGLECT-HEALTH CARE NEGLECT-FAILURE TO dehydrated. The resident was taken to the hospital by his/her family members and was diagnosed with Fairmont 360 Lakeview Methodist HCC x REPOR 12/22/2016 5/12/2017 acute renal failure, urinary tract infection and hypernatremia. x Martin It is alleged that a resident was neglected when staff failed to provide supervision resulting in the resident wandering outside of the facility and being outside for 45 min - 1 hour. Resident had a fall and frostbite on Fairmont 360 Lakeview Methodist HCC x NEGLECT-HEALTH CARE, SUPERVISION 4/4/2017 5/5/2017 legs and fingers. Resident was evaluated in ER. x Martin It is alleged that there are inadequate safety interventions resulting in the ez-stand tipping and a resident fell Fairmont 360 Lakeview Methodist HCC x NEGLECT-HEALTH CARE 4/6/2016 9/9/2016 and sustained an injury. x Martin FALLS DUE TO EQUIP FAILURE, INAPPROPRIATE It is alleged that a resident was neglected when s/he was being transferred in the ez-stand lift and the lift Fairmont 360 Lakeview Methodist HCC x USE OF EQUIPMENT 4/6/2016 9/9/2016 tipped over resulting in the resident sustaining a hip fracture. x Martin NEGLECT-SUPERVISION PHYSICAL PLANT- It is alleged that the resident sustained a burn to the left foot when the resident's foot was leaning against Fairmont 359 Mayo Clinic Health Sys Fairmnt x MAINTENANCE PROBLEMS 12/13/2016 3/13/2017 the baseboard heater. x MARTIN It is alleged that a client was abused when a staff physically assaulted the client. The client has injuries on Fairmont 1205 REM Heartland Inc. A ABUSE-PHYSICAL-STAFF 6/2/2016 10/18/2016 h/her toes. x Martin It is alleged that multiple clients were financally exploited when the alleged perpetrator (AP) stole Fairmont 23692 Vista Prairie at Goldfinch Es x ABUSE-EXPLOITATION-DRUG DIVERSION 04/17,18/2017 11/20/2017 medications from the clients. x Martin It is alleged that multiple clients were financally exploited when the alleged perpetrator (AP) stole Fairmont 23692 Vista Prairie at Goldfinch Es x ABUSE-EXPLOITATION-DRUG DIVERSION 04/17,18/2017 11/20/2017 medications from the clients. x Martin It is alleged that multiple clients were financally exploited when the alleged perpetrator (AP) stole Fairmont 23692 Vista Prairie at Goldfinch Es x ABUSE-EXPLOITATION-DRUG DIVERSION 04/17,18/2017 11/20/2017 medications from the clients. x Martin It is alleged that multiple clients were financally exploited when the alleged perpetrator (AP) stole Fairmont 23692 Vista Prairie at Goldfinch Es x ABUSE-EXPLOITATION-DRUG DIVERSION 04/17,18/2017 11/20/2017 medications from the clients. x Martin It is alleged that multiple clients were financally exploited when the alleged perpetrator (AP) stole Fairmont 23692 Vista Prairie at Goldfinch Es x ABUSE-EXPLOITATION-DRUG DIVERSION 04/17,18/2017 11/20/2017 medications from the clients. x Martin It is alleged that multiple clients were financally exploited when the alleged perpetrator (AP) stole Fairmont 23692 Vista Prairie at Goldfinch Es x ABUSE-EXPLOITATION-DRUG DIVERSION 04/17,18/2017 11/20/2017 medications from the clients. x Martin It is alleged that multiple clients were financally exploited when the alleged perpetrator (AP) stole Fairmont 23692 Vista Prairie at Goldfinch Es x ABUSE-EXPLOITATION-DRUG DIVERSION 04/17,18/2017 11/20/2017 medications from the clients. x Martin It is alleged that multiple clients were financally exploited when the alleged perpetrator (AP) stole Fairmont 23692 Vista Prairie at Goldfinch Est x ABUSE-EXPLOITATION-DRUG DIVERSION 04/17,18/2017 11/20/2017 medications from the clients. x Martin ABUSE-EXPLOITATION-DRUG DIVERSION It is alleged that two clients were financially exploited when the alleged perpetrator took a bottle of FARIBAULT 20398 BROOKDALE FARIBAULT X PATIENT RIGHTS 3/20/2017 4/17/2017 morphine and 2 oxycodone tablets from clients. X Rice PHYSICAL ABUSE BY STAFF AND EMOTIONAL It is alleged that a resident was abused when the alleged perpetrators hid behind a door, jumped out and FARIBAULT 989 FARIBAULT CARE CENTER X ABUSE BY STAFF 6/2/2015 9/8/2015 threw ice at the resident. x Rice It is alleged that a resident was neglected when s/he fell, sustained injuries and needed to be taken to the FARIBAULT 989 FARIBAULT CARE CENTER X NEGLECT OF HEALTH CARE-FALLS 6/2/2015 8/4/2015 emergency room. x Rice It is alleged that two clients were neglected when the facility staff failed to provide adequate supervision. FARIBAULT 27967 FARIBAULT SENIOR LIVING X NEGLECT-SUPERVISION 12/4/2015 3/14/2016 Both clients were partially nude. X Rice

It is alleged that a client was neglected when staff failed to provide adequate supervision while s/he was FARIBAULT 22372 GUEST HOUSE OF FARIBAULT LLC X NEGLECT-SUPERVISION 2/8/2016 2/19/2016 showering. The client suffered a seizure and hit the hot water button, suffering second degree burns. X Rice

FARIBAULT 568 PLEASANT MANOR INC X ABUSE-SEXUAL 5/10/2017 9/11/2017 It is alleged that a resident was abused when the alleged perpetrator sexually assaulted the resident. X Rice

FARIBAULT 568 PLEASANT MANOR INC X ABUSE-SEXUAL 5/10/2017 9/11/2017 It is alleged that a resident was abused when the alleged perpetrator sexually assaulted the resident. X Rice

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 32 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County It is alleged that a resident was neglected when the faculty failed to respond to the resident's change in condition when the resident tested positive for a UTI. The facility transferred the resident to the hospital in FARIBAULT 568 PLEASANT MANOR INC X NEGLECT-HEALTH CARE 2/9/2017 5/30/2017 septic shock. X Rice

FARIBAULT 20152 RISON HOMES INC X ABUSE-SEXUAL 1/20/2017 8/2/2017 It is alleged that neglect of supervision occurred when one client inappropriately touched another. X Rice

FARIBAULT 20152 RISON HOMES INC X ABUSE-SEXUAL 1/20/2017 8/2/2017 It is alleged that neglect of supervision occurred when one client inappropriately touched another. X Rice It is alleged that neglect occurred when a resident did not receive medications, resulting in a blood clot and FARIBAULT 571 ST LUCAS CARE CENTER X NEGLECT OF HEALTH CARE 2/16/2017 8/10/2017 high glucose levels. X Rice

It is alleged that multiple (four) clients were financially exploited when an alleged perpetrator took credit FARMINGTON 21782 FARMINGTON HEALTH SERVICES X EXPLOITATION BY OTHER 12/19/2016 2/28/2017 cards, cash and a checkbook from clients. The alleged perpetrator was caught on a hidden camera and fired. X Dakota NEGLECT-FALLS DUE TO EQUIP FAILURE. FARMINGTON 101 TRINITY CARE CENTER X INAPPROPRIATE USE OF EQUIPMENT 6/9/2016 9/20/2016 It is alleged that a resident was neglected when he/she fell to the ground from a lift. X Dakota 02/28/2017 NEGLECT-FALLS DUE TO EQUIP FAILURE. and Fergus Falls 862 Broen Memorial Home x INAPPROPRIATE USE OF EQUIPMENT 03/01/2017 4/21/2017 It is alleged that a resident was neglected when the resident slid out of an EZ stand transfer onto the floor. x Otter Tail

NEGLECT OF HEALTH CARE NEGLECT OF It is alleged that a resident was neglected when the alleged perpetrator (AP) failed to follow the resident's Fergus Falls 862 Broen Memorial Home x HEALTH CARE-FALLS 3/22/2016 4/21/2016 care plan. The resident was transferred without a gait belt and had a fall with injuries. x Otter Tail It is alleged that a resident was neglected when staff failed to provide adequate catheter care. The resident was transported to the emergency room where it was noted s/he had a bladder infection resistant to oral antibiotics, required an antibiotic irrigation for ten days, and was at risk for sepsis. In addition, mold was Fergus Falls 862 Broen Memorial Home x NEGLECT-HEALTH CARE 1/26/2015 9/28/2015 found in the resident's feeding tube. x Otter Tail

It is alleged that a resident was neglected when the alleged perpetrator (AP) did not follow the resident's Fergus Falls 862 Broen Memorial Home x NEGLECT-HEALTH CARE NEGLECT-FALLS 5/19/2016 4/11/2017 care plan and unsafely transferred the resident resulting in a fall. The resident sustained a head hematoma. x Otter Tail It is alleged that a client was neglected when s/he had a fall with several injuries, including broken ribs. The client was hospitalized and upon return to the facility, s/he has fallen two times within a few days, with a Fergus Falls 21591 Lutheran Brethren Home Care x NEGLECT-FALLS 12/2/2015 2/5/2016 suspected broken wrist. x Otter Tail It is alleged that a client was neglected when staff failed to provide adequate personal cares. The client sits in Fergus Falls 21591 Lutheran Brethren Home Care x NEGLECT OF HEALTH CARE 4/16/2015 8/19/2015 urine soaked briefs and developed skin breakdown as a result. x Otter Tail It is alleged that a client was neglected when staff did not provide adequate catheter care and the client was Fergus Falls 531 MN Veterans Home Fergus Falls x NEGLECT-HEALTH CARE 4/21/2016 6/15/2017 hospitalized. The client is hospitalized with a urinary tract infection. x Otter Tail

02/27/2017 It is alleged that a resident was neglected when staff/alleged perpetrator (AP) did not follow the resident's and plan of care. The AP assisted the resident to walk without the use of a gait belt. The resident fell. The facility Fergus Falls 531 MN Veterans Home Fergus Falls x NEGLECT-FALLS NURSING CARE 02/28/2017 6/10/2017 transferred the resident to the hospital where it determined the resident sustained a hip fracture. x Otter Tail It is alleged that staff neglected a resident when staff failed to provide supervision to the resident during the Fergus Falls 443 Pioneer Care Center x NEGLECT-HEALTH CARE NURSING CARE 1/31/2017 5/1/2017 night shift. x Otter Tail 08/15/2016 TOUCHING/FONDLING BY STAFF NURSING and It is alleged that a resident was abused when the alleged perpetrator (AP) had a sexual relationship with the Fergus Falls 443 Pioneer Care Center x CARE 08/16/2016 8/30/2016 resident. x Otter Tail It is alleged that a resident was neglected when alleged perpetrator (AP)-1 and AP2 did not follow the Fergus Falls 443 Pioneer Care Center x NEGLECT OF HEALTH CARE-FALLS 9/29/2014 3/26/2015 resident's care plan resulting in a fall with injuries. x Otter Tail It is alleged that neglect occurred when a resident was found with significant injuries of unknown origin Fertile 460 Fair Meadow Nursing Home x NEGLECT-UNEXPLAINED INJURY 11/7/2017 3/7/2018 consistent with a fall. However, the facility staff deny the resident fell. x Polk

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 33 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County It is alleged that neglect occurred when a resident was found with significant injuries of unknown origin Fertile 460 Fair Meadow Nursing Home x NEGLECT-UNEXPLAINED INJURY 11/7/2017 3/7/2018 consistent with a fall. However, the facility staff deny the resident fell. x Polk It is alleged that a resident was abused when staff, alleged perpetrator was rough/fast during transfers. This Fertile 460 Fair Meadow Nursing Home x PHYSICAL ABUSE BY STAFF 8/10/2017 11/1/2017 resulted in a bruise to the VA's knuckle. x Polk It is alleged that a resident was abused when staff, alleged perpetrator was rough/fast during transfers. This Fertile 460 Fair Meadow Nursing Home x PHYSICAL ABUSE BY STAFF 8/10/2017 11/1/2017 resulted in a bruise to the VA's knuckle. x Polk It is alleged that a resident was neglected when Alleged Perpetrator (AP) failed to properly assess resident after a fall and resident was in pain for multiple hours before being sent to the emergency room. Resident Foley 27306 Cherrywood Advanced Living x NEGLECT-HEALTH CARE 4/6, 4/7/2015 6/24/2015 was found have broken ribs and acute fractures of the spine. x Benton It is alleged that a client was neglected when a staff, alleged perpetrator, did not follow the care plan when Foley 27306 Cherrywood Advanced Living x NEGLECT-HEALTH CARE 4/6, 4/7/2015 6/16/2015 turning the client and s/he fell out of bed. x Benton It is alleged that a client was neglected when staff failed to assess him/her and update his/her care plan when the client stopped eaten, subsequently the resident lost 15 pounds in 2 wks. It was brought to the Foley 629 Foley Nursing Center x ABUSE-PHYSICAL-STAFF 2/6/2015 7/31/2015 attention of the facility R.N. and no action x Benton It is alleged that a resident was exploited and neglected when the alleged perpetrator (AP) was caught on camera eating the resident's food. In addition, staff failed to provide adequate ADL's, are not feeding the ABUSE-EXPLOITATION-STAFF NEGLECT-HEALTH resident (the resident lost 20 pounds), staff are not changing the resident's clothes, not providing catheter Forest Lake 853 Birchwood Health Care Center x CARE, NUTRITION 4/7/2017 1/25/2018 care, or repositioning the resident. x Washington It is alleged that a resident was neglected when staff failed to provide adequate supervision and Forest Lake 853 Birchwood Health Care Center x NEGLECT - SUPERVISION 4/9/2015 2/18/2016 subsequently the resident was sexually mistreated by a visitor. x Washington

It is alleged that a resident was neglected when staff did not assist the resident to eat. Staff did not assist the Forest Lake 853 Birchwood Health Care Center x NEGLECT OF HEALTH CARE 4/7/2017 1/25/2018 resident to reposition for four to six hours. The resident had a 10 pound weight loss in five months. x Washington It is alleged that financial exploitation occurred when an employee, alleged perpetrator (AP), took narcotic Foreston 25867 Scandia Senior Care LLC x ABUSE-EXPLOITATION-DRUG-DIV 12/11/2017 3/9/2018 medications from a client. x Mille Lacs It is alleged that a client was neglected when staff failed to adequately supervise him/her when s/he left the Foreston 25867 Scandia Senior Care LLC x NEGLECT-SUPERVISION 10/12/2015 12/24/2015 facility and was found walking in a lane of traffic for at least 30 minutes. x Mille Lacs

It is alleged that a client was neglected when the client had second and third degree burns on the client's Fosston 23400 Cornerstone Residence x NEGLECT HEALTH CARE 5/16/2017 8/3/2017 inner thighs, and the client was not sent to the emergency department until the next morning. x Polk

It is alleged that a client was neglected when the client had second and third degree burns on the client's Fosston 23400 Cornerstone Residence x NEGLECT OF SUPERVISION 5/16/2017 8/3/2017 inner thighs, and the client was not sent to the emergency department until the next morning. x Polk

It is alleged that a client was neglected when the client had second and third degree burns on the client's Fosston 23400 Cornerstone Residence x NEGLECT HEALTH CARE 5/16/2017 8/3/2017 inner thighs, and the client was not sent to the emergency department until the next morning. x Polk

It is alleged that a client was neglected when the client had second and third degree burns on the client's Fosston 23400 Cornerstone Residence x NEGLECT OF SUPERVISION 5/16/2017 8/3/2017 inner thighs, and the client was not sent to the emergency department until the next morning. x Polk

It is alleged that a resident was neglected when s/he had a fall with multiple fractures. The resident was hospitalized and put on hospice. IN addition, the resident was found to have multiple fingertip like bruises on his/her inner thigh. Federal deficiencies and state licensing orders were issued in regards to the facility's Franklin 934 GOLDEN LIVINGCENTER FRANKLIN x NEGLECT-HEALTH CARE ABUSE-PHYSICAL 6/20/2016 9/16/2016 failure to report and investigate the resident's bruises that were found on the inner thighs x Renville It is alleged that resident #2 was neglected when facility staff failed to adequately supervise resident #1 Franklin 934 GOLDEN LIVINGCENTER FRANKLIN x ABUSE-SEXUAL NEGLECT-SUPERVISION 5/5/2016 9/13/2016 resulting in inappropriate touching to resident #2. x Renville

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 34 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County

Frazee 20154 FRAZEE ASSISTED LIVING HOME CA x ABUSE-EXPLOITATION-DRUG DIVERSION 1/16/2018 3/13/2018 It is alleged that an exploitation of drug diversion occurred when a client's narcotic medication went missing. x Becker It is alleged theta resident was neglected when the facility staff did not assist the resident with eating. The Frazee 730 Frazee Care Center x NEGLECT-HEALTH CARE 3/8/2017 7/31/17 resident lost weight. Staff left the resident on the toilet for two hours. x Becker NEGLECT OF HEALTH CARE-ENTRAPMENT It is alleged that a client was abused when staff/AP restrained the client in his/her room and blocked the Fridley 27980 FRIDLEY ASSISTED LIVING LLC x PATIENT RIGHTS 7/13/2017 11/9/2017 door. x Anoka

It is alleged that a client was neglected when staff failed to administer his/her seizure medications for four Fridley 27980 FRIDLEY ASSISTED LIVING LLC x NEGLECT-MEDICATIONS 6/30/2015 1/22/2016 days. The client was ultimately hospitalized due to seizures with tongue bites and oral cavity bleeding. x Anoka

It is alleged that a client was neglected when the client sustained an injury requiring stitches and was not assessed in a timely manner. These concerns have been brought to the facilities without resolve. It is alleged NEGLECT-FALLS, HEALTH CARE that a client was neglected when the resident has been found lying in bed and objects are pushed up against the bed, tables, wheelchairs, and lifts. The client is unable to reach the call light. These concerns have been Fridley 27980 Fridley Assisted Living LLC x 2/10/2015 7/16/2015 brought to the facility's attention without resolve. x Anoka

NEGLECT OF SUPERVISION-RESIDENT TO It is alleged that the resident was neglected when staff failed to provide adequate supervision that resulted Fridley 935 Golden Living Center Lynwood x RESIDENT 7/21/2017 3/5/2018 in resident #2 hitting Resident #1 with his walker resulting in a fractured wrist. x Anoka It is alleged that a resident was neglected when her pressure ulcers were not adequately cared for and the Fridley 935 Golden Living Center Lynwood x NEGLECT OF HEALTH CARE-DECUBITI 2/5/2016 3/18/2016 pressure ulcers increased in size. x Anoka

It is alleged that a resident was neglected when s/he fell six times in a ten day period resulting in cuts and NEGLECT-FALLS, HEALTH CARE ABUSE- bruises. The facility failed to adequately assess his/her fall risk and put interventions in place. The resident Fridley 935 Golden Living Center Lynwood x EMOTIONAL-STAFF 7/20/2015 12/10/2015 stated they were scared to be in the facility due to the poor care. x Anoka

It is alleged that the resident was neglected when staff failed to provide adequate supervision for the NEGLECT OF SUPERVISION resident during an off-site appointment. The transportation company did not return the resident to the facility. The facility failed to ensure the resident returned to the facility and failed to initiate the facilities Fridley 935 The Estates at Fridley LLC x 10/31/2017 1/22/2018 missing person policy after the resident never came back. x Anoka

NEGLECT OF SUPERVISION-RESIDENT TO It is alleged that the resident was neglected when staff failed to provide adequate supervision that resulted Fridley 935 The Estates At Fridley LLC x RESIDENT 7/21/2017 3/5/2018 in resident #2 hitting Resident #1 with his walker resulting in a fractured wrist. x Anoka It is alleged that a resident was neglected when her pressure ulcers were not adequately cared for and the Fridley 935 The Estates at Fridley LLC x NEGLECT OF HEALTH CARE-DECUBITI 2/5/2016 3/18/2016 pressure ulcers increased in size. x Anoka

It is alleged that a resident was neglected when s/he fell six times in a ten day period resulting in cuts and NEGLECT-FALLS, HEALTH CARE ABUSE- bruises. The facility failed to adequately assess his/her fall risk and put interventions in place. The resident Fridley 935 The Estates at Fridley LLC x EMOTIONAL-STAFF 7/20/2015 12/10/2015 stated they were scared to be in the facility due to the poor care. x Anoka It is alleged that a resident was financially exploited when the alleged perpetrator (AP) took more than 100 Fridley 935 The Estates At Fridley LLC x ABUSE-EXPLOITATION-STAFF 1/18/2017 6/26/2017 tablets of the residents narcotic medications. x Anoka It is alleged that a resident was abused when the alleged perpetrator (AP) was rough with the resident and Fulda 396 Maple Lawn Senior Care x ABUSE-PHYSICAL-STAFF 4/27/2016 8/9/2016 shoved his/her wrists down. x Murray

Fulda 23225 Maplewood Court Assisted Livin x ABUSE-EXPLOITATION-STAFF 11/7/2016 11/18/2016 It is alleged that a client was financially exploited when the alleged perpetrator (AP) took the client's money. x Murray It is alleged that the resident was neglected when facility staff did not provide adequate monitoring for Gaylord 619 Oak Terrace Health Care Center x DUMPING NURSING CARE LACK OF TRAINING 10/16/2017 3/12/2018 hypoglycemia resulting in a hospitalization and intubation. x Sibley

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 35 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County

It is alleged that a resident was neglected when the facility was unable to manage the resident's behaviors, Gaylord 619 Oak Terrace Health Care Center x NEGLECT OF SUPERVISION 10/16/2017 3/12/2018 causing the resident to become a danger to the resident, other residents, and staff. x Sibley It is alleged that a resident was neglected when staff failed to provide adequate supervision and the resident Gaylord 619 Oak Terrace Health Care Center x NEGLECT-SUPERVISION 3/7/2016 9/20/2016 left the facility and walked eight blocks away to a bar. x Sibley

It is alleged that a resident was neglected when staff failed to provide portable oxygen to the resident while being wheeled to the dining room and his/her face turned blue and s/he had purple lips due to lack of oxygen. Also, the resident had shortness of breath while toileting, became unconscious and fell, sustaining an injury. In addition, staff failed to assess and treat the resident for a change in condition when the resident Gaylord 619 Oak Terrace Health Care Center x NEGLECT-HEALTH CARE 5/4/2015 10/1/2015 gained 40 lb. in 3 weeks and had swollen legs and feet. x Sibley

It is alleged that a resident was neglected when staff failed to administer medications ordered by his/her Gaylord 619 Oak Terrace Health Care Center x NEGLECT-HEALTH CARE 3/30/2015 7/7/2015 physician and the resident became weak, developed high potassium and was hospitalized. x Sibley

It is alleged that a client was neglected when staff failed to administer medications ordered by his/her physician and the client became dehydrated and weak, developed high potassium and was hospitalized. In addition, it is alleged that the facility put the client on hospice without consulting the client's family or Gaylord 20214 Oak Terrace Senior Housing of Gaylord NEGLECT-HEALTH CARE PATIENT RIGHTS 3/6/2015 5/26/2015 physician and the client did not fully understand and did not agree with being on hospice. x Sibley It is alleged that a resident was neglected when facility staff failed to provide adequate medical care for Golden Valley 112 Brookview A Villa Center x Neglect-Health CARE 8/7/2017 1/10/2018 resident's PICC line. Resident was hospitalized for PICC line infection x Hennepin It is alleged that a resident was neglected when facility staff failed to provide adequate wound care and Golden Valley 112 Brookview A Villa Center x NEGLECT-HEALTH CARE 8/3/2017 1/24/2018 assessment resulting in maggots in resident's wound x Hennepin It is alleged that a resident was neglected when facility staff failed to provide proper personal care. The resident sits in urine for days, laundry not done, the resident's face is peeling, money and clothing missing Golden Valley 112 Brookview A Villa Center x Neglect-Healthcare 3/27/2017 9/22/2017 and the room is freezing at night. x Hennepin

it is alleged that a resident was neglected by unnamed staff/alleged perpetrator (AP) when it was discovered that the resident's call button was placed out of reach of the resident and the button taped down so that Golden Valley 112 Brookview A Villa Center x NEGLECT-HEALTH CARE 3/27/2017 9/22/2017 button did not work. Further review found tape residue on numerous other patients call buttons. x Hennepin it is alleged that a resident was neglected when the facility did not schedule a follow-up appointment with the infectious disease clinic and the resident then ran out of antibiotics. The facility transferred the resident Golden Valley 112 Brookview A Villa Center x Neglect-Health Care, medication errors 2/27/2017 9/13/2017 to the hospital. The resident did not return to the facility x Hennepin it is alleged that a resident was abused and neglected when a staff failed to provide proper wound care and a Neglect-Health Care Abuse-Physical-Staff wound vacuum was not applied to the resident's wound for one and half weeks. Staff failed to answer the Golden Valley 112 Brookview A Villa Center x Nursing Care 2/24/2017 9/13/2017 resident's x Hennepin it is alleged that a resident was neglected when facility staff failed to provide proper wound care, medication administration, and adequate bathing. It is also alleged that facility failed to provide adequate heating for Golden Valley 112 Brookview A Villa Center x Neglect-Health Care 5/25/2017 8/17/2017 resident's room x Hennepin

it is alleged that a resident was neglected when facility staff failed to provide adequate wound care after Golden Valley 112 Brookview A Villa Center x Neglect-Decubiti 5/25/2017 8/16/2017 surgery. The resident also developed another sore to buttock which had green exudate x Hennepin

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 36 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County

it is alleged that unnamed residents are neglected by unnamed staff/alleged perpetrators (AP) when emergency response staff responded to a resident's call to 911 to request routine assistance because there were no nursing staff on duty to assist. EMT technicians were unable to locate anyone on the floor Neglect-Health Care Nursing Care Staffing responsible for the residents and determined that at least four hour period passed where there were no Golden Valley 112 Brookview A Villa Center x Shortage 5/25/2017 8/15/2017 trained personnel responsible for the seven residents on the 4th floor. x Hennepin

it is alleged that a resident was neglected when the facility staff failed to change his/her wound vacuum and Golden Valley 112 Brookview A Villa Center x Neglect-Health Care Nursing Care 11/15/2016 5/10/2017 did not apply the wound dressings correctly. As a result, the resident's wounds did not get any smaller. x Hennepin it is alleged that resident #1 was not provided adequate supervision when resident #2 touched him/her Golden Valley 112 Brookview A Villa Center x Neglect-Supervision-Resident to Resident 2/10/2017 5/10/2017 inappropriately x Hennepin

it is alleged that resident was neglected when staff did not suction the resident appropriately or timely. The Golden Valley 112 Brookview A Villa Center x Neglect Health Care 2/10/2017 5/10/2017 resident went into cardiac arrest, the alleged perpetrator did not initiate cardiopulmonary resuscitation x Hennepin it is alleged that a resident was neglected when facility staff failed to provide adequate supervision between hi/her and two other residents. The resident is fearful of sleeping, being alone, and afraid to leave his/her Golden Valley 112 Brookview A Villa Center x Neglect-Supervision 1/3/2017 2/16/2017 room. x Hennepin

it is alleged that a resident was neglected when facility staff failed to provide adequate supervision resulting Golden Valley 112 Brookview A Villa Center x Neglect-Supervision-Resident to Resident 1/11/2016 11/30/2016 in the resident's roommate attacking him/her. The resident was admitted to a hospital with a brain bleed. x Hennepin It is alleged that a resident was neglected when s/he was found to have a maggot infestation in his/her Golden Valley 112 Brookview A Villa Center x Neglect Health Care 7/12/2016 10/7/2016 wounds and the resident was hospitalized. x Hennepin

Golden Valley 112 Brookview A Villa Center x Neglect-Decubiti 3/29/2016 6/20/2016 It is alleged that residents were neglected when the residents developed pressure sores and open areas x Hennepin It is alleged that a resident was neglected when the resident developed rashes and sores all over his/her body. Also, it is alleged that the facility neglected to provide the resident with adequate personal cares and Golden Valley 112 Brookview A Villa Center x Neglect Health Care 3/29/2016 6/20/2016 did not assist the resident to shower for several weeks in a row. x Hennepin

It is alleged that a resident was neglected when his wound care was not being completed properly. The facility was not following the physician's order to use a wound vacuum, and instead was using a different Golden Valley 112 Brookview A Villa Center x Neglect Health Care 12/21/2015 3/16/2016 type of dressing. The resident was hospitalized with an infection in his wound. x Hennepin it is alleged that a resident was neglected when staff failed to properly monitor the resident's oxygen and feeding tube. The resident was on continuous 24 hour feeding and continuous oxygen and s/he went over four hours without feeding and oxygen. The resident's oxygen levels dropped below 70. The resident was Golden Valley 112 Brookview A Villa Center x Neglect Health Care 8/25/2015 1/4/2016 hospitalized four days and later passed away. x Hennepin

it is alleged that resident was neglected when he/she had long call light waits to assist with cares. On one Golden Valley 112 Brookview A Villa Center x Neglect Health Care 8/20/2015 10/28/2015 occasion, the resident sat in feces for 11 hours. The facility was aware of concerns, yet no action was taken. x Hennepin It is alleged that a resident was neglected when facility staff found the resident unresponsive and failed to Golden Valley 183 Colonial Acres Health Care Center x NEGLECT-FAILURE TO DO CPR 11/13/2017 2/21/2018 initiate CPR as directed by physician's orders. x Hennepin

It is alleged that a resident was neglected when s/he became unresponsive requiring emergency medical Golden Valley 112 Golden Valley Rehab and CC x Medication Errors Medication Error 8/18/2017 10/9/2017 care due to having a high level of Clozaril in his system. Resident was not prescribed the medication, Clozaril. x Hennepin

It is alleged that a resident was neglected when s/he became unresponsive requiring emergency medical Golden Valley 112 Golden Valley Rehab and CC x Medication Errors Medication Error 8/18/2017 10/9/2017 care due to having a high level of Clozaril in his system. Resident was not prescribed the medication, Clozaril. x Hennepin

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 37 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County

It is alleged that a resident was neglected when an unknown staff failed to follow appropriate tracheotomy Neglect-Health Care, Failure to Notify Physician and feeding tube instruction resulting in the resident found having trouble breathing, declined condition, Golden Valley 112 Golden Valley Rehab and CC x Abuse-Physical 3/27/2018 10/3/2017 EMS was called to transfer the resident to the hospital . When EMS arrived x Hennepin It is alleged that a resident was abused/neglected causing a large bump and bruise on VA's head and several Golden Valley 112 Golden Valley Rehab and CC x Neglect of Health Care Physical Abuse by Staff 3/27/2017 10/3/2017 bruises and lacerations were found on VA's body x Hennepin

It is alleged that client #1 was financially exploited when alleged perpetrator (AP) took several pieces of the clients' jewelry valued over $3,000.00 and sold it at a pawn shop. In addition, client #2 was financially Golden Valley 20177 Heritage House Assisted Living x ABUSE-EXPLOITATION-STAFF 12/14/2017 3/14/2018 exploited when AP went into client #2's jewelry box and stole jewelry. x Hennepin It is alleged that the client was financially exploited when a staff (AP) used the client's money for his/her HOME HEALTH CARE INC Golden Valley 3337 EXPLOITATION BY STAFF 10/30/2015 2/1/2016 personal use. x Hennepin

It is alleged that a client was neglected when facility staff failed to provide adequate supervision when the client service plan stated the client should have hourly checks. It is alleged that the facility was not Golden Valley 31955 Maple Hill Senior Living x NEGLECT OF HEALTH CARE-FALLS 8/22/2017 2/13/2018 completing hourly checks on client per service plan. The client fell in her room resulting in a femur fracture. x Hennepin It is alleged that abuse occurred, when an employee, the alleged perpetrator (AP) was rough with the client, Golden Valley 26206 Legacy Home Health Care x PHYSICAL ABUSE BY STAFF 11/1/2017 2/14/2018 resulting in bruises. x Hennepin

It is alleged that a client was verbally abused by staff, when the alleged perpetrator yelled at the client in Golden Valley 26206 Legacy Home Health Care x EMOTIONAL ABUSE BY STAFF 3/28/2017 5/10/2017 his/her apartment. It is also alleged that the client is afraid of the alleged perpetrator. x Hennepin It is alleged that a client was physically abused by the alleged perpetrator when the AP pushed the client ABUSE-PHYSICAL PATIENT RIGHTS Golden Valley 26206 Legacy Home Health Care x 3/28/2017 5/2/2017 away from the sink. x Hennepin It is alleged that a client was abused when the alleged perpetrator (AP) spoke to the client in a threatening 12/20/2017 Golden Valley 23981 SUNRISE OF GOLDEN VALLEY x EMOTIONAL ABUSE BY STAFF 10/30/2017 manner that made the client fearful. x Hennepin It is alleged that a client was financially exploited when the staff/alleged perpetrator stole the client's bank card for personal use. AP had not been showing up for work since the theft of the card. Total amount on the Golden Valley 26505 SYNERGY HOMECARE MINNEAPOLIS x ABUSE - EXPLOITATION OTHER 7/17/2017 8/15/2017 card was approx. $830.00 x Hennepin It is alleged that a resident was neglected when the facility failed to develop an adequate care plan for GRAND MARAIS 80 COOK CO NORTHSHORE HOSP &C CTR X NEGLECT HEALTH CARE-FALLS 4/12/2016 12/8/2016 transfers/ambulation, resulting in a fall, facial wounds and a skin tear X Cook NEGLECT-FALLS DUE TO EQUIP FAILURE, INAPPROPRIATE USE OF EQUIPMENT NURSING It is alleged that a resident was neglected when the alleged perpetrator transferred the resident using a GRAND MARAIS 80 NORTH SHORE HEALTH X CARE 2/28/2017 2/28/2017 standing lift. The resident sustained a fractured arm. X Cook It is alleged that a client was neglected when s/he had a change in condition, including abdominal pain and change in mental status. The client was hospitalized with severe dehydration and acute kidney failure. In addition, the resident's personal cares were neglected, as she had a foul smell and the beginning of a Grand Meadow 390 Meadow Manor x NEGLECT-HEALTH CARE 11/23/2015 2/21/2017 pressure ulcer on his/her sacrum. x Mower It is alleged that a resident was neglected when s/he fell during a transfer with a standing lift. Three days later, the resident complained of pain and was sent to the ED where s/he was found to have a fractured Grand Meadow 390 Meadow Manor x NEGLECT-FALLS 8/22,23/2016 2/21/2017 elbow. x Mower

It is alleged that a client was neglected when staff failed to monitor and provide adequate care for his/her Grand Meadow 390 Meadow Manor x NEGLECT-HEALTH CARE 10/29/2015 8/23/2016 wound. The resident's wound went from a stage two to an unstageable ulcer in less than one month. x Mower

It is alleged that a resident was sexually abused by the alleged perpetrator (unknown) while residing at the Grand Meadow 390 Meadow Manor x SEXUAL ABUSE 4/2/2015 10/15/2015 facility. The resident was hospitalized and per the physician had genital lesions of recent genital contact. x Mower

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 38 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County It is alleged that a resident was neglected when a staff, alleged perpetrator (AP) failed to initiate emergency services according to the facility's policy for full code resident when the resident was found not breathing Grand Meadow 390 Meadow Manor x NEGLECT-FAILURE TO DO CPR 1/5/2015 3/26/2015 and had without a pulse. x Mower It is alleged that a resident was financially exploited when an unknown alleged perpetrator switched the resident's morphinen sulfate with mouthwash. Another bottle of morphine sulfate was emptied and filled Grand Meadow 390 Meadow Manor x EXPLOITATION BY DRUG DIVERSION 3/29/2017 7/13/2017 with mouthwash. x Mower It is alleged that a resident was neglected when the alleged perpetrator (AP) transferred the resident in a manner not in accordance with the care plan, which resulted in the resident's left knee being displaced, and Grand Rapids 299 Evergreen Terrace x NEGLECT-HEALTH CARE 9/11/2014 4/3/2015 a fractured femur. x Itasca NEGLECT-SUPERVISION-RESIDENT TO It is alleged that a resident was neglected when facility staff provided inadequate supervision. Resident #2 Grand Rapids 299 Evergreen Terrace x RESIDENT 11/20/2017 3/5/2018 inappropriately touched Resident #1. x Itasca It is alleged that a resident was neglected when facility staff failed to provide adequate personal cares when the resident was care planned to assist to the toilet. It is alleged that the resident slipped in urine sustaining Grand Rapids 299 Evergreen Terrace x NEGLECT-HEALTH CARE, SUPERVISION 7/17/2017 12/12/2017 a fall that caused a fracture. x Itasca

01/31/2017 It is alleged that a resident was neglected when the resident became so constipated that the facility and transferred the resident to the hospital. The resident died at the hospital. The facility did not notify the Grand Rapids 299 Evergreen Terrace x NEGLECT-HEALTH CARE NURSING CARE 02/01/2017 9/25/2017 primary responsible party of the resident's change in condition or need for hospitalization. x Itasca 05/15/2016 It is alleged that a resident was neglected when facility staff failed to ensure physician orders were and transcribed correctly. The resident was not provided with evening insulin for over two weeks and Grand Rapids 299 Evergreen Terrace x NEGLECT-MEDICATIONS 05/16/2016 9/13/2016 experienced neuropathy pain along with elevated blood sugars. x Itasca 08/13/2015 and It is alleged that neglect occurred when a resident developed pressure ulcers from not being repositioned Grand Rapids 299 Evergreen Terrace x NURSING CARE 08/14/2015 12/21/2015 every two hours. In addition, the resident's hygiene tasks were not completed. x Itasca

It is alleged that a resident was neglected when staff failed to provide wound care for his/her ulcers for four 05/07/2015 months and subsequently the wound progressed to the resident's bones. The facility was aware of these and issues and held a care conference for wound care, but did not follow the care plan. In addition, the resident Grand Rapids 299 Evergreen Terrace x NEGLECT-HEALTH CARE 05/08/2015 10/23/2015 was often left unattended in the bathroom for over an hour with no assistance. x Itasca

It is alleged that a resident was neglected when s/he did not receive medication as scheduled for five hours and did not receive urgent medication injection as ordered by the physician. Licensed staff at the facility NEGLECT OF HEALTH CARE STAFFING refused to assess the resident's condition when asked by hospice to do so. It is also alleged that the facility is Grand Rapids 299 Evergreen Terrace x SHORTAGE 3/4/2015 8/26/2015 short staffed and resident's family members were answering other resident's call lights. x Itasca It is alleged that a resident was abused when the alleged perpetrator (AP) attempted to touch him/her inappropriately. The facility did re-assign the AP, but s/he continues to enter the resident's room causing the Grand Rapids 299 Evergreen Terrace x ABUSE-SEXUAL 8/5/2016 10/9/2017 resident emotional distress. x Itasca

It is alleged that the client was abused when the AP forced a client to take medications against his/her will by straddling him/her, holding his/her head and forcing medication by hand into his/her mouth. The client became agitated and bit the AP. In addition it is alleged the facility neglected the same client when the client experienced two major fall incidents with head injury and the staff failed to re-assess the client. The client Grand Rapids 24912 Garden Court Chateau x ABUSE-PHYSICAL-STAFF NEGLECT-FALLS 4/7/2017 9/25/2017 died eight days after the second serious fall due to a closed head injury. x Itasca It is alleged that a client has been abused when a staff, alleged perpetrators (AP) #1 and AP #2 are verbally abusive to the client. In addition, the client refuses evening meals and medications because s/he feels Grand Rapids 24912 Garden Court Chateau x EMOTIONAL ABUSE BY STAFF 9/14/2015 10/15/2015 intimidated by these staff. x Itasca

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 39 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County It is alleged that a client was abused when staff/alleged perpetrator (AP) made sexual remarks to the client. ABUSE-EMOTIONAL-STAFF ABUSE-SEXUAL The AP offered the client her drink and invited the client to the AP's home to get drunk. The client was afraid NEGLECT-HEALTH CARE PATIENT RIGHTS of the AP. It is alleged that the client was neglected when the AP slept while on duty and did not answer call Grand Rapids 24912 Garden Court Chateau x NURSING CARE 4/7/2017 9/25/2017 lights. x Itasca

It is alleged that a resident was neglected when the facility left the resident unattended in the bathroom. The resident fell. The facility transferred the resident to the emergency department where it was determined the Grand Rapids 298 Grand Village x NEGLECT-HEALTH CARE, SUPERVISION 6/14/2017 11/21/2017 resident sustained multiple fractures and a head laceration. x Itasca 03/14/2017 It is alleged that a resident was neglected by unnamed staff/alleged perpetrator when it was discovered that NEGLECT-HEALTH CARE, DECUBITI NEGLECT- and he had developed one large stage 2/3 pressure ulcer that took up his whole bottom as well as eighteen open Grand Rapids 298 Grand Village x FAILURE TO REPORT NURSING CARE 03/15/2017 10/2/2017 sores/tears of at least 3/4" long. x Itasca It is alleged that a resident was neglected when the facility failed to provide necessary dressing changes, showering assistance, and fall precautions when providing rehabilitation to the resident after amputation of 12/27/2016 a leg. In addition, it is alleged the patient's rights were violated when the facility failed to provide and appropriate discharge planning, including evaluate the environment to which the resident would be Grand Rapids 298 Grand Village x NEGLECT OF HEALTH CARE PATIENT RIGHTS 12/28/2017 8/22/2017 discharged. x Itasca

12/27/2017 It is alleged that a resident was neglected when the facility did not evaluate the resident's home situation and and ensure safe mobility prior to discharge from the facility. As a result, the resident fell and the leg would Grand Rapids 298 Grand Village x NEGLECT-HEALTH CARE 12/28/2017 8/22/2017 stitches broke open. This caused pain and led to a wound infection. x Itasca 03/14/2017 It is alleged that a resident was neglected when the staff failed to provide appropriate care that resulted in and the resident vomiting and aspirating. Staff left the resident lay in bed. Resident passed away due to Grand Rapids 298 Grand Village x NEGLECT-HEALTH CARE, FAILURE TO REPORT 03/15/2017 7/6/2017 aspiration pneumonia with severe sepsis. x Itasca

10/25/2016 It is alleged that a resident was neglected when the staff failed to put the call light within the resident's and reach. The resident fell and sustained a head laceration. The facility transferred the resident to the Grand Rapids 298 Grand Village x NEGLECT-FALLS 10/26/2016 3/13/2017 emergency department where the resident was treated with sutures and a dressing to the wound. x Itasca 01/21/2016 and It is alleged that a resident was neglected when s/he was admitted to the hospital with sepsis, unstageable Grand Rapids 298 Grand Village x NEGLECT OF HEALTH CARE 01/22/2016 7/1/2016 and stage 3 ulcers and unknown bruising. x Itasca It is alleged that a Resident #1 was neglected when the facility did not adequately supervise the residents. NEGLECT OF SUPERVISION-RESIDENT TO Resident #2 told Resident #1 to get out of the way and pushed his/her walker into Resident #1. Resident #1 Grand Rapids 298 Grand Village x RESIDENT 3/3/2017 10/2/2017 fell and sustained right hip and knee fractures. x Itasca Is it alleged that a client was financially exploited when a staff, alleged perpetrator (AP) took 45 tablets of Grand Rapids 29046 Majestic Pines x ABUSE-EXPLOITATION-DRUG DIVERSION 6/26/2017 10/17/2017 hydrocodone from the client. x Itasca

It is alleged that a client was neglected when the staff gave him/her a foot soak and the temperature was Grand Rapids 3932 Recover Health NEGLECT-HEALTH CARE 9/11/2015 3/3/2016 too hot, resulting in the client receiving a burn on his/her food that may result in the foot being amputated. x Itasca It is alleged that a client was financially exploited when the AP took the client's personal belongings, Grand Rapids 32062 River Grand Senior Living x ABUSE-EXPLOITATION-STAFF 10/20/2016 4/20/2017 including a driver's license and medical insurance cards. x Itasca

It is alleged that a client was neglected after s/he had multiple falls due to urinary tract infections requiring emergency services. In addition, the staff failed to follow her/his personal cares per the care plan. The client Grand Rapids 26123 Vista Prairie at Manor House x NEGLECT-FALLS, HEALTH CARE 12/16/2015 3/2/2016 is currently hospitalized with sepsis and a femur fracture. x Itasca

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 40 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County

It is alleged that a client was neglected when s/he had a change in condition, including symptoms of labored breathing, bloated appearance, and increased pain. The licensee did not adequately assess that client and Grand Rapids 21725 Whispering Pines Assisted Living x NEGLECT-HEALTH CARE 11/9/2015 1/14/2016 s/he was later found unresponsive. The client was hospitalized. x Itasca It is alleged that a resident was neglected when staff failed to monitor the resident's condition after administering narcotic pain medications, daily laxatives, and after a change to the resident's diuretic medication dosage. The resident was found unresponsive and was hospitalized with dehydration and kidney Granite Falls 725 Municipal Hospital & Granite Manor x NEGLECT-HEALTH CARE 5/5/2015 11/18/2015 failure. x Yellow Medicine

Iit is alleged that a client was financially exploitedf by staff/alleged perpetrators (AP) when the client's Hackensack 28208 Birchview Gardens Assisted Living x ABUSE-EXPLOITATION BY STAFF 8/28/2017 12/13/2017 reloadable credit card was stolen by AP #2 and used by AP #1 to make cash withdrawals. x Cass Hastings 877 AUGUSTANA HCC OF HASTINGS X SEXUAL ABUSE 9/20/2016 9/27/2016 It is alleged that a resident was sexually assaulted. X Dakota

Hastings 1091 HENRY HAGEN RESIDENCE EMOTIONAL ABUSE BY STAFF 8/25/2015 12/15/2017 It is alleged a client was abused when staff screamed at the client and the client was refused dessert. X Dakota It is alleged a resident was neglected when the staff failed to provide supervision when the resident was Hastings 788 MN VETERANS HOME HASTINGS NEGLECT-SUPERVISION 7/14/2015 9/17/2015 found unresponsive and without a pulse. The resident died. X Dakota

HASTINGS 20006 REGINA ASSISTED LIVING X TOUCHING/FONDLING BY OTHER 10/16/2017 2/13/2018 It is alleged that a client was sexually abused by staff when the client was touched in the peri area. X Dakota NEGLECT-SUPERVISION-RESIDENT TO Hastings 20006 REGINA ASSISTED LIVING X RESIDENT 10/24/2016 2/22/2017 It is alleged that a client was neglected when another client entered the room, naked from the waist down. X Dakota Hastings 20006 REGINA ASSISTED LIVING X UNEXPLAINED INJURY 7/23/2015 8/17/2015 It is alleged a client was abused after being found with cruises and cuts, despite no falls. X Dakota PHYSICAL ABUSE BY STAFF It is alleged that a resident was physically and sexually abused when the alleged perpetrator (AP) hit the Hastings 100 Regina Senior Living x TOUCHING/FONDLING BY STAFF 3/10/2017 2/28/2018 resident in the face and pulled his/her legs apart. x Dakota It is alleged that a resident was neglected when staff failed to supervise and the resident wandered out of Hastings 100 REGINA SENIOR LIVING X NEGLECT OF SUPERVISION 5/2/2017 9/25/2017 the facility. X Dakota Hastings 100 REGINA SENIOR LIVING X TOUCHING/FONDLING BY STAFF 1/28/2016 10/27/2016 It is alleged that a resident was inappropriately touched by staff. X Dakota It is alleged that a resident was neglected when his/her foot was wrapped to tightly, resulting in an odor. The Hastings 100 REGINA SENIOR LIVING X NEGLECT-HEALTH CARE 7/8/2015 2/22/2016 infected foot required surgery. X Dakota HASTINGS 100 REGINA SENIOR LIVING X ABUSE-SEXUAL 1/28/2016 10/27/2016 It is alleged that a resident was inappropriately touched by an alleged perpetrator. X Dakota It is alleged that a client was neglected when staff failed to provide adequate supervision. The client was found lying face down on the ground, not properly dressed, with multiple injuries to his/her face requiring Hawley 28491 Hawley Retirement Inc x NEGLECT-SUPERVISION 8/12/2016 1/9/2017 surgery, x Clay

It is alleged that a resident was neglected when facility staff failed to follow the resident's care plan. The Hendricks 340 Hendricks Community Hospital x NEGLECT OF HEALTH CARE 2/17/2016 10/18/2016 resident was left on the bed pan for over six hours and sustained skin breakdown. x Lincoln It is alleged that a resident was abused when staff applied a restraint around the resident's chest and Henning 799 Golden LivingCenter Henning x ABUSE-RESTRAINTS 4/19/2017 5/15/2017 stomach while the resident sat in a wheelchair. x Otter Tail It is alleged that a resident was neglected when facility staff failed to provide interventions after the resident had a fall and was seen on the floor. In addition, staff failed to provide medications as ordered by the Henning 799 Golden LivingCenter Henning x NEGLECT-HEALTH CARE, FALLS 5/18/2016 5/11/2017 physician. x Otter Tail It I alleged that a resident was neglected when staff failed to monitor the resident's condition when s/he was not urinating for two days. In addition, staff failed to check on the resident during the overnight shift and the resident was found unresponsive with a high temperature in the morning. The resident was hospitalized in Henning 799 Golden LivingCenter Henning x NEGLECT-HEALTH CARE 4/6/2015 10/1/2015 the intensive care unit (ICU). x Otter Tail It is alleged that a resident was abused when staff applied a restraint around the resident's chest and Henning 799 Henning Rehab and Healthcare Center x ABUSE-RESTRAINTS 4/19/2017 5/15/2017 stomach while the resident sat in a wheelchair. x Otter Tail

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 41 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County It is alleged that a resident was neglected when facility staff failed to provide interventions after the resident had a fall and was seen on the floor. In addition, staff failed to provide medications as ordered by the Henning 799 Henning Rehab and Healthcare Center x NEGLECT-HEALTH CARE, FALLS 5/18/2016 5/11/2017 physician. x Otter Tail It I alleged that a resident was neglected when staff failed to monitor the resident's condition when s/he was not urinating for two days. In addition, staff failed to check on the resident during the overnight shift and the resident was found unresponsive with a high temperature in the morning. The resident was hospitalized in Henning 799 Henning Rehab and Healthcare Center x NEGLECT-HEALTH CARE 4/6/2015 10/1/2015 the intensive care unit (ICU). x Otter Tail It is alleged that a client was neglected when the home care provider failed to provide supervision resulting in the client falling and was wedged between a table and unknown object. The client passed away due to a Hermantown 20852 Edgewood Hermantown l Senior L x NEGLECT OF SUPERVISION 4/19.20/2017 12/29/2017 subdural hematoma. x St. Louis

It is alleged that a client was abused when staff forced the client into his/her wheelchair causing a toe injury and forcefully pulled the resident up with a transfer belt. Also, it is alleged the client's rights were violated Hermantown 20852 Edgewood Hermantown l Senior L x PHYSICAL ABUSE BY STAFF PATIENT RIGHTS 8/24.25/2016 1/20/2017 when staff made the client go to the dining area when s/he did not want to go. x St. Louis It is alleged that a client was financially exploited when the alleged perpetrator (AP) took the client's money Hermantown 20852 Edgewood Hermantown l Senior L x ABUSE-EXPLOITATION-STAFF 2/24/2016 4/26/2016 for his/her own personal use. x St. Louis

It is alleged that a client was neglected when staff failed to provide adequate assessment after s/he had a change in condition. The patient had three episodes of being unresponsive and a fever of 104.0. The client Hermantown 23771 SUPERIOR VIEW ASSISTED LIVING x NEGLECT OF HEALTH CARE 7/7/2016 8/3/2016 was admitted to the hospital for infection, unresponsiveness, high fever and low oxygen levels. x St. Louis It is alleged that a client was neglected when s/he was found unresponsive. The client was admitted to the hospital with dehydration, hypernatremia, sepsis, and a UTI. Also, it is alleged that the client was unkempt, Hermantown 23771 SUPERIOR VIEW ASSISTED LIVING x NEGLECT-HEALTH CARE 1/25-26/2016 4/15/2016 unshaven, and had poor oral hygiene. x St. Louis It is alleged that a client was abused when staff, alleged perpetrators (AP) tipped the client back in a chair PHYSICAL ABUSE BY STAFF NEGLECT OF and forced him/her to take medications. The client was struggling and did not want to take his/her Hermantown 23771 SUPERIOR VIEW ASSISTED LIVING x HEALTH CARE 11/13/2015 1/19/2016 medications. x St. Louis It is alleged that a client was neglected when he developed a high fever and sepsis. The client's catheter care was not adequate. Staff did not assess the client for a change in condition and the client became Hermantown 23771 SUPERIOR VIEW ASSISTED LIVING x NEGLECT-HEALTH CARE 3/2/2015 9/30/2015 unresponsive. x St. Louis

It is alleged that clients were abused when staff/alleged perpetrator (AP) called one client names and pushed him/her, causing the client to fall. It is also alleged the AP told three clients they had specific bed times and Hermantown 23771 SUPERIOR VIEW ASSISTED LIVING x ABUSE-PHYSICAL, EMOTIONAL 10/30/2015 1/4/2016 yelled at clients when they would try to come out of their rooms. x St. Louis

It is alleged that a client was neglected when s/he had a change in condition, which include low oxygen levels, pain and refusing medications, food and fluid for days. The VA died at the hospital a day later. In Hermantown 23771 SUPERIOR VIEW ASSISTED LIVING x NEGLECT-HEALTH CARE 10/1/2015 12/18/2015 addition, the client had an injury to the leg that the staff didn't know about. x St. Louis It is alleged that a client was abused when the alleged perpetrator struck the client and prevented the client Hibbing 20403 GREENVIEW NORTH x ABUSE-PHYSICAL-STAFF PATIENT RIGHTS 11/21-22/2016 3/2/2017 from leaving a room. x St. Louis It is alleged that a client was abused when the alleged perpetrator put his/her hands on the client's waist and Hibbing 20403 GREENVIEW NORTH x PHYSICAL ABUSE BY STAFF 11/21-22/2016 1/9/2017 pushed the client through an entryway. x St. Louis

It is alleged that a client was neglected when the facility failed to provide adequate supervision resulting in multiple falls, a concussion, and multiple fractures. The facility failed to transfer the client to the hospital for evaluation after his/her first two incidents. Finally, the client was transferred to the ER after the third Hibbing 20403 GREENVIEW NORTH x NEGLECT-HEALTH CARE,FALLS 11/21-22/2016 12/12/2016 incident. The client passed away due to complications of blunt force injuries. x St. Louis

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 42 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County It is alleged that a resident was neglected when s/he had a fall and staff alleged perpetrator picked the resident up and sat him/her in a chair when the resident's care plan stated he/she was bed bound due to a hip fracture and could only be inclined at 15-30 degrees. The resident was left in the chair for at least two hours. The facility did not notify hospice of the fall. Family brought these concerns to the facility and nothing Hibbing 858 GUARDIAN ANGELS HEALTH & REHAB x NEGLECT-HEALTH CARE 7/9-10/2015 10/01/2015 was done. x St. Louis Hibbing 858 Guardian Angels Health & Rehab x NEGLECT-FALLS 11/15/2107 3/5/2018 It is alleged that neglect occurred related to a resident's falls resulting in head injuries. x St. Louis

It is alleged that a resident was neglected when the staff failed to adequately perform personal cares and reposition the resident as needed. The resident was admitted to the hospital with open wounds, abrasions in his/her peri area and had non-blanchable areas on the spine and coccyx. The resident was hospitalized three Hibbing 858 GUARDIAN ANGELS HEALTH & REHAB x NEGLECT-HEALTH CARE 4/30/2015 9/2/2015 weeks ago and had a red coccyx with chafing at the time. x St. Louis It is alleged that the resident was neglected when facility staff did not provide adequate monitoring for Hibbing 858 Guardian Angels Health & Rehabilitation Centerx NEGLECT-HEALTH CARE 1/3/2018 3/13/2018 hypoglycemia resulting in a hospitalization and intubation. x St. Louis

It is alleged that six individuals who resided in the facility had controlled substances stolen from their Hibbing 1315 RANGE CENTER MAPLEVIEW HOME EXPLOITATION BY DRUG DIVERSION 3/13-14/2017 05/25/2017 medication supplies from staff/alleged perpetrator (AP). Individuals sustained no negative outcome. x St. Louis It is alleged that a patient was financially exploited when the alleged perpetrator (AP) took two checks from Hibbing 859 UNIVERSITY MEDICAL CTR MESABI PATIENT RIGHTS ABUSE-EXPLOITATION-STAFF 9/8/2016 2/28/2017 the patient's checkbook. x St. Louis It is alleged that client was financially exploited when the alleged perpetrator (AP) took two checks from the Hibbing 859 University Medical Ctr Mesabi PATIENT RIGHTS ABUSE-EXPLOITATION-STAFF 9/8/2016 2/3/2017 patient's checkbook. x St. Louis

It is alleged that a client was neglected when the facility falsified the client's medical records, including an incident where the progress note originally stated the client was feeling suicidal. The note was changed to read the client was having a good night. It is alleged the client was abused when the alleged perpetrator yelled at the client. It is alleged the staff members posted pictures of clients and information about the PATIENT RIGHTS EMOTIONAL ABUSE BY STAFF clients on social media and non-staff members had access to the posts. In addition, it is alleged the facility Hill City 21006 Chappy's Golden Shores x NEGLECT OF HEALTH CARE 10/20/2017 2/28/2018 administered one client's medications to another client. x Aitken It is alleged that a client was neglected when staff failed to provide adequate wound care to an amputee. Hill City 21006 Chappy's Golden Shores x NEGLECT-HEALTH CARE 12/1/2015 12/29/2015 The client was brought to the hospital for treatment of an ulcer on his/her back. x Aitken It is alleged that a client was sexually assaulted when the client was outside smoking and was attacked by an Holdingford 24162 Hyatt House x ABUSE-SEXUAL PATIENT RIGHTS 1/13/2017 8/15/2017 alleged perpetrator. The facility did not assess the client. x Stearns

The resident fell receiving assistance from AP. AP did not notify nursing staff so resident could be immediately assessed. AP denied the resident fell four times, before admitting resident did fall while in her care. Resident hit his/her head. Resulting in a bump 1.5 cm, an abrasion on bridge of the nose 1.0 cm. No Hopkins 727 Augustana Chapel View Care Center NEGLECT OF HEALTH CARE 2/13/2017 12/7/2017 hospitalization. AP no longer employed at the facility. X Hennepin Staff did not adequately assess or monitor the resident, resident was short of breath. Staff declined to transfer resident to the hospital at least 8 hours. Hospital determined the resident had suffered a heat Hopkins 727 Augustana Chapel View Care Center X NEGLECT-HEALTH CARE 2/14/2017 11/6/2017 attack. X Hennepin It is alleged that a client was abused when a staff, alleged perpetrator, hit the client in the back and on the Hopkins 24214 Gentle Health Initiative x ABUSE-PHYSICAL-STAFF 2/12/2016 2/12/2016 head. The AP also pulled the client's hair. x Hennepin It is alleged that a resident was neglected when facility staff failed to administer medication as prescribed by Nov 23& 24, the physician. Resident missed multiple doses of Coumadin, and was hospitalized with an infection to the Hopkins 872 Golden Living Center-Hopkins x NEGLECT - MEDICATIONS 2015 1/26/2016 right temporal lobe and was found to be in A-fib. x Hennepin It is alleged that a client was neglected when the facility staff failed to provide adequate care after the client experienced a hip fracture. It is alleged that staff were unaware of the hip fracture and manipulated her leg Hopkins 26529 Grace Homes x Neglect-Health Care 9/25/2017 11/21/2017 causing severe pain to the client. x Hennepin

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 43 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County It is alleged that a resident was neglected when a facility staff made a medication error by transcribing the Hopkins 727 Augustanna Chapel View Care Ctr x Neglect-Medication Errors 4/11/2017 8/11/2017 order incorrectly and administering medication to the resident. x Hennepin It is alleged that the facility did not follow the resident's special diet, and s/he choked and died a few days Hopkins 727 Augustanna Chapel View Care Ctr x Neglect-Nutrition 3/30/2016 8/17/2016 later from aspiration pneumonia x Hennepin

It is alleged that a resident was neglected when s/he was in the facility for short term rehab after a surgery and the facility failed to adequately care for and assess the surgical site. Within 12 hours of being discharged from the facility, the resident was in surgery because there was a massive infection at the surgical site. The Hopkins 727 Augustanna Chapel View Care Ctr x NEGLECT-HEALTH CARE 8/4/2015 11/2/2015 resident has had three subsequent surgeries related to this infection. x Hennepin

Hopkins 872 Hopkins Health Services x Abuse-Sexual 12/12/2017 2/20/2018 It is alleged that a resident was abused when the alleged perpetrator touched him/her inappropriately. x Hennepin It is alleged that a resident was neglected when staff failed to provide adequate supervision when s/he was Houston 286 Valley View Healthcare & Rehab x NEGLECT-HEALTH CARE, SUPERVISION 4/14/2016 10/6/2016 given hot packs and suffered 1st degree burns. x Houston

It is alleged that a client was neglected when s/he suffered a broken tibia and fibula approximately four weeks ago and staff did not assess or seek treatment for this. In addition, the client was not repositioned as NEGLECT-HEALTH CARE, DECUBITI ABUSE- needed, developing significant wounds of his/her feet. In addition, the client was improperly restrained. Staff Hudson 24968 Peaceful Living LLC x RESTRAINTS 7/1/2015 12/31/2015 used a gait belt to restrain the client's leg from rotating when it was broken. x Washington 06/14/2016 and It is alleged clients are being abused when the alleged perpetrators treated clients in a disparaging and Hugo 23369 Hugo GW LLC x ABUSE-EMOTIONAL-STAFF PATIENT RIGHTS 06/15/2016 8/24/2016 humiliating manner, taking photos and video of clients with props indicating illicit behavior. x Washington It is alleged that neglect of supervision occurred, when Client #1 hit and pushed down Client #2, causing NEGLECT-SUPERVISION-RESIDENT TO injury to her/his arms and knuckles. Facility is aware of this, but does not have protocols in place to prevent Hugo 23369 Hugo GW LLC x RESIDENT 1/27/2015 5/5/2015 reoccurrence. x Washington

It is alleged that clients were financially exploited when AP #1 and AP #3 stole money from the facility. AP #3 stole $10,000 when AP#3 wrote checks and AP #1 was involved in the theft. AP #1 was also alleged to have stolen the clients' rent monies the facility received from insurance companies. It is alleged that clients had medications stolen. AP #4 stole the medications for own use, which included use in the facility basement. It is alleged that clients' rights were violated when AP #2 worked impaired, under the influence of marijuana International Falls 20001 Decker's Family Care Inc x EXPLOITATION-DRUG DIVERSION 5/5/2017 9/25/2017 and/or other substances. x Koochiching 11/27/2017 and It is alleged that a resident was financially exploited when only the alleged perpetrator (AP) signed out International Falls 322 Good Samaritan Society International Falls x EXPLOITATION BY DRUG DIVERSION 11/28/2017 2/13/2018 multiple doses of as needed narcotic pain medication. x Koochiching It is alleged that a client was abused and neglected when staff/alleged perpetrator (AP) was rough with the NEGLECT-HEALTH CARE ABUSE-EMOTIONAL, client by picking the client up by the arms causing large bruises. The AP threw clothes at the client asking International Falls 29497 Good Samaritan Society Northwinds x PHYSICAL-STAFF 5/24/2017 7/12/2017 why the client was not dressed and was x Koochiching

It is alleged that a client was abused and neglected when staff/alleged perpetrator (AP) was rout with the client by picking the client up by the arms causing large bruises. The AP threw clothes at the client asking NEGLECT OF HEALTH CARE PHYSICAL ABUSE BY why the client was not dressed and was verbally abusive to the client. The client's right middle shin open International Falls 29497 Good Samaritan Society Northwinds x STAFF 5/24/2017 7/12/2017 wound drained green pus and blood. The client is scared of retaliation. x Koochiching It is alleged that a resident was neglected following a 40 pound weight loss in less that 4 weeks. The resident INVER GROVE HEIGHTS 22 GOOD SAM SOCIETY INVER GR HGTS X NEGLECT OF HEALTH CARE 11/28/2015 7/14/2016 was not bathed in 3 weeks and suffered dehydration. X Dakota INVER GROVE HEIGHTS 27377 INVER GROVE HEIGHTS WP II LLC X ABUSE-PHYSICAL-STAFF 2/2/2015 5/29/2015 It is alleged that a client was abused when a staff member hit him/her on the top of the head. X Dakota INVER GROVE HEIGHTS 27377 INVER GROVE HEIGHTS WP II LLC X ABUSE-PHYSICAL-STAFF 2/2/2015 5/29/2015 It is alleged that a client was abused by staff, resulting in injuries. X Dakota

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 44 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County It is alleged that a client was neglected when the staff, alleged perpetrator, failed to test the client's blood sugar level and did not administer the clients insulin for two days. The client was confused, vomiting and INVER GROVE HEIGHTS 26132 INVER GROVE HEIGHTS WP LLC X NEGLECT-HEALTH CARE 11/3/2015 1/11/2016 hospitalized. X Dakota NEGLECT-SUPERVISION-RESIDENT TO INVER GROVE HEIGHTS 27377 INVER GROVE HEIGHTS WP LLC X RESIDENT 12/6/2017 12/19/2017 It is alleged that a client was neglected when the client was sexually assaulted by another client. X Dakota

INVER GROVE HEIGHTS 26132 INVER GROVE HEIGHTS WP LLC X EXPLOITATION BY STAFF 8/23/2017 9/15/2017 It is alleged that financial exploitation occurred when the alleged perpetrator stole a client's credit cards. X Dakota

INVER GROVE HEIGHTS 27377 INVER GROVE HEIGHTS WP LLC X ABUSE-PHYSICAL, EMOTIONAL-STAFF 8/6/2015 9/11/2015 It is alleged a client was abused when the staff member pushed the client and slapped his/her hands away. X Dakota It is alleged that a resident was neglected when staff failed to monitor the resident's medical condition, INVER GROVE HEIGHTS 22 OOD SAM SOCIETY INVER GR HGTS X NEGLECT-HEALTH CARE 3/3/2015 6/5/2015 resulting in hospitalization for 10 days. X Dakota It is alleged that a client was neglected when she/he was unsupervised while in the bathroom and suffered a INVER GROVE HEIGHTS 21030 SPECTRUM COMMUNITY HEALTH INC NEGLECT-FALLS, SUPERVISION 9/14/2015 11/20/2015 femur fracture. X Dakota It is alleged a client was neglected when the facility installed a lock on the client's bathroom door which the client could not operate and the client could not use the bathroom when needed. It is alleged staff EMOTIONAL ABUSE BY STAFF NEGLECT OF administered as needed medications to the client when the client did not need them, causing the client to be Inver Grove Heights 21030 Spectrum Community Health Inc x HEALTH CARE 12/26,27/2017 2/23/2018 "out of it". x Dakota

INVER GROVE HEIGHTS 21030 SPECTRUM COMMUNITY HEALTH INC X NEGLECT-MEDICATIONS 12/17/2015 6/3/2016 It is alleged that a client was neglected when staff failed to administer several doses of medication. X Dakota It is alleged that multiple residents were financially exploited when staff/alleged perpetrator took the INVER GROVE HEIGHTS 829 WOODLYN HEIGHTS HEALTHCARE CTR X EXPLOITATION -DRUG DIVERSION 7/8/2015 9/23/2015 residents' narcotic medication for personal use. X Dakota It is alleged that a resident was neglected when staff failed to ensure the physician's orders were followed. INVER GROVE HEIGHTS 829 WOODLYN HEIGHTS HEALTHCARE CTR X NEGLECT-HEALTH CARE 11/4/2015 11/14/2016 The resident became dehydrated and died. X Dakota It is alleged that a resident was neglected when staff failed to remove an opioid pain patch from the resident INVER GROVE HEIGHTS 829 WOODLYN HEIGHTS HEALTHCARE CTR X NEGLECT-HEALTH CARE 8/25/2015 1/22/2016 and applied another patch, resulting in the resident's hospitalization. X Dakota It is alleged that a resident was physically abused by a staff, alleged perpetrator (AP) when the AP slapped Ivanhoe 339 Divine Providence Health Center x ABUSE-PHYSICAL-STAFF 2/8/2017 6/28/2017 the resident's hand causing a large skin tear. x Lincoln It is alleged that a resident was sexually assaulted by an unknown alleged perpetrator, and the facility did not Jackson 303 Good Samaritan Society Jackson x ABUSE-SEXUAL 6/2/2016 8/17/2016 do any other follow-up or investigation. x Jackson It is alleged that the alleged perpetrator (AP) emotionally abuse a client when AP was very mean in general. The client feels like s/he has no rights in the facility, is depressed, and cries all the time. The client does not want to make complaints against AP because s/he fears worse treatment. The client cries every day and is Jackson 25317 Lakeview Assisted Living x EMOTIONAL ABUSE BY STAFF 8/7/2017 9/19/2017 fearful of AP. x Jackson It is alleged that a resident was neglected when the primary doctor was not called or updated on resident's Janesville 681 Janesville Nursing Home x NEGLECT-HEALTH CARE 1/20/2017 3/7/2017 declining health status. The resident expired that morning. x Waseca It is alleged that the facility neglected a client. The client did not receive the necessary care and services in Jordan 28511 Oak Terr Sr Housing of Jordan NEGLECT OF HEALTH CARE 4/4/2017 10/17/2017 accordance with his/her service agreement, and in a dignified manner. x Scott NURSING CARE NEGLECT OF HEALTH CARE- It is alleged that a client was neglected when the client sustained a fall after the facility did not toilet the Jordan 28511 Oak Terr Sr Housing of Jordan x FALLS 4/4/2017 10/31/2017 client according to the plan of care. x Scott It is alleged that neglect of supervision occurred when two clients had inappropriate touching and a physical altercation. Client #1 reported of bruising, pain and a dislocated hip reported locking himself/herself in their Jordan 20964 Valleyview of Jordan LLC x NEGLECT-SUPERVISION 11/16/2015 2/10/2016 room due to being afraid. x Scott It is alleged that a resident was neglected when staff failed to monitor the resident after having surgery and the resident developed severe wounds, and sepsis requiring hospitalization, and the need for further surgery Kenyon 145 Kenyon Sunset Home x NEGLECT-HEALTH CARE 2/5/2015 5/26/2015 for wounds and pressure ulcers. x Goodhue It is alleged that a resident was neglected when staff failed to provide medications for several days in a row Kenyon 145 Kenyon Sunset Home x NEGLECT-HEALTH CARE 3/16/2016 7/13/2016 and s/he suffered a stroke. x Goodhue

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 45 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County It is alleged that a resident was neglected when the facility staff did not do proper assessment when the 02/02/2017 resident had a fall. Resident had bruising on the face and family found him/her unresponsive. Resident was NEGLECT-HEALTH CARE, FAILURE TO NOTIFY and taken to the hospital. It was determined the resident had a closed head injury. The resident passed away the Kenyon 145 Kenyon Sunset Home x PHYSICIAN 02/03/2017 9/7/2017 following day. x Goodhue It is alleged that a resident was neglected when the facility staff did not do proper assessment when the 02/02/2017 resident had a fall. Resident had bruising on the face and family found him/her unresponsive. Resident was NEGLECT-HEALTH CARE, FAILURE TO NOTIFY and taken to the hospital. It was determined the resident had a closed head injury. The resident passed away the Kenyon 145 Kenyon Sunset Home x PHYSICIAN 02/03/2017 9/7/2017 following day. x Goodhue It is alleged that a resident was neglected when the facility staff did not do proper assessment when the 02/02/2017 resident had a fall. Resident had bruising on the face and family found him/her unresponsive. Resident was NEGLECT-HEALTH CARE NEGLECT-FAILURE TO and taken to the hospital. It was determined the resident had a closed head injury. The resident passed away the Kenyon 145 Kenyon Sunset Home x REPORT 02/03/2017 9/7/2017 following day. x Goodhue It is alleged that a resident was neglected when the facility staff did not do proper assessment when the 02/02/2017 resident had a fall. Resident had bruising on the face and family found him/her unresponsive. Resident was NEGLECT-HEALTH CARE, FAILURE TO NOTIFY and taken to the hospital. It was determined the resident had a closed head injury. The resident passed away the Kenyon 145 Kenyon Sunset Home x PHYSICIAN 02/03/2017 9/7/2017 following day. x Goodhue 05/16/2016 and It is alleged that a resident was abused when the alleged perpetrator (AP) grabbed the resident's arm and Lake City 770 Mayo Clinic Health Systems Lake City x ABUSE-PHYSICAL-STAFF 05/17/2016 4/20/2017 pulled the resident up in a manner that resulted in the resident crying. The resident is non-verbal. x Wabasha

It is alleged that a resident was neglected when staff failed to provide personal cares in a timely manner and Lake City 770 Mayo Clinic Health Systems Lake City x NEGLECT OF HEALTH CARE - FALLS 6/17/2015 8/3/2015 did not follow toileting protocol. The resident fell and sustained a fracture. x Wabasha NEGLECT-SUPERVISION-RESIDENT TO It is alleged that a client was abused when another client inappropriately touched Client #1. The client was Lake City 31882 River Oaks At Lake Pepin LLC x RESIDENT 2/21/2017 10/2/2017 fearful of unwanted advances. x Wabasha

It is alleged the facility failed to provide adequate supervision for clients when Client #3 inappropriately touched and kissed Client #1, and inappropriately touched, kissed, and attempted to disrobe Client #2. Both Lake City 31882 River Oaks At Lake Pepin LLC x NEGLECT-SUPERVISION 2/21/2017 10/2/2017 Client #1 and Client #2 are scared and do not feel safe around Client #3. x Wabasha It is alleged that a client was financially exploited by a staff, alleged perpetrator (AP) using the client's credit Lake Elmo 27924 Brightstar of St Croix Valley x ABUSE-EXPLOITATION-STAFF 9/8/2017 9/25/2017 cards for his/her own use. x Washington It is alleged that a resident was neglected when the resident fell from a mechanical lift during a transfer NEGLECT-FALLS DUE TO EQUIPMENT FAILURE, when the arm of the lift broke. The resident was transferred to the hospital after being unresponsive for 30 Lakefield 302 Colonial Manor Nursing Home x INAPPROPRIATE USE OF EQUIPMENT 11/3/2016 5/3/2017 minutes. The resident was found to have spine fractures. x Jackson

LAKEVILLE 23850 2 CARING HANDS X NEGLECT-HEALTH CARE, MEDICATIONS 1/4/2017 7/3/2017 It is alleged that five clients were neglected when the facility failed to provide appropriate nursing care. X Dakota

It is alleged that a client was physically assaulted when a staff member punched the resident in the client's LAKEVILLE 31329 DAMACARE HEALTH SERVICES LLC X ABUSE-PHYSICAL-STAFF 6/20/2017 2/28/2018 jaw. The client is afraid, and also alleges the staff is selling illicit drugs at the facility. X Dakota

NEGLECT-HEALTH CARE ABUSE-EMOTIONAL- It is alleged that the facility did not follow state and federal guidelines after a spot was found on a resident's LAKEVILLE 1654 MSOCS LAKEVILLE JONQUIL STAFF 7/27/2016 12/27/2016 head and determined to be cancer. The client also was not treated with respect. X Dakota

LAKEVILLE 1654 MSOCS LAKEVILLE JONQUIL ABUSE-EMOTIONAL-STAFF 7/27/2016 9/27/2016 It is alleged a client was abused when an employee yelled at the client for exhibiting OCD behavior. X Dakota

LAKEVILLE 26626 WALKER METHODIST HIGHVIEW HILL X ABUSE-PHYSICAL-STAFF 4/6/2017 5/1/2017 It is alleged that a client was physically abused when an alleged perpetrator hit the client on the forehead. X Dakota It is alleged that a resident was sexually abused by an alleged perpetrator. A sexual assault exam was LAKEVILLE 26626 WALKER METHODIST HIGHVIEW HILL X ABUSE-SEXUAL 10/23/2017 2/8/2018 completed at a hospital. X Dakota

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 46 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County It is alleged that a resident was sexually abused by an alleged perpetrator. A sexual assault exam was LAKEVILLE 26626 WALKER METHODIST HIGHVIEW HILL X ABUSE-SEXUAL 6/28/2017 2/8/2018 completed at a hospital. X Dakota It is alleged that a resident was neglected when the resident fell from a mechanical lift transfer and began having tremors. The facility later transferred the resident to the hospital. The resident had a subdural Le Center 800 Central Health Care x NEGLECT-FALLS 11/1/2016 8/1/2017 hematoma (blood clot on the brain). x Le Sueur

Le Center 20376 The Beacon At Le Center x ABUSE-PHYSICAL-STAFF 1/12/2018 2/22/2018 It is alleged that a client was abused when the alleged perpetrator hit the resident, causing bruising. x Le Sueur

It is alleged that a client was neglected when staff failed to provide adequate precaution and the client LILYDALE 29017 LILYDALE SENIOR LIVING X NEGLECT-SUPERVISION 4/6/2016 6/9/2016 swallowed an insulin pen cap that got lodged in the throat. The client is now on a feeding tube. X Dakota

It is alleged that a client was neglected when a staff/(AP) failed to provide adequate supervision to the client. NEGLECT-SUPERVISION The AP, who worked overnight, did not see the client in the room and did not attempt to locate him/hre. The next day, cleaning staff foundt he client in the closet on the floor. Client was covered in feces and urine Lino Lakes 31673 Lino Lakes GW LLC x 7/21/2017 1/17/2018 and had a large bruise on the buttock and right shoulder. Client was taken to the hospital. x Anoka

It is alleged that a client was neglected when a staff/(AP) failed to provide adequate supervision to the client. NEGLECT-SUPERVISION The AP, who worked overnight, did not see the client in the room and did not attempt to locate him/hre. The next day, cleaning staff foundt he client in the closet on the floor. Client was covered in feces and urine Lino Lakes 31673 Lino Lakes GW LLC x 7/21/2017 1/17/2018 and had a large bruise on the buttock and right shoulder. Client was taken to the hospital. x Anoka

It is alleged that a client was abused when staff, alleged perpetrators (AP #1) and (AP #2) taunted, Lino Lake 27529 Lino Lakes Assisted Living LLC x PATIENT RIGHTS PHYSICAL ABUSE BY STAFF 6/12/2017 8/15/2017 restrained, and used profanities towards the client. A witness recorded the allged abuse on a cell phone. x Anoka

It is alleged that a client was abused when staff, alleged perpetrators (AP #1) and (AP #2) taunted, Lino Lake 27529 Lino Lakes Assisted Living LLC x ABUSE-PHYSICAL, EMOTIONAL, RESTRAINTS 6/12/2017 8/15/2017 restrained, and used profanities towards the client. A witness recorded the allged abuse on a cell phone. x Anoka

It is alleged that a client was abused when staff, alleged perpetrators (AP #1) and (AP #2) taunted, Lino Lake 27529 Lino Lakes Assisted Living LLC x EMOTIONAL ABUSE BY STAFF 6/12/2017 8/15/2017 restrained, and used profanities towards the client. A witness recorded the allged abuse on a cell phone. x Anoka It is alleged that a client was neglected when a staff, alleged perpetrator (AP( failed to follow the clients care Lino Lake 27529 Lino Lakes Assisted Living LLC x NEGLECT OF HEALTH CARE-FALLS 9/18/2014 5/12/2015 plan when transferring the client, resulting in a fall and broken ribs. x Anoka 05/02/2016 and It is alleged that a client was neglected when staff failed to provide adequate assessments when s/he had a Lino Lakes 27529 Lino Lakes Assisted Living LLC x NEGLECT-HEALTH CARE 05/03/2016 6/1/2016 rectal bleed for two days and a nose bleed for thirteen hours. The client was hospitalized. x Anoka It is alleged that a client has been neglected when staff failed to apply his/her prescription cream and the Lino Lakes 27529 Lino Lakes Assisted Living LLC x NEGLECT-HEALTH CARE 7/15/2015 12/1/2015 client developed sores that continue to worsen. x Anoka It is alleged that a client was neglected when staff provided inadequate supervision resulting in falls with Lino Lakes 27529 Lino Lakes Assisted Living LLC x NEGLECT-HEALTH CARE 4/13/2015 7/14/2015 injuries and lack of care. x Anoka It is alleged that a client was abused when the alleged perpetrator (AP) verbally abused the client, yelled at the client, and denied the client services. In addition, the alleged perpetrator is rough with the client when moving him/her. In addition, the alleged perpetrator failed to provide the client with adequate personal EMOTIONAL ABUSE BY STAFF PHYSICAL ABUSE cares subsequently causing sores and did not complete range of motion exercises according to therapy Little Canada 23141 Lifespan Home Care Services inc x BY STAFF NEGLECT OF HEALTH CARE 4/23/2015 7/28/2015 plans. x Ramsey

It is alleged that the Alleged Perpetrator (AP) financially exploited a patient by stealing the patient's prescribed medication and replacing it with a different medication. The medication with which it was Little Canada 22064 Regency Home Healthcare Services ABUSE EXPLOITATION BY STAFF 1/31/2017 12/18/2017 replaced allegedly caused a side effect which required hospitalization of the patient. x Ramsey

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 47 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County It is alleged that the Alleged Perpetrator (AP) financially exploited two patients Patient #1 and Patient #2 by Little Canada 22064 Regency Home Healthcare Services ABUSE EXPLOITATION BY STAFF 1/31/2017 12/18/2017 stealing the client's medication and replacing it with a different medication. x Ramsey 06/06/2016 and It is alleged that a client was physically and emotionally abused when alleged perpetrator has hit and said Little Canada 22064 Regency Home Healthcare Services ABUSE-PHYSICAL, EMOTIONAL 06/07/2016 9/20/2016 inappropriate statements to the client. x Ramsey 04/07/2016 it is alleged that a patient was neglected when home care staff failed to remove plastic off of patient's insulin and pump causing the patient not to receive insulin. Patient was admitted to the hospital with diabetic Little Canada 22064 Regency Home Healthcare Services NEGLECT-HEALTH CARE 04/08/2016 7/25/2016 ketoacidosis. x Ramsey 06/06/2016 It is alleged that a client was emotionally abused when staff yell and swear at him/her. In addition, the and client's care plan is not being followed and s/he is not receiving adequate repositioning, range of motion, Little Canada 22064 Regency Home Healthcare Services ABUSE-EMOTIONAL-STAFF NURSING CARE 06/07/2016 9/20/2016 and has lost a significant amount of weight. x Ramsey

It is alleged that a client was neglected when s/he had a dislocated shoulder due to an unknown traumatic Little Canada 22064 Regency Home Healthcare Services NEGLECT-HEALTH CARE 11/18/2015 8/26/2016 event and client is non verbal, has inability to move, turn his/her body or to walk. x Ramsey It is alleged that a client was neglected when staff failed to provide adequate personal cares, assessments NEGLECT-HEALTH CARE NURSING CARE LACK and overall cares according to the client's care plans. Also, it is alleged that staff are not properly trained and Little Falls 27367 Highland Senior Living Communi x OF TRAINING 10/1/2015 4/6/2016 supervised to provide adequate nursing cares for clients. x Morrison It is alleged that clients #1 and #2 were financially exploited when staff, alleged perpetrator, (AP), took their Little Falls 27367 Highland Senior Living Communi x EXPLOITATION BY DRUG DIVERSION 2/11/2016 3/15/2016 narcotic medication for his/her own personal use. x Morrison

It is alleged that a client was neglected when the alleged perpetrator failed to provide an adequate medical Little Falls 21049 Minnesota Heritage House x NEGLECT OF HEALTH CARE 1/19/2018 3/9/2018 assessment when the client had a change in condition resulting in the client's death. x Morrison It is alleged that client had been neglected when the client did not get insulin injection for one to four hours after requested. The client subsequently had mood swings and dizziness. This occurred about four times a Little Falls 21049 Minnesota Heritage House x NEGLECT-HEALTH CARE 9/24/2015 12/27/2017 week. X Morrison 10/31, It is alleged that a client was neglected when the facility staff administered a narcotic medication to the Little Falls 21049 Minnesota Heritage House x NEGLECT OF HEALTH CARE-MEDICATIONS 9/1/2017 12/27/2017 client, which caused the client's death. The medication was missing. X Morrison NEGLECT-SUPERVISION-RESIDENT TO It is alleged that clients were neglected when an altercation occurred between the clients. Client #1 tried to Little Falls 21049 Minnesota Heritage House x RESIDENT 6/15,16/2017 9/26/2017 strike Client #2 with a chair. x Morrison It is alleged that neglect occurred when the facility inadequately supervised a client when the client started a Little Falls 21049 Minnesota Heritage House x NEGLECT OF SUPERVISION SAFETY HAZARDS 8/31, 9/1/2017 9/24/2017 fire at the facility and eloped. x Morrison NEGLECT-SUPERVISION-RESIDENT TO It is alleged that a client was neglected when the facility failed to supervise clients and the client received a Little Falls 21049 Minnesota Heritage House x RESIDENT 8/31, 9/1/2017 9/24/2017 bite on the arm. x Morrison

It is alleged that a client was neglected when a staff member intentionally administered the client the wrong Little Falls 21049 Minnesota Heritage House x NEGLECT-MEDICATIONS 8/31, 9/1/2017 9/22/2017 medication, because the client's supply of the correct medication had run out. x Morrison

Little Falls 21049 Minnesota Heritage House x NEGLECT OF SUPERVISION - RES TO RES 2/6,7/2017 7/5/2017 It is alleged that two clients were neglected when one client slapped the other, causing the first client to fall. x Morrison It is alleged that five clients were neglected when the facility failed to maintain adequate staffing, administer NEGLECT OF HEALTH CARE NEGLECT OF medications in a timely manner, process new orders in a timely manner, complete personal cares, assess HEALTH CARE-FALLS NURSING CARE changes in condition and provide adequate training to direct care staff. In addition, it is alleged there was an Little Falls 21049 Minnesota Heritage House x MEDICATION ADMINISTRATION 2/6,7/2017 7/5/2017 increase in the number of falls in the facility. x Morrison It is alleged that a client was abused when staff screamed and yelled at him/her. The client is fearful of staff. The document has been re-scanned to the MDH website. The report has been revised after additional Little Falls 21049 Minnesota Heritage House x ABUSE-EMOTIONAL-STAFF 4/6,7/2016 5/31/2016 information was received August 2, 2015. x Crow Wing

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 48 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County It is alleged that client had been neglected when the client did not get insulin injection for one to four hours after requested. The client subsequently had mood swings and dizziness. This occurred about four times a Little Falls 21049 Minnesota Heritage House x NEGLECT-HEALTH CARE 9/24/2015 4/11/2016 week. X Morrison It is alleged that a client was neglected when the care plan was not being followed when a client had a fall Little Falls 21049 MN Heritage House x NEGLECT OF HEALTH CARE - FALLS 8/31,9/1/2017 9/22/2017 that resulted in death. x Morrison It is alleged that neglect occurred when a fire was intentionally set. The fire at the facility led to the Little Falls 21049 MN Heritage House x NEGLECT-SUPERVISION 6/15,16/2017 9/14/2017 evacuation of more than 30 assisted living residents. x Morrison It is alleged that a client was neglected when the client had an unexplained injury to his/her forearm. The client was made to wait a significant period of time to have his/her catheter flushed when it was needed and Little Falls 21049 MN Heritage House x NEGLECT-HEALTH CARE UNEXPLAINED INJURY 2/6,7/2017 8/3/2017 the client's environment was not kept clean. x Morrison

It is alleged that a resident was neglected when the facility staff failed to follow proper skin checks ordered Little Falls 817 St Ottos Care Center Inc x NEGLECT-HEALTH CARE 2/8/2017 11/15/2017 by the physician. As a result, the resident sustained a pressure ulcer which needed surgical debridement. x Morrison

It is alleged that a resident was neglected when the facility staff failed to follow proper skin checks ordered Little Falls 817 St Ottos Care Center Inc x NEGLECT-HEALTH CARE, SUPERVISION 2/8/2017 11/15/2017 by the physician. As a result, the resident sustained a pressure ulcer which needed surgical debridement. x Morrison 10/27/2015 It is alleged that a resident was abused when the alleged perpetrator (AP) physically dragged the resident and back to his/her room causing a bruise to the resident's arm. In addition, the AP told the resident s/he Littlefork 324 Littlefork Medical Center x PHYSICAL, EMOTIONAL ABUSE BY STAFF 10/28/2015 11/28/2016 smelled. x Koochiching It is alleged that the resident was neglected when staff failed to monitor and assess the resident's change in Long Prairie 778 Centracare Health System Long x NEGLECT-HEALTH CARE 3/31/2015 8/31/2015 respiratory status and the resident died. x Todd It is alleged that a client was neglected when a staff failed to adequately assess the client's supervision needs Lonsdale 26772 THE VILLAGES OF LONSDALE NEGLECT-HEALTH CARE, SUPERVISION 6/10/2015 6/10/2015 and did not keep the client safe. The client attempted suicide. X Rice

Luverne 575 Good Samaritan Society Mary Jane Brown x ABUSE-RESTRAINTS 1/24/2017 2/15/2017 It is alleged that a resident was inappropriately restrained in a wheelchair by staff/alleged perpetrators (AP). x Rock

SAFETY HAZARDS FALLS DUE TO EQUIPMENT It is alleged that a resident was neglected when the resident fell during transfer with a mechanical lift due to Luverne 411 MN Veterans Home Luverne x FAIRLURE 2/28/2017 10/9/2017 mechanical malfunction of lift. Resident sustained injury to right hip and right knee. x Rock It is alleged that a resident was abused when the alleged perpetrator pushed the resident's forehead down ABUSE-PHYSICAL, EMOTIONAL Mabel 124 Green Lea Senior Living x 9/7/2016 12/28/2016 and covered his/her face with unused disposable brief. x Fillmore It is alleged that a resident was neglected when s/he had a fall and staff placed him/her in a wheelchair when the resident had extreme hip pain, leg pain, and head injury, the resident died at the hospital. In addition, it is alleged that the staff did not know the procedures to call for emergency services and when the emergency services arrived, it took staff 15 minutes to locate the resident's identification and medical Madella 695 Luther Memorial Home x NEGLECT-FALLS LACK OF TRAINING 10/21/2015 8/16/2016 information for the hospital. x Watonwan It is alleged that a client was sexually abused when staff/alleged perpetrator (AP) groped the client Madison 28354 Grace Haven Assisted Living x ABUSE-SEXUAL 3/30/2017 11/28/2017 inappropriately. x Lac Qui Parle 09/10/2015 and It is alleged that a resident was neglected when staff administered a dose of Morphine ten times what was Mahnomen 353 Mahnomen Health Center x NEGLECT OF HEALTH CARE-MEDICATIONS 09/11/2015 2/1/2016 ordered. The resident passed away less than two hours later. x Mahnomen

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 49 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County

It is alleged that residents were neglected when staff failed to assess Resident #1 when the resident was having chest pains along with difficulty breathing; the resident passed away. Resident #2 was not adequately assessed while having a high fever for four days and increasing inability to walk. Resident #3 continued to receive laxatives and stool softener when the resident was having diarrhea and pressure ulcers were not monitored and treated appropriately. In addition, medications were not ordered in a timely manner for 12/29/2014 Resident #4 and Resident #5, resulting in Resident #4 not receiving antibiotics for several days and Resident NEGLECT-HEALTH CARE, MEDICATIONS, and #5 missing diabetes medication for a week. These resident concerns were reported to the Director of Mahnomen 353 Mahnomen Health Center x DECUBITI 12/30/2014 4/17/2015 Nursing (DON) and a Registered Nurse (RN). x Mahnomen

It is alleged that a client was abused when the alleged perpetrator (AP) slammed the client into his/her chair and grabbed the client's nose. In addition, it is alleged the AP is rough with cares and verbally abusive to all Mahtomedi 28352 Coventry Senior Living x ABUSE-PHYSICAL, EMOTIONAL 7/18/2016 9/6/2016 clients on the first floor. The AP was yelling and calling the clients names in a threatening manner. x Washington 12/26/2017 NEGLECT OF SUPERVISION NEGLECT OF It is alleged that a client was neglected when h/she fell and experienced a femur fracture, but the facility did Mahtomedi 28352 Ebenezer Management Services HEALTH CARE-FALLS 12/28/2016 not identify the fracture or send the client for further evaluation until 2 days later. x Hennepin

NEGLECT OF SUPERVISION NEGLECT OF It is alleged that a client was neglected when h/she fell and experienced a femur fracture, but the facility did Mahtomedi 28352 Ebenezer Management Services HEALTH CARE-FALLS 12/28/2016 12/26/2017 not identify the fracture or send the client for further evaluation until 2 days later. x Washington It is alleged that several clients were financially exploited when a staff member, alleged perpetrator (AP), Mankato 25816 Autumn Grace x ABUSE-EXPLOITATION-DRUG DIVERSION 8/22/2017 9/15/2017 took the client's narcotic medications for their own personal use. x Blue Earth It is alleged that several clients were financially exploited when a staff member, alleged perpetrator (AP), Mankato 25816 Autumn Grace x ABUSE-EXPLOITATION-DRUG DIVERSION 8/22/2017 9/15/2017 took the client's narcotic medications for their own personal use. x Blue Earth It is alleged that several clients were financially exploited when a staff member, alleged perpetrator (AP), Mankato 25816 Autumn Grace x ABUSE-EXPLOITATION-DRUG DIVERSION 8/22/2017 9/15/2017 took the client's narcotic medications for their own personal use. x Blue Earth It is alleged that several clients were financially exploited when a staff member, alleged perpetrator (AP), Mankato 25816 Autumn Grace x ABUSE-EXPLOITATION-DRUG DIVERSION 8/22/2017 9/15/2017 took the client's narcotic medications for their own personal use. x Blue Earth It is alleged that several clients were financially exploited when a staff member, alleged perpetrator (AP), Mankato 25816 Autumn Grace x ABUSE-EXPLOITATION-DRUG DIVERSION 8/22/2017 9/15/2017 took the client's narcotic medications for their own personal use. x Blue Earth It is alleged that several clients were financially exploited when a staff member, alleged perpetrator (AP), Mankato 25816 Autumn Grace x ABUSE-EXPLOITATION-DRUG DIVERSION 8/22/2017 9/15/2017 took the client's narcotic medications for their own personal use. x Blue Earth It is alleged that several clients were financially exploited when a staff member, alleged perpetrator (AP), Mankato 25816 Autumn Grace x ABUSE-EXPLOITATION-DRUG DIVERSION 8/22/2017 9/15/2017 took the client's narcotic medications for their own personal use. x Blue Earth

It is alleged that a client was abused when staff/alleged perpetrator sprayed an unknown chemical on the client. The client sustained a burn and was hospitalized. The alleged perpetrator swore at client. It is alleged that the client was neglected when staff/alleged perpetrator did not assist the client with care and transfer needs. The alleged perpetrator neglected the client's catheter so that the catheter plugged and caused Mankato 25816 Autumn Grace x Abuse-Physical, Emotional Neglect-Health Care 6/1/2017 11/2/2017 bacteria. The client was hospitalized at least four times for this. x Blue Earth It is alleged that a client was abused when alleged perpetrator (AP) was rude and abusive to the client, slammed the client's shoulder into the door and threatened to do so again. In addition, the AP made Mankato 25816 Autumn Grace x Abuse-Physical, Emotional 4/3/2017 4/25/2017 emotionally abusive comments and signs towards the client. x Blue Earth

It is alleged that a client is not adequately supervised as s/he is frequently hitting, grabbing and pinching Mankato 25816 Autumn Grace x Neglect-Supervision-Resident to Resident 3/24/2015 4/16/2015 other clients. The facility is aware and has not made changes to the care plan to prevent further incidents. x Blue Earth

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 50 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County It is alleged that a client was abused when staff pull on his/her arm and neck to get the client up, causing bruises. Also it is alleged that staff yell at the client and call him/her a liar. In addition, it is alleged that the NEGLECT-HEALTH CARE Abuse-Physical, facility is providing inadequate catheter care and this has led to the client having bladder infections, kidney Mankato 23093 Grace Senior Services INC x Emotional 11/3/2015 9/30/2016 infections and sepsis. x Blue Earth ABUSE-EXPLOITATION-DRUG DIVERSION It is alleged that a resident was exploited when the staff/alleged perpetrator took the resident's medications Mankato 31 Hillcrest Care & Rehab Center x Neglect-Retaliation Against reporter 6/2/2017 8/23/2017 for their own use. x Blue Earth

It is alleged that a resident was neglected when the facility delayed transferring him/her to the ER for Mankato 31 Hillcrest Care & Rehab Center x NEGLECT-HEALTH CARE Nursing Care 8/16/2016 5/22/2017 evaluation. The resident was hospitalized as a result of a stroke with possible long-term damage. x Blue Earth It is alleged that a client was neglected when the facility staff failed to reconcile admission orders and continued to administer coumadin. The client required emergency medical services due to abdominal bleed Mankato 20485 Laurels Edge Assisted Living x Neglect-Medication Errors 9/21/2017 12/19/2017 and acute renal failure. x Blue Earth It is alleged that a resident was neglected when the facility failed to provide him/her with an appropriate diet. Resident was served food that was not cut into small pieces resulting in the resident choking, becoming asphyxiated and passing away. In addition, it is alleged that the facility staff did not know how to do the Mankato 20485 Laurels Edge Assisted Living x NEGLECT-HEALTH CARE 1/28/2017 6/28/2017 Heimlich maneuver on the resident. x Blue Earth It is alleged that a resident was neglected when staff applied an instant hot compress to the resident. The Mankato 35 Laurels Peak Care & Rehab Ctr x NEGLECT-HEALTH CARE 4/10/2017 6/9/2017 resident received a burn that blistered and required medi al treatment. x Blue Earth

It is alleged that a resident was neglected when staff failed to assess him/her adequately after a change in condition. The resident is diagnosed with diabetes and presented being lethargic, and not eating and did not Mankato 35 Laurels Peak Care & Rehab Ctr x NEGLECT-HEALTH CARE 12/15/2015 8/31/2016 have his/her blood levels checked for multiple days and was hospitalized. x Blue Earth It is alleged that a resident was neglected when s/he did not receive a physician ordered blood draw and this error was not discovered for 18 days. The resident did not receive any Coumadin medication during this time Mankato 35 Laurels Peak Care & Rehab Ctr x NEGLECT-HEALTH CARE 7/30/2015 8/2/2016 and was hospitalized for a week as a result. x Blue Earth

It is alleged that a resident was neglected when staff failed to follow doctors' orders and gave the resident food and drink by mouth causing the resident pain, discomfort and anxiety. In addition, the resident suffered Neglect-Health Care, Nutrition, Falls, Pain pain due to not receiving pain medication in a timely manner and the resident's call light was snot answered Mankato 35 Laurels Peak Care & Rehab Ctr x Management 1/2/2015 6/23/2015 in a timely manner when the resident had two falls. x Blue Earth It is alleged that a client was neglected when the facility failed to provide adequate supervision resulting in Mankato 29566 New Perspective Mankato x Neglect-Falls Nursing Care 9/22/2016 7/13/2017 multiple falls and abrasions. x Blue Earth It is alleged that a resident was financially exploited when the alleged perpetrator (A) used a resident's credit Mankato 38 Oaklawn Care & Rehab Center x ABUSE-EXPLOITATION-STAFF 2/2/2017 12/4/2017 card to make unauthorized purchases. x Blue Earth It is alleged that a client was neglected when another client allegedly entered the client's apartment and did Rape by Other Neglect of Supervision-Resident an inappropriate sexual act without consent. The client mentioned the abuse was an actual penetration Mankato 26043 Old Main Village x to Resident 3/2/2017 7/3/2017 without his/her consent x Blue Earth It is alleged that a client was neglected when another client allegedly entered the client's apartment and did Rape by Other Neglect of Supervision-Resident an inappropriate sexual act without consent. The client mentioned the abuse was an actual penetration Mankato 26043 Old Main Village x to Resident 3/2/2017 7/3/2017 without his/her consent x Blue Earth It is alleged that a resident was neglected when staff/alleged perpetrator failed to follow the care plan for Neglect-Falls Due to Equip transfers with a mechanical lift. During the transfer the left strap came off and the resident fell to the floor, Mankato 36 Pathstone Living x Failure/Inappropriate Use of Equipment 6/26/2017 8/28/2017 sustaining a fractured leg and hip x Blue Earth It is alleged that a client was abused when employee (G), the alleged perpetrator (AP), physically assaulted Mankato 1537 REM HEARTLAND INC BIRCH Physical Abuse By Staff 8/26/2015 10/16/2015 the client and the client sustained a wound on his left hip. x Blue Earth

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 51 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County It is alleged that a client was neglected when staff failed to provide adequate assessment when s/he had a change in condition in his/her wound. The client has a blister on his/her heel with infection and is currently Mankato 30109 Water's Edge x NEGLECT-HEALTH CARE 4/12/2016 9/19/2016 hospitalized. x Blue Earth

It is alleged that a client was neglected by staff when the AP refused to assist client with toileting resulting in a fall when the client attempted toilet herself/himself. The AP refused to help client to the toilet at 1:48am so the client soiled herself/himself and the bed. The client attempted to get out of bed at 3-3:30am and fell. The AP found the resident about 4:40am and reluctantly and roughly assisted the client into the unclean bed. Maple Grove 27690 Arbor Lakes Senior Living x NEGLECT-HEALTH CARE 6/26/2017 12/6/2017 The client was transported to ER at shift change and found to have a fractured hip. x Hennepin It is alleged that a client was sexually assaulted. The client was seen at a hospital and had a sexual assault Maple Grove 27690 Arbor Lakes Senior Living x Sexual Abuse 3/18/2015 11/16/2015 exam completed x Hennepin It is alleged that a client was neglected when facility staff failed to ensure a door was closed and locked properly, resulting in the client falling in his/her wheelchair down a flight of stairs. The client died five days Maple Grove 21386 CSL Rose Arbor LLC x NEGLECT-HEALTH CARE 5/4/2017 7/7/2017 later due to a consequence of blunt force injuries x Hennepin It is alleged that neglect occurred when a client is not receiving services as required. In addition, the client is Maple Grove 22064 REGENCY HOME HEALTHCARE SERVIC NEGLECT OF HEALTH CARE 12/29/2017 3/8/2018 fearful of some of the staff. x Hennepin NEGLECT-MEDICATION ERRORS, NEGLECT It is alleged that a resident was neglected when a medication (omeprazole) was discontinued w/o a Maple Plain 950 HAVEN HOMES OF MAPLE PLAIN x MEDICATION ERROR 8/3/2017 8/3/2017 physician order. x Hennepin It is alleged that the resident was financially exploited when the alleged perpetrator stole the residents ring Maple Plain 950 HAVEN HOMES OF MAPLE PLAIN x ABUSE-EXPLOITATION-STAFF 4/18/2017 10/9/2017 and sold it to the local pawn shop. The total financial loss was unknown. x Hennepin It is alleged that a resident was sexually abused when alleged perpetrators (AP #1 and AP #2) were in Maple Plain 950 Haven Homes of Maple Plain x Abuse-Sexual 1/31/2017 8/8/2017 resident's room, changing the resident's brief. x Hennepin It is alleged that a resident was neglected when the alleged perpetrator (AP) failed to follow the resident's Maple Plain 950 Haven Homes of Maple Plain x Unexplained Injury/Fracture 5/31/2016 3/3/2017 care plan for a transfer, resulting in the resident sustaining a fractured right hip. x Hennepin It is alleged that a resident, who was near death, was neglected when staff failed to give the resident pain Mapleton 37 Mapelton Community Home x Neglect-Pain Management Nursing Care 12/7/2016 8/22/2017 medication in a timely manner and the resident experienced increased pain. x Blue Earth

It is alleged that a resident was neglected when staff failed to properly care for the resident's catheter and Mapleton 37 Mapelton Community Home x NEGLECT-HEALTH CARE 9/11/2015 10/4/2016 abdominal drainage tubes, which resulted in the tubes being pulled out and other complications x Blue Earth It is alleged that a resident was neglected when s/he sustained a fibula spiral fracture during a transfer Mapleton 37 Mapelton Community Home x Unexplained Injury/Fracture 4/4/2016 9/9/2016 performed by facility staff. x Blue Earth

It is alleged that a client was abused by staff/alleged perpetrator (AP) when the AP stood over the client and Maplewood 1603 Howard House ABUSE-EMOTIONAL-STAFF 6/20/2017 8/28/2017 told the client over and over again that the AP did not like the client. The client was afraid of the AP. x Ramsey It is alleged that a client was neglected when s/he lost over 60 pounds over a few months. Also, the client had been left in urine soaked bedding and clothing and call lights were not being answered in a timely Maplewood 29005 Lake Phalen Opco LLC x NEGLECT-HEALTH CARE 8/23/2017 9/25/2017 manner. x Ramsey It is alleged that a client was neglected when staff/alleged perpetrator (AP) assisted the client with a shower. After the shower staff noted the client's face, neck, chest, and abdomen were red and warm to touch. The 1/8/2018 client had a blister on the forehead. The facility checked the water and determined there was a mechanical NEGLECT OF HEALTH CARE, PHYSICAL PLANT- issue when the water was noted to be 128 degrees when turned all the way up. The AP said the water valve Maplewood 1599 Living Well Cope MAINTENANCE PROBLEMS 10/24/2017 was turned half way up. x Ramsey It is alleged that a client was neglected when staff/alleged perpetrator (AP) left the client in the shower in the morning. The client sustained first and second-degree burns on the face. The facility transferred the Maplewood 1599 Living Well Cope NEGLECT OF SUPERVISION 10/24/2017 1/8/2018 client to the emergency room for treatment later in the afternoon. x Ramsey It is alleged that a client was abused when staff physically forced the client into a bathtub and forcefully Maplewood 1599 Living Well Cope ABUSE-PHYSICAL PATIENT RIGHTS 6/2/2015 9/8/2015 removed the client's clothing after the client stated s/he did not want a bath. x Ramsey

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 52 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County It is alleged that a client was exploited when staff/alleged perpetrator (AP) took jewelry from the client and Maplewood 31955 Maple Hill Senior Living LLC x ABUSE-EXPLOITATION-STAFF 6/20/2017 1/2/2018 pawned it for $60.00. x Ramsey It is alleged that a client was neglected when the alleged perpetrator failed to administer the client's medication as ordered. The client did not receive Diltiazem for 8-10 days. The client's condition declined and Maplewood 31955 Maple Hill Senior Living LLC x NEGLECT-MEDICATIONS, HEALTH CARE 6/29/2017 1/2/2018 the client was hospitalized. x Ramsey It is alleged that a resident was neglected by facility staff when the resident was found to have bed bugs on Maplewood 520 Maplewood Care Center x NEGLECT OF HEALTH CARE 11/13/2017 1/5/2018 clothing and around the PICC line. x Ramsey

It is alleged that a resident was neglected when the facility failed to provide proper intervention to prevent Maplewood 520 Maplewood Care Center x NEGLECT OF HEALTH CARE-DECUBITI 6/22/2017 12/22/2017 pressure ulcers from developing. The resident had pressure ulcers on his tailbone and back. x Ramsey It is alleged that a resident was neglected when staff failed to provide assistance with any tube feeding or Maplewood 520 Maplewood Care Center x NEGLECT-HEALTH CARE 4/7/2015 11/17/2015 activities of daily living. The client remained in a chair for three days. x Ramsey 02/04/2015 It is alleged that a resident's health care was neglected related to the resident's dehydration, shortness of and breath and high potassium level. The resident was sent to the hospital for evaluation and required Maplewood 520 Maplewood Care Center x NEGLECT-HEALTH CARE 02/05/2015 6/22/2015 hospitalization. x Ramsey It is alleged that a resident was neglected when s/he fell, and staff did not properly assess the resident after the fall. Family requested that the resident be taken to the hospital, and staff refused. Resident was later hospitalized with a broken knee. In addition, staff did not provide adequate personal care, as the resident Maplewood 520 Maplewood Care Center x NEGLECT OF HEALTH CARE 4/20/2015 3/6/2017 had skin breakdown and rash. x Ramsey 02/04/2015 and It is alleged that a resident was neglected when staff failed to provide adequate care resulting in several Maplewood 520 Maplewood Care Center x NEGLECT-HEALTH CARE, DECUBITI 02/05/2015 6/22/2015 open wounds, malnutrition, and sepsis. The resident was admitted to the hospital. x Ramsey It is alleged that a client was financially exploited by a facility staff, alleged perpetrator (AP), when the staff Maplewood 28758 Morning Glory Home Care x EXPLOITATION BY DRUG DIVERSION 11/14/2017 12/5/2017 took the client's narcotic medication for their own use. x Washington It is alleged that a resident was neglected when a staff member/alleged perpetrator (AP) did not follow the resident's plan of care. The resident fell out of the wheelchair and sustained a bruise to the head. The facility Maplewood 23589 Phoenix at Carver NEGLECT OF HEALTH CARE-FALLS 2/28/2017 7/20/2017 transferred the resident to the hospital. x Ramsey It is alleged that a client was neglected when s/he had a fall with injuries and was found deceased the Maplewood 23589 Phoenix at Carver NEGLECT-HEALTH CARE 9/2/2015 3/29/2016 following morning. x Ramsey It is alleged that a resident was neglected when the alleged perpetrator failed to follow the resident's care Maplewood 846 Ramsey County Care Center x NEGLECT-HEALTH CARE, FALLS 12/19/2016 6/28/2017 plan. As a result, the resident had a fall and sustained a left femur fracture. x Ramsey

It is alleged that a resident was neglected when the resident had a change in condition, including symptoms of fluid build-up in lower extremities and difficulty breathing. Family requested emergency services, and the resident was hospitalized in the ICU. Also, the resident had a fall, and the facility did not provide adequate nursing care to the wounds on the resident's head. When the resident was hospitalized a few days later, the Maplewood 846 Ramsey County Care Center x NEGLECT-HEALTH CARE 4/7/2016 8/19/2016 hospital stitched the wound. x Ramsey It is alleged that a resident was abused by unknown staff. The resident has multiple bruising throughout Maplewood 846 Ramsey County Care Center x ABUSE-SEXUAL 8/20/2015 12/22/2015 his/her body including inner thighs and arms. x Ramsey NEGLECT-SUPERVISION-RESIDENT TO It is alleged that Resident #1 was neglected when staff failed to provide adequate supervision that resulted Maplewood 846 Ramsey County Care Center x RESIDENT 1/12/2018 2/5/2018 in Resident #2 touching Resident #1 on the breast. x Ramsey It is alleged that a client was neglected and the client's rights were violated when facility staff gave a ten day notice of the facilities intent to stop providing services for the client without providing necessary Maplewood 31955 Maple Hill Senior Living x NEGLECT-HEALTH CARE PATIENT RIGHTS 6/22/2017 1/2/2018 documentation. x Ramsey

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 53 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County It is alleged a client was neglected when s/he eloped from a facility and was found by law enforcement in a restaurant parking lot over an hour and a half later. In addition, it is alleged the client's rights were violated when the facility refused to allow the client to return to the facility without providing appropriate discharge Maplewood 31955 Maple Hill Senior Living x NEGLECT OF SUPERVISION PATIENT RIGHTS 3/7/2017 3/9/2017 notice and planning. x Ramsey 04/27/2016, 04/28/2016 It is alleged that clients were neglected when staff failed to administer insulin, pain medications, and and psychotropic medications. Also, it is alleged that clients have been overdosed on medications due to Maplewood 31955 Maple Hill Senior Living x NEGLECT-MEDICATIONS 04/29/2016 8/26/2016 medication errors. x Ramsey 04/27/2016, 04/28/2016 It is alleged the client #1 was neglected when s/he had a fall with a head injury and died the next day. It is NEGLECT-FALLS NEGLECT-SUPERVISION- and also alleged, that the facility failed to provide adequate supervision to two clients when client #2 kissed Maplewood 31955 Maple Hill Senior Living x RESIDENT TO RESIDENT 04/29/2016 8/26/2016 client #1. x Ramsey

It is alleged the client was neglected when s/he eloped from the facility, although the facility had indications s/he intended to do so, and was found by law enforcement in a restaurant parking lot over a hour and a half later. In addition, it is alleged the client's rights were violated when the facility refused to allow the client to Maplewood 31955 Maple Hill Senior Living LLC x PATIENT RIGHTS NEGLECT OF SUPERVISION 1/30/2017 8/15/2017 return to the facility, without providing appropriate discharge notice and planning. x Ramsey

Marshall 343 Avera Morningside Heights CC x EXPLOITATION BY STAFF 6/19/2017 10/13/2017 It is alleged that a resident was exploited when an alleged perpetrator (AP) took a resident's iPad. x Lyon It is alleged that a resident was neglected when the facility did not notify the physician when the resident NEGLECT-FAILURE TO NOTIFY PHYSICIAN had a change in condition, and did not provide cardiopulmonary resuscitation when the resident was later Marshall 343 Avera Morningside Heights CC x NEGLECT-FAILURE TO DO CPR 9/5/2017 10/9/2017 found without a pulse or respirations. x Lyon It is alleged that residents were abused when the alleged perpetrator was rough with them during cares, Marshall 343 Avera Morningside Heights CC x PHYSICAL ABUSE BY STAFF 5/3/2016 4/3/2017 leaving bruises. x Lyon It is alleged that a resident has been neglected when staff unplug the ventilator alarm. The ventilator alarm 03/16/2015 goes off, staff does not respond in a timely manner, and the resident has been found gasping for air. It has and been brought to the attention of the facility and they report the ventilator alarm makes too much noise, so it Marshall 343 Avera Morningside Heights CC x NEGLECT-HEALTH CARE 03/17/2015 9/23/2015 has been shut off. x Lyon

It is alleged that financial exploitation occurred when a client's liquid narcotic medication remaining in the ABUSE-EXPLOITATION-DRUG DIVERSION bottle was less than it should be on more than one occasion. If diversion isn't going on, then the concert is Marshall 29444 Heritage Pointe Senior Living x NEGLECT-MEDICATION ERRORS 11/16/2017 1/16/2018 that neglect occurred when the client received more medication than what was ordered by the physician. x Lyon It is alleged that two clients were financially exploited when the alleged perpetrator (AP) took the clients' Medford 29745 Medford Senior Care LLC x EXPLOITATION BY STAFF 5/25/2016 8/5/2016 money. x Steele

It is alleged that neglect of supervision occurred when the facility failed to provide adequate supervision to Menahga 678 Green Pine Acres Nursing Home x NEGLECT-SUPERVISION 5/9/2016 12/28/2016 two residents when one resident grabbed and pushed another resident resulting in bruises and fear. x Wadena It is alleged that a resident was abused when an alleged perpetrator (AP) was witnessed making Menahga 678 GREEN PINE ACRES NURSING HOME x EMOTIONAL ABUSE BY STAFF 1/17/2018 3/13/2018 inappropriate comments to the resident. x Wadena It is alleged that a client was neglected when the facility failed to complete daily skin checks that resulted in Mendota Heights 24782 Dungarvin Minnesota LLC x NEGLECT-DECUBITI, HEALTH CARE 12/29/2017 3/14/2018 a leg wound from a compression sock. x Dakota 07/06/2016 and Mendota Heights 31288 Highland GW LLC x SEXUAL ABUSE 117 07/07/2016 8/29/2016 It is alleged that a client was abused when the alleged perpetrator (AP) touched him/her inappropriately. x Ramsey It is alleged that a client was financially exploited when the alleged perpetrator stole the client's medication Mendota Heights 29407 MENDOTA HEIGHTS WP LLC EXPLOITATION BY DRUG DIVERSION 6/15/2015 11/25/2015 and used it for personal use. X Dakota

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 54 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County It is alleged that a client was neglected when staff failed to administer the client's insulin, resulting in a Mendota Heights 29407 MENDOTA HEIGHTS WP LLC X NEGLECT-MEDICATIONS 3/10/2015 4/2/2015 diabetic crisis. X Dakota It is alleged that a client was abused when the alleged perpetrator pushed the client down and was verbally Mendota Heights 29407 MENDOTA HEIGHTS WP LLC X ABUSE-PHYSICAL, EMOTIONAL 2/10/2016 4/21/2016 abusive. X Dakota It is alleged that a client was neglected when the client developed bed sores because the facility staff failed NEGLECT OF HEALTH CARE-DECUBITI NEGLECT to reposition the client. In addition, the client had significant water retention and a decline in mental status. Milaca 23743 Heritage House of Milaca x OF HEALTH CARE 07/11,12/2017 12/27/2017 The facility did not address these issues. x Mille Lacs It is alleged that a client was neglected when, after a fall, staff did not assess the client before moving the client. Staff did not offer further assessment or care when the client reported pain, was unable to eat, and Milaca 23743 Heritage House of Milaca x NEGLECT-FALLS 07/11,12/2017 11/7/2017 had reduced range of motion due to the fall. x Mille Lacs It is alleged that a resident was not supervised when the resident had oxygen and an oxygen mask on, lit up a cigarette and sustained burns to the side of the face and lungs. Staff extinguished the fire and called for emergency medical services. The resident was transferred to a hospital and then transferred to a burn unit Milaca 23743 Heritage House of Milaca x NEGLECT-SUPERVISION NURSING CARE 11/01,02/2016 2/3/2017 at a second hospital. x Mille Lacs It is alleged that a resident was not supervised when the resident had oxygen and an oxygen mask on, lit up a cigarette and sustained burns to the side of the face and lungs. Staff extinguished the fire and called for emergency medical services. The resident was transferred to a hospital and then transferred to a burn unit Milaca 23743 Heritage House of Milaca x NEGLECT-SUPERVISION 11/01,02/2016 2/3/2017 at a second hospital. x Mille Lacs

It is alleged that a client was neglected when the facility failed to ensure the client's oxygen tanks were filled, Milaca 23743 Heritage House of Milaca x PATIENT RIGHTS NEGLECT OF HEALTH CARE 10/16/2017 12/22/2017 failed to answer call lights in a timely manner, and failed to change the client's catheter bag. x Mille Lacs

It is alleged that a client was neglected when the facility failed to ensure the client's oxygen tanks were filled, Milaca 23743 Heritage House of Milaca x PATIENT RIGHTS NEGLECT OF HEALTH CARE 10/16/2017 12/22/2017 failed to answer call lights in a timely manner, and failed to change the client's catheter bag. x Mille Lacs

It is alleged that a client was neglected when facility staff failed to assess and monitor the client. Facility staff found the client unresponsive and transferred the client to the hospital. It is alleged the client had a Milaca 23743 Heritage House of Milaca x NEGLECT-HEALTH CARE 10/5/2017 12/15/2017 subdural hemotoma and large decubitis ulcer. The client was taken off life support and passed away. x Mille Lacs It is alleged that a client was financially exploited when the alleged perpetrator (AP) signed out a tablet of Milaca 23743 Heritage House of Milaca x EXPLOITATION BY DRUG DIVERSION 11/9/2017 12/5/2017 the client's as needed oxycodone, but did not administer it to the client. x Mille Lacs It is alleged that a resident was neglected when facility staff failed to provide adequate supervision resulting Minneapolis 993 Andrew Residence x NEGLECT OF SUPERVISION 11/29/2017 1/8/2018 in resident committing suicide. x Hennepin It is alleged that a resident was neglected when facility staff failed to provide adequate supervision resulting Minneapolis 993 Andrew Residence x NEGLECT OF SUPERVISION 11/29/2017 1/8/2018 in resident committing suicide. x Hennepin It is alleged that a resident was neglected when the facility failed to supervise the resident which resulted in the resident burning his/her ring finger on a hot dinner plate during mealtime. The resident's burn was Minneapolis 993 Andrew Residence x Neglect-Supervision 3/14/2017 7/3/2017 identified as a second-degree burn. x Hennepin

It is alleged that a resident was neglected when the facility staff failed to provide proper supervision. VA Minneapolis 993 Andrew Residence x Neglect of Supervision 3/14/2017 7/3/2017 eloped from facility and was found deceased from a drug overdose in a hotel three days later x Hennepin It is alleged that a resident (R2) was neglected when the facility staff failed to provide adequate supervise Minneapolis 993 Andrew Residence x Abuse-Sexual Neglect-Supervision 3/8/2016 5/18/2016 resulting in sexual touching by another resident (R1) x Hennepin It is alleged that a resident was neglected when facility staff failed to follow policy and procedure regarding supervision of residents. The resident was missing for multiple hours without staff knowledge and was found intoxicated in the community, was taken to the emergency room, and diagnosed with a left parietal subdural Minneapolis 993 Andrew Residence x Neglect of Supervision 3/8/2016 5/16/2016 hematoma. x Hennepin

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 55 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County It is alleged that a resident was neglected when staff failed to provide adequate supervision and the resident left the facility. The resident was not located for three days. The facility did not contact the police or file a Minneapolis 993 Andrew Residence x Neglect-Supervision 11/30/2015 1/14/2016 missing person's report. x Hennepin Staff failed to provide adequate pain meds to resident. Resident would lay in pain. Also call lights are not 5/31,61,2,3/20 being answered in a timely manner. Investigation was unable to determine how long or frequently resident Minneapolis 164 Augustana HCC of MPLS. X NEGLECT-PAIN MANAGEMENT NURSING CARE 17 3/30/2017 laid in pain. X Hennepin Client was financially exploited when client's money in the amount of $6,00 went missing from the clients Minneapolis 25859 Augustana Residential Care X BUSE-EXPLOITATION-OTHER 8/27/2017 10/20/2017 room. X Hennepin It is alleged that a resident was abused when an alleged perpetrator (AP) physically abused the resident by Minneapolis 164 Augustanna HCC of Minneapolis x Physical abuse by staff 4/12/2016 1/23/2017 slapping the resident x Hennepin It is alleged that a resident was neglected when facility staff failed to provide adequate supervision and the resident eloped out of the facility. The resident was found multiple miles away from the facility, and the Minneapolis 164 Augustanna HCC of Minneapolis x Neglect-Supervision 5/31/2016 3/27/2017 facility staff was not aware the resident was missing x Hennepin It is alleged that a resident was neglected related to a wound that had developed on the resident's left hand. In addition, facility staff failed to assist the resident eat, causing weight loss. A urinary analysis was not obtained timely after symptoms of a urinary tract infection developed. The resident was given increased Minneapolis 164 Augustanna HCC of Minneapolis x Neglect 5/31/2016 3/27/2017 doses of morphine. x Hennepin

It is alleged that a resident was neglected when the facility failed to provide adequate supervision resulting in a fall at the nurses station. The facility failed to provide further evaluation despite the resident's severe leg pain. Finally, the facility transferred the resident to the hospital when s/he became unresponsive. the resident was diagnosed with a fractured femur and hip socket on the right leg. The resident passed away due Minneapolis 164 Augustanna HCC of Minneapolis x Neglect-Health Care Neglect-Supervision 2/21/2017 3/15/2017 to complications of fall/fracture and decreased mobility. x Hennepin NEGLECT-HEALTH CARE, Supervision Patient It is alleged that a resident was neglected, when the facility failed to provide appropriate safety interventions Minneapolis 164 Augustanna HCC of Minneapolis x rights 12/20/2016 1/12/2017 related to smoking while using oxygen x Hennepin

It is alleged that a resident was neglected when the resident had a change in condition, including diarrhea Minneapolis 164 Augustanna HCC of Minneapolis x NEGLECT-HEALTH CARE 10/12/2015 7/18/2016 and vomiting, and was hospitalized with C-difficile, sepsis, and a urinary tract infection. x Hennepin It is alleged that a resident was neglected when s/he developed a stage two-pressure ulcer. In addition. It is alleged that the staff did not complete a bath and a skin check on the resident the weekend prior to the Minneapolis 164 Augustanna HCC of Minneapolis x NEGLECT-HEALTH CARE 11/17/2015 3/29/2016 discovery of the pressure ulcer. x Hennepin It is alleged that neglect occurred when a resident was to have dressing changes to his/her suprapubic catheter daily. The dressing changes were not done for five days and the dressing was crusted to his/her skin. In addition, the resident was not repositioned as needed and developed a pressure ulcer that became Minneapolis 164 Augustanna HCC of Minneapolis x NEGLECT-HEALTH CARE 8/24/2015 10/21/2015 infected during his/her stay at the facility x Hennepin It is alleged that a client was neglected by staff when the client did not receive appropriate medical Minneapolis 3383 Augustanna Home Health Care Srv x Neglect of Health Care 7/25/2017 2/15/2018 assessment and care, resulting in hospitalization x Hennepin It is alleged that a client was neglected when another client entered the client's apartment without his/her Minneapolis 3383 Augustanna Home Health Care Srv x Abuse-Sexual 1/5/2017 6/9/2017 permission inappropriately touched, and tried to have sex with, the client. x Hennepin

It is alleged that a client was neglected when another client entered the client's apartment without his/her Minneapolis 3383 Augustanna Home Health Care Srv x Neglect-Supervision-Resident to Resident 1/5/2017 6/9/2017 permission and inappropriately touched, and tried to have sex with, the client. x Hennepin It is alleged that a client was neglected when another client entered the client's apartment without his/her Minneapolis 3383 Augustanna Home Health Care Srv x Abuse-Sexual 1/5/2017 6/9/2017 permission inappropriately touched, and tried to have sex with, the client. x Hennepin Abuse -sexual neglect supervision resident to It is alleged that a client was neglected when another client entered the client's apartment without his/her Minneapolis 3383 Augustanna Home Health Care Srv x resident 1/5/2017 6/9/2017 permission inappropriately touched, and tried to have sex with, the client. x Hennepin

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 56 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County

It is alleged that a client was neglected when staff refused to assist the client with cares and dressing Minneapolis 3383 Augustanna Home Health Care Srv x Neglect-Health Care 11/19/2015 5/16/2016 changes. S/he has discussed concerns with facility nurse but the situation hasn't gotten better. x Hennepin

Neglect-Supervision-Resident to Resident It is alleged that a client was neglected when staff failed to provide adequate supervision and another client Minneapolis 3383 Augustanna Home Health Care Srv x Sexual Abuse 9/8/2015 12/31/2015 sexually assaulted her. The client reported this to staff at the facility and the facility took no further action x Hennepin

it is alleged that a client was neglected when the staff administered his/her medications and then also Minneapolis 3383 Augustanna Home Health Care Srv x NEGLECT-MEDICATIONS 8/27/2015 9/24/2015 administered another client's medication to the client. The client was hospitalized for two days as a result. x Hennepin It is alleged that client were not adequately supervised when client #1 punched client #2 several times in the face, slapped the client, and cut the client's face with a sharp object resulting in a two inch cut. The client Minneapolis 3383 Augustanna Home Health Care Srv x Neglect-Supervision-Resident to Resident 3/3/2015 4/13/2015 was subsequently hospitalized. x Hennepin

ABUSE-EXPLOITATION-Staff Abuse-Exploitation It is alleged that a client was financially exploited when a staff, alleged perpetrator (AP), took a bottle of Minneapolis 25859 Augustanna Residential Care x DRUG DIVERSION Patient Rights 8/15/2017 9/26/2017 hydrocodone tablets from the client's apartment. x Hennepin It is alleged that neglect of supervision occurred when a client jumped out of his/her 5th floor window and Minneapolis 25859 Augustanna Residential Care x Neglect-Supervision 11/10/2015 1/25/2016 passed away. x Hennepin It is alleged that a client was neglected when staff failed to properly assess and provide medical services after s/he had a fall and was unresponsive. The client was sent to the hospital the following day with a bump Minneapolis 25859 Augustanna Residential Care x Neglect-Health Care, Falls, Failure to report 9/17/2015 1/22/2016 on the forehead and high blood pressure. x Hennepin

It is alleged that a resident was neglected when the resident was sent from the nursing home to the clinic in a medi-van and the resident was left in a waiting room with no supervision. The facility sent guardianship paperwork with the resident that clearly stated resident needs to be monitored 24 hours a day in home and Minneapolis 960 Benedictine Health Ctr of Mpls x Neglect-Health Care, Supervision 2/9/2017 9/15/2017 community. The resident was nonverbal and does not have any way to explain anything. x Hennepin

It is alleged that a resident has been neglected when staff improperly cleaned the resident's tracheostomy and the resident suffered broken blood vessels in his/her neck. Staff failed to properly reposition and Minneapolis 960 Benedictine Health Ctr of Mpls x NEGLECT-HEALTH CARE 6/11/2015 3/16/2016 provide adequate personal cares for the resident and the resident developed open wounds. x Hennepin

it is alleged that a resident was neglected when staff failed to properly monitor and follow physician's orders Minneapolis 167 Bethany Residence and Rehab CT x NEGLECT-HEALTH CARE 8/1/2016 9/1/2016 for caring of the resident's wound. The resident is currently hospitalized for treatment of the wound. x Hennepin

It is alleged that a resident was neglected when staff failed to provide adequate fall interventions after s/he has fallen several times over the past weeks with multiple injuries. In addition, that resident's care is not being completed and is left lying in bed for several hours. Also, the resident's rights were violated when the facility refused a request and told the resident s/he can only see the facility doctor. The resident is fearful of Minneapolis 167 Bethany Residence and Rehab CT x Neglect-Health Care Patient Rights 4/29/2016 8/2/2016 requesting further medical attention. x Hennepin It is alleged that a resident was neglected when facility staff failed to provide adequate supervision and s/he Minneapolis 168 Birchwood Care Home x Neglect of Supervision 6/16/2016 8/24/2016 was sexually assaulted by another resident. x Hennepin Minneapolis 168 Birchwood Care Home X NEGLECT-SUPERVISION 8/23/2017 6/26/2017 Two different reports about the same allegation X Hennepin Resident #! And Resident #2 were neglected when facility failed to provide adequate supervision that Minneapolis 168 Birchwood Care Home X SEXUAL ABUSE 8/23/2017 6/26/2017 resulted in Resident #1 being sexually assaulted #2. X Hennepin

Client was abused when faculty staff failed to adequately address client's aggressive behavior. Faculty staff Minneapolis 26125 Brotts Family Care Center LLC ABUSE-PHYSICAL 10/1/2015 10/1/2015 sprayed cleaning solution in the air at the client to stop the aggressive behavior. AP felt in fear for her safety. X Hennepin

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 57 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County it is alleged the facility neglected to supervise two residents when resident #2 forced him/herself on Minneapolis 176 Bywood East Health Care x Neglect-Supervision-Resident to Resident 4/24/2017 6/10/2017 Resident #1 to have sex. x Hennepin it is alleged the facility neglected to supervise two residents when resident #2 forced him/herself on Minneapolis 176 Bywood East Health Care x Neglect-Supervision-Resident to Resident 4/24/2017 6/10/2017 Resident #1 to have sex. x Hennepin it is alleged that a resident was financially exploited when an unknown alleged perpetrator received VA's card and went on to impersonate the VA, calling VA's bank to cancel card and requesting to receive a new Minneapolis 176 Bywood East Health Care x Abuse-Exploitation-other 4/21/2017 6/7/2017 one. x Hennepin

it is alleged that a resident was neglected when facility staff failed to develop a care plan to keep resident Minneapolis 176 Bywood East Health Care x Neglect of health Care-Falls 5/13/2016 9/20/2016 safe from injury, Resident had a fall and sustained a left knee and cervical fracture x Hennepin it is alleged that a resident was neglected when the alleged perpetrator did not provide appropriate care and did not administer the resident's insulin on time resulting in the resident's blood sugar going up. The resident's condition declined, s/he fell and was taken to hospital. In addition, the resident's wallet went Minneapolis 166 Camden Care Center x Neglect-Health Care, Medications 4/12/2017 10/4/2017 missing or was misplaced. x Hennepin it is alleged that a resident was sexually abused when an employee, the Alleged Perpetrator (AP), Minneapolis 166 Camden Care Center x Sexual Abuse 4/22/2016 5/4/2016 inappropriately touched him/her during personal care x Hennepin it is alleged that a resident was neglected when the staff failed to provide adequate wound assessment and Minneapolis 166 Camden Care Center x Neglect-Decubiti 6/5/2015 2/18/2016 wound care to the resident and the wound became infected x Hennepin it is alleged that a resident was neglected when s/he arrived at the emergency room covered in urine, strong Minneapolis 166 Camden Care Center x Neglect-Health Care 1/22/2016 2/11/2016 odors, body secretions, and pressure ulcers on both legs. x Hennepin

it is alleged that a resident was neglected when s/he developed kidney failure resulting in hospitalization, had developed two new pressure ulcers since admission to the facility, and had developed skin breakdown in his/her perineal area due to sitting in his/her stool for long periods of time. In addition, it is alleged that the Minneapolis 166 Camden Care Center x Neglect-Health Care-Abuse-Emotional Staff 10/30/2015 1/28/2016 resident is abused when staff yell at him/her regarding his/her incontinence. x Hennepin Minneapolis 166 Camden Care Center x Neglect of Supervision NOT FOUND 1/21/2016 NOT FOUND x Hennepin

it is alleged that a resident was neglected when staff failed to provide adequate supervision. The resident is Minneapolis 166 Camden Care Center x Neglect-Supervision 11/6/2015 1/20/2016 on a civil commitment at the facility and has not been located in multiple hours. x Hennepin Resident was neglected when the call light failed to work during a period pf respiratory distress. Failed to Failure to do CPR-Failure to report physical provide appropriate emergency medical services resulting in resident's death. The resident passed away Minneapolis 166 Camden Care Center X plant problems 6/30/2017 10/23/2017 before emergency services arrived. X Hennepin AP told resident to shut up. AP are rough with cares causing discomfort for resident. Facility staff are not 8/03,04,05/20 administering the residents medications according to the physicians orders. Resident has received the dose Minneapolis 166 Camden Care Center X ABUSE-STAFF NEGLECT-MEDICATION ERRORS 16 12/12/2016 twice of the oxycodone. X Hennepin ABUSE- NEGLECT-MEDICATIONS NURSING Minneapolis 166 Camden Care Center X CARE 11/29/2016 Two different reports about the same allegation X Hennepin It is alleged that neglect occurred when the facility failed to respond to resident's change in condition and as Minneapolis 984 Catholic Eldercare on Main x Neglect Health Care 12/1/2016 7/3/2017 a result the resident will have a permanent catheter. x Hennepin

It is alleged that a resident was abused when staff transferred the resident in a rough manner and grabbed the resident by the transfer belt. The resident was found to have a broken vertebrae. Also, it is alleged that Minneapolis 984 Catholic Eldercare on Main x Abuse-Physical-Staff Neglect-Health Care 6/10/2016 8/17/2016 the resident's personal cares are not being done in a timely manner x Hennepin Neglect of health Care and Neglect of Health It is alleged that a resident was neglected when alleged perpetrator (AP) did not follow the resident's care Minneapolis 984 Catholic Eldercare on Main x Care-Falls 4/26/2016 7/25/2016 plan. The resident had a fall and sustained a subdural hematoma. x Hennepin

Minneapolis 984 Catholic Eldercare on main X ABUSE-SEXUAL 5/30/2017 10/19/2017 Resident was sexually abused by an unknown staff member. X Hennepin

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 58 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County NEGLECT-SUPERVISION-RESIDENT TO Minneapolis 23905 Clare Housing X RESIDENT 2/16/2017 7/28/2017 Client #1 was sexually assaulted by other clients client #2 AND CLIENT #3. X Hennepin It is alleged that a resident was neglected when the facility did not assess and monitor the resident. The resident was admitted to the hospital with abnormal labs, required blood transfusions, and had a non- Minneapolis 5 Crest View Lutheran Home x NEGLECT-HEALTH CARE 10/16/2017 3/7/2018 healing cellulitis despite two weeks of treatment. x Anoka

It was alleged the resident was neglected when the facility did not adequately assess, monitor or supervise the resident. The resident jumped from a 2nd floor window. The facility transferred the resident to the Minneapolis 191 Ebenezer Care Center x NEGLECT-HEALTH CARE, SUPERVISION 12/6/2017 2/12/2018 hospital with severe injuries. The resident had prior threats of self harm. x Hennepin

Client was abused when the AP pulled the client up in forceful manner and was pushed back into the chair abruptly. AP was speaking to the resident in a threating manner. In addition all residents are not being Minneapolis 27108 Ebenezer Care Center x NEGLECT-HEALTH CARE ABUSE-Physical 3/30/2017 11/6/2017 provide with adequate cares, are being talked to in a disrespectful manner. X Hennepin

Minneapolis 27108 Ebenezer Care Center x ABUSE-PHYSICAL 3/30/2017 11/6/2017 Client was abused when the AP was yelling at the client and threw them into a chair. X Hennepin

A resident was abused when AP was physically abusive towards a resident causing an injury and slapped resident in the face. A staff member reported to management that they observed another staff member the AP provide rough cares, use demeaning language and open-hand slap the resident. Also observed AP forcefully wash the resident's face such that the residents head was pushed back, and from side-to side. AP turned the resident from side to side with cares in bed in such a way that the resident's foot hot the wall. AP also held the resident's arm against the resident's body with turns. The staff member saw and heard the open-hand slap. During the course of cares by the AP, the resident obtained a skin tear measuring 4 cm in length by .5 cm width in the groin area. Nurse that treated the skin tear denied having any concerns with Minneapolis 191 Ebenezer Care Center x PHYSICAL ABUSE BY STAFF 6/8/2017 6/27/2017 behavior of the AP. X Hennepin

Resident was neglected when facility staff failed to transfer a resident per their care plan. Resident had a fall and sustained a bilateral femur fracture. The care plan directed that two staff use an EZ-stand to transfer the resident from the wheelchair to the toilet. The staff member transferred the resident without assistance. The resident's knee buckled and the resident became unsteady, The staff member called for help, three staff members lowered the resident to the floor. The resident was transferred to the hospital. The hospital Minneapolis 191 Ebenezer Care Center x NEGLECT-HEALTH CARE, FALLS 2/1/2016 4/28/2017 diagnosed bilateral femur fractures. X Hennepin November 6, Minneapolis 28789 Ebenezer Home Care x ABUSE-EMOTIONAL-STAFF 20-17 12/22/2017 It is alleged that client was abused when alleged perpetrator spoke to the client in a threatening manner. x Hennepin

Dec It is alleged that a client was neglected when facility staff failed to check on the client, after the client failed Minneapolis 27108 Ebenezer Home Care x NEGLECT-HEALTH CARE, SUPERVISION 26&27,2017 12/13/2017 to call for assistance after a call. The client was on the floor from 11:10pm - 8:45am the next morning. x Hennepin 10/19/2017 and It is alleged that a client was neglected when the facility administered incorrect medications. This led to Minneapolis 27773 Ebenezer Home Care x NEGLECT-MEDICATION ERRORS 10/20/2017 3/13/2018 erratic behaviors and probable suicide from a five story window. x Hennepin Financial exploitation-drug diversion occurred when multiple medications went missing. Client's medications Minneapolis 28789 Ebenezer Home Care x EXPLOITATION BY DRUG DIVERSION 12/13/2017 12/15/2017 were kept in a locked drawer. X Hennepin

It is alleged that client was neglected when agency staff soaked the client's feet in too high temperature of Minneapolis 2187 Fairview Home Care & Hospice NEGLECT HEALTH CARE March 28,2016 8/2/2016 water. The client was transported to the hospital burn unit with 2nd and 3rd degree burns to his / her feet. x Hennepin It is alleged that a client was exploited when the alleged perpetrator took 100 tablets of Oxycodone for Minneapolis 2187 Fairview Home Care and Hospice x Abuse-Exploitation-Drug Diversion 8/14/2017 1/22/2018 personal use x Hennepin

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 59 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County It is alleged that a patient was financially exploited when staff/alleged perpetrator (AP) took $200-$300 from Minneapolis 2187 Fairview Home Care and Hospice x Abuse-Exploitation- Staff 5/25/2017 11/6/2017 the patient's home x Hennepin It is alleged that a patient was exploited by staff when the alleged perpetrator took the patient's pain Minneapolis 2187 Fairview Home Care and Hospice x Abuse-Exploitation-Drug Diversion 2/22/2017 4/17/2017 medication. x Hennepin It is alleged that a resident was financially exploited when the AP took the resident's funds for his/her Minneapolis 937 Golden Living Center Chateau x Abuse-Exploitation-Staff 6/22/2015 10/27/2015 personal use. x Hennepin

It is alleged that a resident was neglected when facility staff failed to provide emergency medical services after the client fell. It is alleged that the client lay on the floor for 4 hours after the fall. The client was sent Minneapolis 23665 Golden Nest LLC x NEGLECT-FALLS, HEALTH CARE 9/18/2017 1/17/2018 to the hospital 2 days later and was admitted to ICU with neck fracture and brain hemorrhage and later died. x Hennepin It is alleged that Resident #1 and Resident #2 were neglected when staff failed to provide adequate NEGLECT-SUPERVISION-RESIDENT TO supervision when Resident #2 pushed Resident #1 resulting in a head laceration requiring emergency Minneapolis 208 Grand Ave Rest Home x RESIDENT 11/28/2018 2/22/2018 medical services. x Hennepin Neglect-Health Care-Decubiti Neglect of Health It is alleged that a resident was neglected when facility staff failed to provide adequate medical care Minneapolis 208 Grand Ave Rest Home x Care 6/27/2017 12/4/2017 resulting in a resident developing a stage III pressure injury x Hennepin It is alleged that a resident was neglected after the resident was found to have a right knee fracture of Minneapolis 216 Jones Harrison Residence x Unexplained Injury/Fracture 5/9/2016 11/4/2016 unknown origin. x Hennepin NEGLECT OF HEALTH CARE-FALLS NEGLECT OF It is alleged that a resident was neglected when, when the alleged perpetrator failed to follow the care plan. Minneapolis 233 MN VETERANS HOME - MPLS x HEALTH CARE 4/17/2017 4/17/2017 The resident fell, sustained injuries and died two days later. x Hennepin

It is alleged that the resident's were exploited when that alleged perpetrator took the residents psychotropic pain medications for his/her own use several times per week for his/her own use since June 2014 resulting in 12/3/2014 & the residents showing signs of increased pain and agitation. It is also alleged that this has been reported Minneapolis 233 MN VETERANS HOME - MPLS x ABUSE-EXPLOITATION-DRUG DIVERSION 3/15/2015 8/24/2015 internally and the facility had retaliated against the reporter. x Hennepin It is alleged that a resident was neglected when s/he had a fall out of a full body lift causing a cervical fracture. The resident passed away 11 days later, cause of death was determined to be cardiorespiratory Neglect of Health Care-Falls Due to Equip. complications of immobility, blunt force neck injury, and a fall. In addition, the facility failed to provide Minneapolis 233 MN Veterans Home Minneapolis x Failure Neglect of Health Care-Falls 8/25/2016 8/25/2016 proper lift sheet and equipment for lift being used. x Hennepin 12/11/2017, 12/12/2017 and It is alleged that a resident did not receive adequate nursing care. The resident had long toenails, a bruise on Minneapolis 233 MN Veterans Home Minneapolis x NURSING CARE 12/13/2017 3/13/2018 the right hip and right hand, and a laceration on the buttocks. x Hennepin January 24 & It is alleged that a client was neglected when staff failed to administer his/her anti psychotropic medications Minneapolis 29409 N & V HELPFUL HEART CARE INC x NEGLECT - MEDICATIONS 25 2017 5/9/2017 for several months, causing a decline in the client's mental health. x Hennepin It is alleged that a client was neglected when facility staff failed to provide adequate care to the client. The Minneapolis 20218 North Oaks On Emerson x NEGLECT-HEALTH CARE 7/7/2017 2/23/2018 client had an emergency surgery due to a blood clot in his/her dialysis access. x Hennepin

It is alleged that a client was neglected when facility staff failed to provide adequate care to the client. The Minneapolis 20218 North Oaks On Emerson x NEGLECT-HEALTH CARE 7/7/2017 2/23/2018 client fell, pushed the life alert pendent button, and laid on the floor for 30 minutes. x Hennepin It is alleged that a resident was exploited when a staff, alleged perpetrator (AP) took the residents narcotic Minneapolis 96 Providence Place x Exploitation by Drug Diversion 4/16/2015 5/26/2015 medication for their own use. x Hennepin It is alleged that the resident was neglected when he/she was transferred out of the facility w/o adequate communication with the resident or with the receiving facility. As a result the resident suffered emotional distress, and the receiving facility, immediately transferred the resident to the emergency department, Minneapolis 96 Providence Place x NEGLECT-HEALTH CARE DUMPING 12/27/2016 3/31/2017 where he/she was left for over 2 days. x Hennepin It is alleged that a resident was exploited when staff/alleged perpetrator (AP), collected a dollar and a lighter Minneapolis 20103 Rakhma INC x Exploitation by Staff 4/7/2017 12/22/2017 from the resident for personal use. x Hennepin

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 60 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County

It is alleged that clients were neglected when staff failed to provide adequate supervision, resulting in an incident in which Client 2 touched Client 1 inappropriately. In addition, it is alleged client 1 was neglected Minneapolis 20103 Rakhma INC x Neglect-Supervision-Resident to Resident 4/20/2017 12/12/2017 when staff failed to provide adequate supervision leading to Client 2 exposing him/herself. x Hennepin

It is alleged that clients were neglected when staff failed to provide adequate supervision, resulting in an incident in which Client 2 touched Client 1 inappropriately. In addition, it is alleged client 1 was neglected Minneapolis 20103 Rakhma INC x Neglect-Supervision-Resident to Resident 4/20/2017 12/12/2017 when staff failed to provide adequate supervision leading to Client 2 exposing him/herself. x Hennepin It is alleged that abuse occurred when a staff, alleged perpetrator (AP) spit on and hit a resident. The facility REDEEMER RESIDENCE INC terminated the AP but did not report the abuse. In addition it is alleged that the facility is short staffed of Minneapolis 160 x ABUSE-PHYSICAL-STAFF STAFFING SHORTAGE 8/8/2015 11/2/2015 both licensed nursing staff and aides. x Hennepin NEGLECT-SUPERVISION-RESIDENT TO It is alleged that the facility staff failed to provide adequate supervision when Client #1 exposed him/herself Minneapolis 21654 REM HENNEPIN INC LYNDALE RESIDENT 1/19/2017 6/30/2017 and blocked the doorway to Client #2. Client #2 is fearful of Client #1. x Hennepin It is alleged that a resident was neglected when facility staff failed to provide adequate supervision. The Minneapolis 937 The Estates at Chateau LLC x NEGLECT OF SUPERVISION 10/24/2017 3/12/2018 resident was found hanging in the closet and passed away. x Hennepin 08/04/2017 It is alleged that the resident was neglected when facility staff did not monitor the resident when a decline in and condition. occurred and the resident passed away. Staff failed to provide adequate medical care and Minneapolis 937 The Estates at Chateau LLC x NEGLECT-HEALTH CARE, SUPERVISION 08/07/2017 3/7/2018 supervision x Hennepin It is alleged that a resident was neglected when he had a change of condition and facility staff administered FAILURE TO NOTIFIY PHYSICIAN NEGLECT OF Roxanol. Resident fell 30 minutes later and facility failed to provide adequate medical assessment after HEALTH CARE NEGLECT OF HEALTH CARE- resident fell. Facility staff failed to notify hospice provider of change in condition and fall. Resident passed Minneapolis 175 THE VILLA AT BRYN MAWR x FALLS 8/15/2017 1/22/2018 away 3 hours later. x Hennepin TOUCHING /FONDLING BY OTHER 7/10/2017 It is alleged that resident was abused by unknown alleged perpetrator when the resident claimed that Minneapolis 175 THE VILLA AT BRYN MAWR x 3/14/2017 someone licked his/ her genitals, gave him / her a rash and bit one breast. x Hennepin It is alleged that a resident was financially exploited when a staff member alleged perpetrator (AP), took the Minneapolis 175 THE VILLA AT BRYN MAWR x EXPLOITATION - DRUG DIVERSION 11/19&20/2015 7/18/2016 resident's pain medication for his/her own personal use. x Hennepin It is alleged that a client was abused when alleged perpetrator hit her/him several times in the head and Minneapolis 23694 UNITY HEALTH CARE x ABUSE-PHYSICAL-STAFF ABUSE-RESTRAINT 6/23/2016 8/22/2016 locked the client in his/her room. x Hennepin It is alleged that a client was abused when a staff, alleged perpetrator (AP), was verbally abusive to the Minneapolis 23694 UNITY HEALTH CARE x ABUSE-EMOTIONAL-STAFF 8/25/2015 12/24/2015 client, causing the client to cry. x Hennepin

NEGLECT-HEALTH CARE, FAILURE TO DO CPR It is alleged that the resident was neglected when the call light failed to work and resident could not alert NEGLECLT-FAILURE TO REPORT PHYSICAL staff for assistance during a period of respiratory distress. Facility failed to provide appropriate emergency Minneapolis 166 VICTORY HEALTH & REHAB CTR x PLANT-MAINTENANCE PROBLEMS 6/30/2017 10/23/2017 medical services resulting in resident's death. x Hennepin It was alleged that a resident was abused when alleged perpetrators told the resident to shut up. Also it is alleged that the AP are rough with cares, causing the resident discomfort. Also, it is alleged that the facility ABUSE-PHYSICAL, EMOTIONAL-STAFF NEGLECT- staff are not administering the residents medications according to physicians orders and the resident has Minneapolis 166 VICTORY HEALTH & REHAB CTR x MEDICATION ERRORS MEDICATION ERROR 8/3, 4, 5/2016 12/12/2016 received twice the dose of his/her oxycodone. x Hennepin It was alleged that a resident was abused when alleged perpetrator (unknown staff) told the resident to shut ABUSE-EMOTIONAL-STAFF NEGLECT- up. It is alleged that the facility staff have not been administering the residents medication as ordered by the Minneapolis 166 VICTORY HEALTH & REHAB CTR x MEDICATIONS NURSING CARE 8/3, 4, 5/2016 11/29/2016 physician. x Hennepin It is alleged that a client was neglected when the facility did not administer medication and the client Minneapolis 03712 Volunteers of America of Minne x NEGLECT-MEDICATIONS 9/8/2017 3/7/2018 sustained a seizure. x Hennepin

It is alleged that a resident was neglected when an alleged perpetrator (unknown) provided rough care to the resident. The resident had excruciating pain, hip dislocation, due to rough physical therapy provided by Minneapolis 276 WALKER METHODIST HEALTH CTR x NEGLECT-HEALTH CARE 8/3/2017 10/31/2017 the AP. Resident was taken to the hospital for total hip replacement. x Hennepin

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 61 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County December It is alleged that a resident was abused when he/she was sexually assaulted by an unknown person alleged Minneapolis 276 WALKER METHODIST HEALTH CTR x RAPE BY OTHER PENETRATION BY OTHER 22&23 2015 12/18/2015 perpetrator (AP) x Hennepin

It is alleged was neglected when he/she put on the call light for staff to assist with toileting and no staff 6/23/2015 responded for an hour and the resident ended up falling on the floor. The resident had to call a family member to call the facility to obtain assistance to the resident. When staff came to assist the resident, the Minneapolis 276 WALKER METHODIST HEALTH CTR x NEGLECT-HEALTH CARE 8/5/2015 staff pulled on his/her arm causing pain and difficulty with physical therapy. x Hennepin It is alleged a client was neglected when an individual attempted to force the client to have sex and injured Minneapolis 23337 TOUCHSTONE MENTAL HEALTH x NEGLECT-SUPERVISION 3/27/2017 6/28/2017 the client's finger during an altercation in the facility. x Hennepin

Minneapolis 23337 TOUCHSTONE MENTAL HEALTH x ABUSE-EMOTIONAL-STAFF 2/14/2017 6/23/2017 It is alleged that abuse occurred when staff made threatening and forceful advances towards the client. x Hennepin It is alleged that a client was financially exploited when several withdrawals were made from the client's Minnetonka 1403 REM HENNEPIN MINNETONKA EXPLOITATION BY OTHER 5/17/2017 3/9/2018 account. x Hennepin

It is alleged that a client was neglected when s/he did not receive his/her Neurontin medication for four Minnetonka 23866 Brookdale Minnetonka x NEGLECT-Medications 1/12/2016 6/9/2016 days. The client began to have withdrawal symptoms and suicidal thoughts x Hennepin It is alleged that a client was abused when alleged perpetrator shaved client's pubic hair and played with Minnetonka 20677 Brookdale Minnetonka Carlson x TOUCHING/FONDLING BY STAFF 1/2/2018 1/24/2018 his/her private parts. x Hennepin it is alleged that a client was neglected when the facility failed to provide appropriate care, resulting in a fall Minnetonka 20677 Brookdale Minnetonka Carlson P x NEGLECT-MEDICATIONS Medication Error 10/6/2016 10/26/2017 and fractures from a lift x Hennepin Fall Due Equipment Failure Neglect of health it is alleged that a client was neglected when the facility failed to provide appropriate care, resulting in a fall Minnetonka 20677 Brookdale Minnetonka Carlson P x care-falls 10/6/2016 10/26/2017 and fractures from a lift x Hennepin ABUSE-EXPLOITATION-Staff Abuse-Exploitation it is alleged that a client was financially exploited when a staff alleged perpetrator (AP) took pain medication Minnetonka 20677 Brookdale Minnetonka Carlson P x DRUG DIVERSION 9/14/2015 12/4/2015 and money from the client for her/his own personal use x Hennepin It is alleged that a client was neglected when s/he was hit by a hoyer lift two times in the last month causing Minnetonka 20677 Brookdale Minnetonka Carlson P x NEGLECT-HEALTH CARE 6/23/2016 8/2/2016 injuries. x Hennepin It is alleged that a resident was abused when a staff grabbed resident's hair and asked the resident how PHYSICAL ABUSE BY STAFF Minnetonka 28083 PROVISIONAL HOME HEALTH LLC x 7/24/2017 12/12/2017 he/she liked it. x Hennepin It is alleged that the client was neglected when staff failed to administer thirteen doses of his seizure Minnetonka 1403 REM Hennepin Minnetonka Medication Errors 9/1/2016 2/13/2017 medication. The client has a seizure, became unresponsive and was hospitalized. x Hennepin 8/1/2017 It is alleged that a client was neglected when the facility failed to answer call lights in a timely manner. The NEGLECT-HEALTH CARE, FALLS ABUSE- client fell and sustained a fractured femur and subsequently passed away. In addition the facility staff were Minnetonka 30281 THE WATERS SR LVG MGMT LLC x PHYSICAL-STAFF 8/1/2017 rough with cares, failed to provide daily personal cares, medication administration and meals. x Hennepin It is alleged a client was abused when a staff/alleged perpetrator hit the client. Client was found in the Minnetonka 30281 THE WATERS SR LVG MGMT LLC x ABUSE-PHYSICAL 6/14/2017 7/24/2017 bathroom with a bleeding cut to the lip. x Hennepin EXPLOITATION BY DRUG DIVERSION DRUG It is alleged that a client was financially exploited when the alleged perpetrator diverted two tablets of 3/14/2017 Minnetonka 30281 THE WATERS SR LVG MGMT LLC x DIVERSION 12/7/2016 oxycodone from the client's medication supply. x Hennepin

It is alleged that the client was neglected when the facility failed to provide enough supervision, resulting in the resident being found on the floor by the EMS and then taken to the hospital. At the hospital when a urinary catheter was inserted inside the resident, hospital staff noticed labial bruising, a vaginal tear, bruising Minnetonka 30281 THE WATERS SR LVG MGMT LLC x NEGLECT-FALLS UNEXPLAINED INJURY 12/7/2016 3/6/2017 to the right and left upper arm, and bruising to the left wrist. x Hennepin

It is alleged that a resident was abused when a staff, AP hit and kicked the resident. The AP yelled at the Montevideo 62 Luther Haven x ABUSE-PHYSICAL, EMOTIONAL-STAFF 1/28/2016 6/6/2016 resident. The resident if fearful. . . . The facility terminated the AP's employment as a result of the incident. x Chippewa

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 62 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County

It is alleged that a client was verbally abused and threatened by the AP when the AP said to the client "turn Montevideo 1266 REM SW Services Montevideo ABUSE-EMOTIONAL-STAFF 2/13/2017 8/7/2017 around right now and put your stuff in the sink like staff told you." x Chippewa It is alleged that a client was abused by alleged perpetrator (AP) #1, AP #2, and AP #3. The AP's yell and scare PHYSICAL ABUSE BY STAFF EMOTIONAL ABUSE the client and AP #1 pulled hard on the client's arm. It is alleged that the three AP's are also verbally abusive Montgomery 26604 Traditions of Montgomery LLC x BY STAFF 10/19/2017 11/21/2017 to other clients. x Le Sueur

It is alleged that a resident was neglected when the resident had a change in condition, including symptoms of drowsiness, inability to speak, and unresponsiveness for several days. The resident was hospitalized in Monticello 717 Centracare Health Monticello x NEGLECT-HEALTH CARE 3/30/2016 9/26/2016 critical condition, with severe dehydration, and possible kidney failure. x Wright 01/25/2018 NEGLECT OF HEALTH CARE STAFFING and It is alleged that a client was neglected when facility staff failed to provide adequate personal care according Moorhead 23403 Arbor Park Living Center x SHORTAGE 01/26/2018 3/13/2018 to the client's service plan. It is also alleged that the facility is short staffed resulting in neglecting the client. x Clay It is alleged that a resident was neglected when the resident fell into a ditch and facility staff failed to NEGLECT HEALTHCARE:FALLS NEGLECT OF provide adequate evaluation to his condition post fall; which let to his admittance to the hospital in critical Moorhead 938 Moorhead Rehab & HCC x HEALTHCARE 12/13,14/2017 2/20/2018 condition. x Clay It is alleged that a resident was financially exploited when staff, an alleged perpetrator, took narcotic Moorhead Golden LivingCenter Moorhead x EXPLOITATION - DRUG DIVERSION 2/16/2016 2/20/2017 medications from the resident for his/her own personal use. x Clay

It is alleged that a resident was neglected when staff was using a mechanical lift to transfer the resident and s/he fell out of the lilt hitting his/her head on the floor. The staff did not adequately assess the resident after NEGLECT-HEALTH CARE, FALLS DUE TO EQUIP the fall for change in condition when the resident was vomiting and confused. The resident was not sent to Moorhead Golden Living Center Moorhead x FAILURE, IMAPPROPRIATE USE OF EQUIP 6/1/2018 9/1/2015 the hospital until the next day and was found to have a skull fracture and two brain bleeds. x Clay It is alleged that financial exploitation occurred when unknown client medications were diverted by an EXPLOITATION BY DRUG DIVERSION Moose Lake 23530 Augustana Oakview Care Center LLC x 12/4/2017 2/14/2018 unknown staff person. x Carlton

Multiple patients were financially exploited by an alleged perpetrator while receiving care at the hospital. (Report was concluded on 5/1/17, but amended on 5/22/17 by Kris Lohrke) . . .The AP was terminated from employment at the hospital and the hospital did reimburse all of the patients the money that went missing. Moose Lake 27650 Mercy Hospital ABUSE-EXPLOITATION-STAFF 2/27/2017 5/22/2017 The AP was contacted but declined an interview. x Carlton

Multiple patients were financially exploited by an alleged perpetrator while receiving care at the hospital. (Report was concluded on 5/1/17, but amended on 5/22/17 by Kris Lohrke) . . .The AP was terminated from employment at the hospital and the hospital did reimburse all of the patients the money that went missing. Moose Lake 27650 Mercy Hospital ABUSE-EXPLOITATION-STAFF 2/27/2017 5/22/2017 The AP was contacted but declined an interview. x Carlton Multiple patients were financially exploited by an alleged perpetrator while receiving care at the hospital. (Report was concluded on 5/1/17, but amended on 5/22/17 by Kris Lohrke) . . .The AP was terminated from Moose Lake 27650 Mercy Hospital ABUSE-EXPLOITATION-STAFF 2/27/2017 5/22/2017 employment at the hospital and the hospital did reimburse all of the patients the money that went missing. x Carlton

Multiple patients were financially exploited by an alleged perpetrator while receiving care at the hospital. (Report was concluded on 5/1/17, but amended on 5/22/17 by Kris Lohrke) . . .The AP was terminated from employment at the hospital and the hospital did reimburse all of the patients the money that went missing. Moose Lake 27650 Mercy Hospital ABUSE-EXPLOITATION-STAFF 2/27/2017 5/22/2017 The AP was contacted but declined an interview. x Carlton Multiple patients were financially exploited by an alleged perpetrator while receiving care at the hospital. ABUSE-FINANCIAL EXPLOITATION-STAFF (Report was concluded on 5/1/17, but amended on 5/22/17 by Kris Lohrke) . . .The AP was terminated from Moose Lake 27650 Mercy Hospital 2/27/2017 5/22/2017 employment at the hospital and the hospital did reimburse all of the patients the money that went missing. x Carlton

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 63 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County It is alleged that clients are neglected when the clients in the memory care unit are left unsupervised. As a result, there have been several falls, not enough staff to provide adequate personal cares and assistance Mora 3022 St. Clare Living Community of Mora x NEGLECT-SUPERVISION, HEALTH CARE 10/28/2015 1/20/2016 with transfers. x Kanabec Morgan 542 Gil Mor Manor x NEGLECT-HEALTH CARE 4/20/2016 6/21/2016 It is alleged that a resident was neglected when s/he had a fall and sustained a broken hip. x Redwood 12/05/2017, 12/06/2017 NEGLECT OF SUPERVISION-RESIDENT TO and It is alleged that Resident #1 and Resident #2 were neglected when facility staff failed to provide adequate Morris 654 West Wind Village x RESIDENT 12/07/2017 3/6/2018 supervision and Resident #1 stated Resident #2 slapped him/her. x Stevens

It is alleged that a resident was neglected when facility staff did not assess for an acute illness and the Morris 654 West Wind Village x NEGLECT OF HEALTH CARE 12/5,6,7/201 3/1/2018 resident was sent to the emergency department (ED) where a urinary tract infection (UTI) was identified. x Stevens

It is alleged that Resident #1 and Resident #2 were neglected when the facility staff failed to provide Morris 654 West Wind Village x NEG. OF SUPERVISION: RESIDENT TO RESIDENT 12/5,6,7/2017 3/1/2018 adequate supervision resulting in Resident #2 hitting Resident #1. Resident #1 developed a swollen lip. x Stevens It is alleged that a resident was neglected when staff failed to use a total assist lift appropriately resulting in a Morris 654 WEST WIND VILLAGE x FALLS DUE TO EQUIPMENT FAILURE 12/5,6,7/2017 3/13/2018 fall. x Stevens

It is alleged that a resident was sexually assaulted by an unknown alleged perpetrator (AP) when the resident presented to an emergency room (ER) for neurological changes with tremors and poor intake. During the body assessment in the ER, it was noted that the resident had significant bruising to her entire body Morris 654 West Wind Village x ABUSE-SEXUAL UNEXPLAINED INJURY 5/22,23/2017 12/4/2017 including the resident's genitalia and a linear tear to the right side of the vaginal wall. x Stevens

It is alleged that a resident was sexually assaulted by an unknown alleged perpetrator (AP) when the resident presented to an emergency room (ER) for neurological changes with tremors and poor intake. During the body assessment in the ER, it was noted that the resident had significant bruising to her entire body Morris 654 West Wind Village x ABUSE-SEXUAL 5/22,23/2017 12/4/2017 including the resident's genitalia and a linear tear to the right side of the vaginal wall. x Stevens

It is alleged that a resident was sexually assaulted by an unknown alleged perpetrator (AP) when the resident presented to an emergency room (ER) for neurological changes with tremors and poor intake. During the body assessment in the ER, it was noted that the resident had significant bruising to her entire body Morris 654 West Wind Village x ABUSE-SEXUAL 5/22,23/2017 12/4/2017 including the resident's genitalia and a linear tear to the right side of the vaginal wall. x Stevens It is alleged that a resident was neglected when staff failed to properly assess the resident when s/he had shortness of breath and coughing for three days and staff did not have the resident evaluated by emergency Morris 654 West Wind Village x NEGLECT OF HEALTH CARE 2/15/2015 7/21/2015 services. The resident was later admitted to the hospital with aspiration pneumonia and passed away. x Stevens It is alleged that a resident was neglected when s/he was administered the incorrect medication and s/he New Brighton 940 Benedictine Health Center Innsbruck x NEGLECT OF HEALTH CARE-MEDICATIONS 01/23/20173/30/2016 5/12/2016 developed a brain bleed. x Ramsey and It is alleged that a resident was neglected when the facility provided the resident with a hot pack. The New Brighton 940 Benedictine Health Center Innsbruck x NEGLECT-HEALTH CARE 01/24/2017 3/30/2017 Itresident is alleged sustained that a resident a burn to was the neglected lower back. when staff did not administer pain medications and anti-nausea x Ramsey NEGLECT OF HEALTH CARE MEDICATION medications as requested by the resident. Staff administered the medications 14 hours after requested by New Brighton 940 Benedictine Health Center Innsbruck x ERRORS 3/1/2017 3/30/2017 Itthe is resident.alleged that The a resident resident was was in neglected so much whenpain and staff felt failed as though to provide s/he adequate was dying. wound Staff checkedcare in accordance the x Ramsey with the physician's orders. The wound became inflamed with drainage with black markings surrounding New Brighton 940 Benedictine Health Center Innsbruck x NEGLECT-HEALTH CARE 09/02/20153/1/2017 2/3/2017 Itwound. is alleged Also, that staff a residentfailed to wasmonitor neglected the resident's when staff change failed in to condition adequately when assess s/he the became resident unresponsive when s/he x Ramsey and developed a persistent cough, was losing weight, and was unable to eat for 10 days. The resident was taken New Brighton 940 Benedictine Health Center Innsbruck x NEGLECT OF HEALTH CARE 04/18/201609/03/2015 11/14/2016 to the hospital and admitted for blood clots in her/his lungs. x Ramsey and It is alleged that a resident was neglected when s/he was found by facility staff deceased in his/her closet. In New Brighton 940 Benedictine Health Center Innsbruck x NEGLECT-FALLS, HEALTH CARE 04/19/2016 7/18/2016 addition, facility staff failed to comply with catheter and pain medication orders. x Ramsey

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 64 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County It is alleged that a resident was abused when the alleged perpetrator was rough with the resident and the New Brighton 940 Benedictine Health Center Innsbruck x PHYSICAL ABUSE BY STAFF 2/18/2016 6/24/2016 resident developed bruises. x Ramsey It is alleged that a resident was neglected when s/he was left unattended in the easy stand lift for New Brighton 114 Health and Rehab New Brighton x NEGLECT-HEALTH CARE 08/16/2016,7/18/2016 6/23/2017 approximately one hour and the resident was found deceased. x Ramsey 08/17/2016 New Brighton 114 Health and Rehab New Brighton x NURSING CARE NEGLECT-HEALTH CARE and 4/19/2017 It is alleged that the facility staff failed to provide residents with dental hygiene cares. x Ramsey It is alleged that a resident was neglected when facility staff failed to ensure resident was assessed for blood New Brighton 114 Health and Rehab New Brighton x NEGLECT-HEALTH CARE 12/28/2015 1/19/2016 Itclots. is alleged The resident that a resident was admitted was neglected to the hospital when thewith nursing a blood home clot and staff passed did not away properly a few provide days later. dialysis. In x Ramsey addition the resident had multiple falls and the facility did not notify the family. The resident hit his/her head New Brighton 114 Health and Rehab New Brighton x NEGLECT-HEALTH CARE, FALLS 4/29/2015 11/18/2015 during one of these falls. The resident was then sent out of the facility for dialysis, was too sick to receive x Ramsey PHYSICAL ABUSE BY STAFF EMOTIONAL ABUSE It is alleged that a resident is being hit and pinched by staff. In addition, the resident is very scared and New Brighton 114 Health and Rehab New Brighton x BY STAFF 7/22/2015 8/4/2015 reports staff holler at the resident. x Ramsey

It is alleged that a resident was neglected when staff failed to provide adequate cares and assess for change in condition when the resident became lethargic, was dehydrated, had abdominal bruising and subsequently New Brighton 114 Health and Rehab New Brighton x NEGLECT-HEALTH CARE 2/6/2015 5/20/2015 was hospitalized with a ruptured spleen, sepsis, and deep wounds. x Ramsey It is alleged that a resident was neglected when staff failed to provide adequate personal cares, repositioning NEGLECT-HEALTH CARE 4/27/2015 and catheter cares to the resident in a timely manner resulting in the resident being hospitalized and New Brighton 114 Health and Rehab New Brighton x 3/23/2015 needing surgery for decubiti. x Ramsey It is alleged that a resident was neglected when staff failed to provide adequate wound cares and assessment and personal cares. The resident developed new pressure ulcers, gangrene, and subsequently New Brighton 114 Health and Rehab New Brighton x NEGLECT-HEALTH CARE 2/2/2015 12/14/2015 died. x Ramsey

It is alleged that a resident was neglected when staff failed to adequately asses him/her for change in 06/30/2015 condition when the resident was not able to swallow, was very weak, had a low pulse and the resident was and hospitalized with severe dehydration, malnutrition and sepsis. The resident lost 53 pounds in four months New Brighton 507 New Brighton Care Center x NEGLECT OF HEALTH CARE NEGLECT-DECUBITI 07/02/2015 3/31/2016 and had developed two golf ball sized bedsores that were untreated. x Ramsey 11/28/2016 It is alleged that a resident was neglected when the alleged perpetrator (AP)/staff administered wrong NEGLECT-MEDICATION ERRORS MEDICATION and medications to the resident. The resident was transferred to the hospital when emergency medical New Brighton 114 New Brighton OPCO LLC x ERROR 11/29/2016 1/8/2018 treatment was required. x Ramsey 11/28/2016 It is alleged that a resident was neglected when the alleged perpetrator (AP)/staff administered wrong NEGLECT-HEALTH CARE, MEDICATION ERRORS, and medications to the resident. The resident was transferred to the hospital when emergency medical New Brighton 114 New Brighton OPCO LLC x FAILURE TO REPORT 11/29/2016 1/8/2018 treatment was required. x Ramsey

It is alleged that a resident was abused when staff were rough with cares and he/she had finger sized bruises New Hope 898 Good Sam Society Ambassador x Abuse-Physical-staff 2/12/2015 9/14/2015 on her arms and hands. The facility did not notify the guardian or document the injuries. x Hennepin

It is alleged that a client was neglected when staff failed to supervise the client. Staff found the client in the parking garage where the client had sustained a fall. Later that morning client had a low body temperature. New Hope 2852 Home Health at North Ridge x Neglect-Supervision Patient Rights 12/27/2016 6/14/2017 The facility transferred the client to the hospital. The client did not return. x Hennepin It is alleged that client #1 was neglected when facility staff failed to provide adequate supervision that resulted in Client #2 injuring Client #1 lefts hand. Client #1 required emergency medical services and hand New Hope 1563 MTAI Minnehaha Creek Neglect-Supervision-Resident to Resident 11/9/2017 12/29/2017 surgery due to the injury. x Hennepin It is alleged that a resident was neglected when a staff/alleged perpetrator (AP) administered a higher than ordered dose of narcotic, the resident was found on the floor, paramedic responded and found the resident New Hope 238 North Ridge Health and Rehab x Neglect-Medication Errors, Health Care 4/6/2017 12/18/2017 dead. x Hennepin

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 65 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County

December 15 It is alleged that neglect occurred when the resident had a change in condition that was not noticed by New Hope 238 North Ridge Health and Rehab x NEGLECT OF HEALTH CARE & 16 2016 7/14/2017 facility staff and not responded to timely. The resident had a stroke and was hospitalized. x Hennepin January 26& It was alleged that the resident was neglected when he/she had a fall and sustained a femur fracture. The New Hope 238 North Ridge Health and Rehab x NEGLECT-HEALTH CARE 27 2016 2/23/2017 resident passed away approximately one week later. x Hennepin February 3, 4 5 It is alleged that a resident was abused when the staff/ alleged perpetrator slapped the resident. The New Hope 238 North Ridge Health and Rehab x ABUSE-PHYSICAL-STAFF 2016 10/10/2016 resident is fearful for his/her life. x Hennepin

It is alleged that the resident suffered a hip and skull fracture when staff failed to follow the care plan for New Hope 238 North Ridge Health and Rehab x NEGLECT-HEALTH CARE May 19,20 2016 4/22/2016 transfers and did not properly transfer the resident with the appropriate mechanical lift. x Hennepin

It is alleged that two residents (R1 and R2) were abused when several employees, the Alleged Perpetrators New Hope 261 St Therese Home x Abuse-Physical, Emotional-Staff 1/25/2015 1/29/2016 (Aps), punched and were rough with the residents, resulting in bruising and skin tears. x Hennepin It is alleged that the resident was abused by an unknown employee, an unknown alleged perpetrator, and New Hope 261 St Therese Home x PHYSICAL ABUSE BY STAFF 6/22/2017 3/7/2018 other staff observed the abuse. x Hennepin It is alleged that the resident was abused by an unknown employee, an unknown alleged perpetrator, and New Hope 261 St Therese Home x PHYSICAL ABUSE BY STAFF 6/22/2017 3/7/2018 other staff observed the abuse. x Hennepin 08/16/2016, It is alleged that a resident was neglected when staff failed to provide adequate supervision when the 08/17/2016 resident was left unattended in the smoking area and developed blisters/burns on the resident's legs and NEGLECT OF SUPERVISION NEGLECT OF and groin area. In addition, it is alleged that the resident was neglected when s/he developed pressure ulcers New Hope (New Brighton) 114 Health and Rehab New Brighton x HEALTH CARE NURSING CARE 08/18/2016 4/19/2017 while at the facility. x Ramsey 08/16/2016, It is alleged that a resident was neglected when staff failed to provide adequate supervision when the 08/17/2016 resident was left unattended in the smoking area and developed blisters/burns on the resident's legs and and groin area. In addition, it is alleged that the resident was neglected when s/he developed pressure ulcers New Hope (New Brighton) 114 Health and Rehab New Brighton x NEGLECT-SUPERVISION NURSING CARE 08/18/2016 4/19/2017 while at the facility. x Ramsey

It is alleged that a patient was neglected when staff did not provide adequate care and monitoring of the patient's feet after a stage 2 pressure ulcer was noted. Staff had inconsistent skin documentation and the New London 2204 Lake Region Home Health NEGLECT OF HEALTH CARE-DECUBITI 11/1/2017 2/20/2018 client was found later to have red, swollen feet and a second open area. x Kandiyohi It is alleged that a patient was neglected when a staff, alleged perpetrator (AP) failed to set up the patient's medications. The patient missed ten days of medication and subsequently was found unconscious in her bed New London 2204 Lake Region Home Health NEGLECT-MEDICATIONS 1/27/2015 6/1/2015 and hospitalized with pneumonia. x Kandiyohi

It is alleged that a resident was neglected when an employee, the Alleged Perpetrator (AP), did not follow New Prague 811 Mala Strana Care & Rehab Ctr x NEGLECT- HEALTH CARE, FALLS 5/17/2016 8/30/2016 the resident's care plan and the resident fell, resulting in multiple facial injuries. x Scott

It is alleged staff failed to supervise residents when a resident (Resident #2) entered another resident's room New Prague 811 Mala Strana Care & Rehab Ctr x NEGLECT-SUPERVISION 1/12/2017 10/9/2017 (Resident #1), inappropriately touched his/her breast, and attempted to engage in a sexual act. x Scott It is alleged that a resident was neglected when staff failed to provide adequate supervision. The resident New Prague 811 Mala Strana Care & Rehab Ctr x NEGLECT-SUPERVISION 5/17/2016 5/30/2017 was found unresponsive and expired in the emergency room. x Scott It is alleged that a resident was abused when Alleged Perpetrator (AP) placed her/his hand over the New Richland 748 New Richland Care Center x ABUSE-PHYSICAL, EMOTIONAL-STAFF 2/9/2016 2/25/2016 resident's mouth to prevent the resident from yelling out. x Waseca

It is alleged that a client was neglected when facility staff failed to provide adequate supervision to the New Richland 20378 The Beacon at New Richmond x NEGLECT OF SUPERVISION 8/23/2017 3/8/2018 resident. The client eloped from the facility and was found in a ditch the next day by a passerby. x Waseca

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 66 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County

It is alleged that a client was neglected when facility staff failed to provide adequate supervision to the New Richland 20378 The Beacon at New Richmond x NEGLECT OF SUPERVISION 8/23/2017 3/8/2018 resident. The client eloped from the facility and was found in a ditch tHe next day by a passerby. x Waseca

It is alleged that a client was neglected when facility staff failed to provide adequate supervision to the New Richland 20378 The Beacon at New Richmond x NEGLECT OF SUPERVISION 8/23/2017 3/8/2018 resident. The client eloped from the facility and was found in a ditch the next day by a passerby. x Waseca It is alleged that a resident was neglected when s/he had an allergic reaction to medication for her/her kidney infection and quit eating, drinking, and became unresponsive. The facility did not seek out emergency services when the resident became unresponsive. The resident was eventially hospitalized and was very dehydrated. In addition, the facility staff is incorrectly administering the resident's nebulizer New Ulm 434 Oak Hills Living Center x NEGLECT-HEALTH CARE 5/16/2016 5/16/2016 treatments. x Brown It is alleged that a resident was neglected when staff did not follow the care plan to set the chair alarm correctly. The resident fell from the chair. The resident transferred to the hospital where it was determined New Ulm 434 Oak Hills Living Center x NEGLECT-FALLS 3/1/2017 9/20/2017 the resident suffered a hip fracture. x Brown It is alleged that a client was neglected when the client ran out of narcotic pain medication several times, resulting in the client experiencing withdrawal symptions. The client has been out of the medications for New Ulm 29912 Welcome Home Health Care Inc x NEGLECT-MEDICATIONS 10/27/2015 8/17/2016 three-four days at a time. x Brown

It is alleged that a client was neglected when s/he lost a significant amount of weight when staff failed to assist him/her with eating. IN addition, it is alleged that the licensee does not provide adequate personal New Ulm 29912 Welcome Home Health Care Inc x NEGLECT-HEALTH CARE 1/21/2016 4/1/2016 cares and is not following the care plan, as the facility is transferring the client with one staff instead of two. x Brown It is alleged that a client was neglected when staffed failed to provide adequate supervision on several occasions and s/he was sexually assaulted. In addition, staff observed him/her being sexually assaulted by a New Ulm 29912 Welcome Home Health Care Inc NEGLECT-SUPERVISION LACK OF TRAINING 3/15/2016 visitor and did not report in a timely manner. x Brown It is alleged that a client was neglected when s/he fell off the toilet and was found unconsious. Staff did not follow protocol and attempted to move the client back on the toilet when s/he was found unconscious. The New Ulm 29912 Welcome Home Health Care Inc x NEGLECT-HEALTH CARE 6/16/2016 2/16/2016 client was hospitalized and had a broken hip. x Brown OTHER PENETRATION BY STAFF It is alleged that a client was sexually abused by staff when alleged perpetrator (AP) fondled and sexually Newport 23519 Phoenix at Newport TOUCHING/FONDLING BY STAFF 11/18/2016 5/12/2017 assaulted the client. x Washington

It is alleged that a client attempted to harm self by wrapping a cord around his/her neck and the client was Newport 23519 Phoenix at Newport SELF ABUSE OTHER PENETRATION BY STAFF 11/18/2016 5/12/2017 brought to the hospital. It was later reported that a staff member had sexually abused the client. x Washington It is alleged that a client was sexually abused by staff when the alleged perpetrator (AP) sexually assaulted Newport 23519 Phoenix at Newport OTHER PENETRATION BY STAFF 11/18/2016 5/12/2017 the client. x Washington It is alleged that a client was abused when two staff members inappropriately touched the client's private TOUCHING/FONDLING BY STAFF part without consent. The client stated that s/he did not like it and tried to kill him/herself. The client stated Newport 23519 Phoenix at Newport 11/18/2016 5/12/2017 that s/he also does not want to stay in this facility. x Washington It is alleged that a client was abused when two staff members inappropriately touched the client's private part without consent. The client stated that s/he did not like it and tried to kill him/herself. The client stated Newport 23519 Phoenix at Newport TOUCHING/FONDLING BY STAFF 11/18/2016 5/12/2017 that s/he also does not want to stay in this facility. x Washington It is alleged that a client was sexually abused by staff when the alleged perpetrator (AP) sexually assaulted Newport 23519 Phoenix at Newport ABUSE-SEXUAL 11/18/2016 5/12/2017 the client. x Washington 12/14/2015 and North Oaks 20539 Brookdale North Oaks x NEGLECT OF HEALTH CARE 12/15/2015 7/28/2016 It is alleged that a client was neglected when s/he had a fall and passed away the next day. x Ramsey It is alleged that a client was financially exploited when an alleged perpetrator took a large diamond ring and North Oaks 28191 Waverly Gardens x ABUSE-EXPLOITATION-STAFF 11/17/2017 3/12/2018 diamond tennis bracelet. x Ramsey

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 67 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County It is alleged that a client was neglected when s/he was choking and died as a result. In addition, the facility North Oaks 28191 Waverly Gardens x NEGLECT OF SUPERVISION 12/2/2015 7/18/2016 did not have a POLST for the client. x Ramsey It is alleged that financial exploitation occurred when a staff, alleged perpetrator (AP) stole $646.00 from the North Saint Paul 21714 Healthstar Home Health ABUSE-EXPLOITATION-OTHER 2/10/2015 6/18/2015 client. x Ramsey It is alleged that a client was neglected when facility staff did not follow medication instruction and administered incorrect dose of Coumadin. The client's condition declined, s/he suffered from bleeding gums North Saint Paul 31484 Polar Ridge Sr Living x NEGLECT-HEALTH CARE, MEDICATION ERRORS 3/3/2017 6/20/2017 and red colored urine. x Ramsey Northfield 1163 Laura Baker Services Assoc EXPLOITATION BY OTHER 7/30/2015 3/22/2016 Money was taken from the client's checking account, staff had access to the client's account. X Rice Northfield 1163 Laura Baker Services Assoc NEGLECT 11/18/2015 11/18/2015 Client was abused when staff restrained the client, the client sustained injuries. X Rice It is alleged that a resident was financially exploited when the alleged perpetrator too the resident's NORTHFIELD 1163 LAURA BAKER SERVICES ASSOC EXPLOITATION BY DRUG DIVERSION 1/27/2016 4/27/2016 controlled substance medication for personal use. X Rice It is alleged that the client was neglected when staff failed to provide supervision to a client while the client NORTHFIELD 1163 LAURA BAKER SERVICES ASSOC NEGLECT-SUPERVISION 1/12/2015 6/23/2015 was eating and choked. Emergency medicine was performed incorrectly. X Rice It is alleged that a resident was neglected when the alleged perpetrator (AP) did not properly apply the wheelchair seatbelt, and the resident fell out the wheelchair and was transported to the ED and found to Northfield 1163 LAURA BAKER SERVICES ASSOC NEGLECT OF HEALTH CARE-FALLS 3/14/2017 3/12/2018 have a broken nose. x Rice It is alleged that a client was abused when a staff/alleged perpetrator, grabbed the client's sweatshirt, pulling the client to the floor and straddled the client to restrain him. The client felt threatened and was crying and NORTHFIELD 1163 LAURA BAKER SERVICES ASSOC ABUSE-EMOTIONAL, PHYSICAL 10/28/2015 10/10/2016 visibly upset. X Rice NORTHFIELD 567 NORTHFIELD CARE CENTER INC X NEGLECT OF HEALTH CARE-FALLS 3/18/2016 3/31/2016 It is alleged the client was neglected and fell, suffering a subdural hematoma. X Rice

It is alleged that a resident was neglected when staff did not properly assess the resident for a change in NORTHFIELD 567 NORTHFIELD CARE CENTER INC X NEGLECT-HEALTH CARE 5/5/2015 12/14/2015 condition that included chest pain and numbness in her extremities. The hospital diagnosed a heart attack. X Rice It is alleged that 9 residents were financially exploited when staff used residents' funds for personal use. NORTHFIELD 566 NORTHFIELD HOSPITAL LONG TERM X EXPLOITATION BY STAFF 6/8/2015 8/7/2015 Specific amounts of money were missing from a locked safe. X Dakota NEGLECT OF HEALTH CARE-FALLS NEGLECT OF Alleged perpetrator didn't follow care plan. Transferred the resident with no belt. Resident hit their head, Northfield 564 Three Links Care Center X HEALTH 6/8/2017 12/29/2017 massive brain bleed. Resident never regained consciousness. X Rice

NEGLECT OF HEALTH CARE - FALLS DUE TO Northfield 564 Three Links Care Center X EQUIP FAILURE-INAPPROPRIATE USE OF EQUIP 11/18/2017 12/29/2017 Employee failed to follow policy when transferring with a lift. Resident fell, sustained a fracture. X Rice Alleged perpetrator failed to follow policy when transferring with a stand lift. Resident fell sustained a Northfield 564 Three Links Care Center X FALLS DUE TO EQUIPMENT FAILURE 10/18/2017 12/29/2017 fracture. X Rice

NEGLECT-SUPERVISION SAFETY HAZARDS Northfield 564 Three Links Care Center X PHYSICAL PLANT-MAINTENANCE PROBLEMS 1/19/2017 5/1/2017 Resident was neglected, sustained a burn to the left 5th finger from broken baseboard heater. X Rice

It is alleged that 2 residents were abused when the staff/alleged perpetrators took photos and videos of the residents during personal situations and distributed the photos and videos to over 100 people. The photos NORTHFIELD 564 THREE LINKS CARE CENTER X EMOTIONAL ABUSE BY STAFF 1/6/2015 4/3/2015 and videos were of a derogatory nature, including one client receiving incontinence care. X Rice

NORTHFIELD 564 THREE LINKS CARE CENTER X EXPLOITATION - DRUG DIVERSION 3/27/2017 9/7/2017 It is alleged that a resident was exploited when staff took two vials of the resident's haloperidol medication. X Rice It is alleged that a resident was sexually abused by staff when the perpetrator stuck his finger in the NORTHFIELD 564 THREE LINKS CARE CENTER X N/A 6/19/2017 9/7/2017 resident's rectum. X Rice It is alleged that a resident was sexually abused by staff when the perpetrator stuck his finger in the NORTHFIELD 564 THREE LINKS CARE CENTER X N/A 6/19/2017 9/7/2017 resident's rectum. X Rice It is alleged that a resident was sexually abused by staff when the perpetrator stuck his finger in the NORTHFIELD 564 THREE LINKS CARE CENTER X N/A 6/19/2017 9/7/2017 resident's rectum. X Rice

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 68 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County It is alleged that a resident was sexually abused when the alleged perpetrator inappropriate touched the resident all over the resident's body. The incident happened at bedtime, and the resident was afraid to tell NORTHFIELD 564 THREE LINKS CARE CENTER X ABUSE-SEXUAL 1/19/2017 4/21/2017 others. X Rice It is alleged that a resident was sexually abused when the alleged perpetrator inappropriate touched the resident all over the resident's body. The incident happened at bedtime, and the resident was afraid to tell NORTHFIELD 564 THREE LINKS CARE CENTER X ABUSE-SEXUAL 1/19/2017 4/21/2017 others. X Rice It is alleged that a client was neglected when staff did not supervise the client. Staff were unable to locate 12/20/2016 the client late at night. Two hours later, staff contacted law enforcement. Law enforcement notified the NEGLECT OF SUPERVISION NEGLECT OF and facility about two and a half hours later that the client was found outside in the inclement weather and was Oak Park Heights 28193 Boutwell's Landing x HEALTH CARE 12/21/2016 6/9/2017 deceased. x Washington

Oak Park Heights 25613 Gables of Boutwell's Landing x ABUSE - SEXUAL 1/4/2016 3/17/2017 It is alleged that a resident was sexually assaulted by the Alleged Perpetrator (AP), identity unknown. x Washington

It is alleged that a resident was neglected when the resident slipped out of the shower chair. The resident Oak Park Heights 25613 Gables of Boutwell's Landing x NEGLECT-FALLS NURSING CARE 12/1/2016 12/28/2016 was transferred to the hospital ten days later and was found to have a significantly fractured leg. x Washington It is alleged that a resident was neglected when facility staff failed to provide adequate supervision when the resident utilized heat packs on her shoulder. The resdient developed a 4 centimeter (cm) by 5 cm blister Oak Park Heights 25613 Gables of Boutwell's Landing x NEGLECT - SUPERVISION 11/22/2017 2/5/2018 wound on her left shoulder. x Washington ABUSE-EMOTIONAL-STAFF NEGLECT-HEALTH Oak Park Heights 28226 Oak Park Senior Living x CARE ABUSE-PHYSICAL-STAFF 1/30/2017 5/10/2017 It is alleged that a client was physically and emotionally abused by the alleged perpetrator (AP). x Washington It is alleged that a client was neglected when a staff, alleged perpetrator (AP) administered another client's medications to the client, so the client would sleep and prevent the client from using her/his call light and Oak Park Heights 28226 Oak Park Senior Living NEGLECT - MEDICATIONS 3/23/2015 3/23/2015 bother staff. x Washington It is alleged that a client was financially exploited when the alleged perpetrator (AP) used the client's credit Oakdale 32521 Comforcare Home Care St Paul E x ABUSE - EXPLOITATION - STAFF 8/29/2017 10/6/2017 card for personal use without the client's authorization. x Washington It is alleged that a client was financially exploited when the alleged perpretrator (AP) used the client's credit Oakdale 32521 Comforcare Home Care St Paul E x ABUSE - EXPLOITATION - STAFF 8/29/2017 10/6/2017 card for personal use without the client's authorization. x Washington It is alleged that clients (#1, #2, #3) were financially exploited when a staff, alleged perpetrator took the Ogilvie 26359 Signe and Olivias x ABUSE-EXPLOITATION-DRUG DIVERSION 4/6/2016 9/20/2016 client's medication for his/her own personal use. x Kanabec EMOTIONAL ABUSE BY STAFF NEGLECT OF Olivia 939 Olivia Rehab & HCC x SUPERVISION 2/24/2017 6/14/2017 It is alleged that residents were abused when the alleged perpetrator was rude towards the residents. x Renville

It is alleged that a client was neglected when two alleged perpetrators (AP #1 and AP #2) failed to follow appropriate care of a skin laceration. Both AP #1 and AP #2 used the client's robe tie as a tourniquet to the client's arm and left it on overnight. Next morning, the client developed swollen fingers and a bright red, Onamia 24552 Lake Song Assisted Living x NEGLECT-HEALTH CARE, SUPERVISION 03/28,29/2017 12/22/2017 noticeable groove in the arm from the tourniquet. The client passed away due to sepsis. x Mille Lacs

It is alleged that a client was neglected when two alleged perpetrators (AP #1 and AP #2) failed to follow appropriate care of a skin laceration. Both AP #1 and AP #2 used the client's robe tie as a tourniquet to the client's arm and left it on overnight. Next morning, the client developed swollen fingers and a bright red, Onamia 24552 Lake Song Assisted Living x NEGLECT-HEALTH CARE, SUPERVISION 03/28,29/2017 12/22/2017 noticeable groove in the arm from the tourniquet. The client passed away due to sepsis. x Mille Lacs It is alleged that a client was financially exploited when a staff member/alleged perpetrator took $100 from Onamia 24552 Lake Song Assisted Living x ABUSE-EXPLOITATION-STAFF 03/28,29/2017 12/22/2017 the client. x Mille Lacs NEGLECT OF HEALTH CARE-DECUBITI NEGLECT It is alleged that a resident was neglected when the facility failed to provide appropriate care to a pressure Ortonville 771 Fairway View Neighborhoods x OF HEALTH CARE 6/12/2017 8/11/2017 ulcer resulting in a stage 4 pressure ulcer on the resident's coccyx. x Big Stone It is alleged that a residen was verbally abused by alleged perpetrators (AP #1 and AP #2) when they swear Ortonville 771 Fairway View Neighborhoods x ABUSE-EMOTIONAL-STAFF 7/6/2017 8/11/2017 at the resident and are rude to the resident. x Big Stone

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 69 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County It is alleged that a client was neglected s/he received a double dose of medications became very disoriented, Osseo 20531 BenedictineSenior Living at Steeple Point x NEGLECT-HEALTH CARE 8/26/2015 2/9/2016 and had low blood pressure. The client was hospitalized. x Hennepin It was alleged that the residence was abused when he/she reported and a staff, alleged perpetrator (AP) began to call the resident names and make mean comments to him/her. The resident feels intimidated and Osseo 733 THE VILLA AT OSSEO x ABUSE-EMOTIONAL-STAFF 9/15/2015 9/7/2016 has been isolating to avoid the AP. x Hennepin It is alleged that a patient was neglected when a staff, alleged perpetrator unsafely transferred, dumping water on his / her face. Emergency response called, CPR administered. Admitted to hospital with Ostego 21487 Accurate Home Care LLC NURSING CARE NEGLECT-HEALTH CARE Feb 2 - 3 2016 2/2/2017 pneumonia. x Wright 08/31/2017 It is alleged that a client was neglected when staff/alleged perpetrator (AP) inappropriately transferred the and client with the use of a mechanical lift. The client sustained a fall that resulted in loss of a tooth, loosened Otsego 21487 Accurate Home Care LLC PATIENT RIGHTS 09/05/2017 1/11/2018 teeth, a swollen cheek and wrists and continued pain. x Wright 01/18/2017 and It is alleged that a client was neglected when a nurse did not show to the client's home to provide scheduled Otsego 21487 Accurate Home Care LLC NEGLECT-HEALTH CARE NURSING CARE 01/19/2017 2/2/2017 care and the client had to go to the emergency room. There is no adequate plan of care in place. x Wright 12/28/2015 and It is alleged that a client was neglected when an alleged perpetrator provided and served client with multiple Otsego 21487 Accurate Home Care LLC NURSING CARE NEGLECT-HEALTH CARE 12/29/2015 5/10/2016 glasses of wine without a physician order. x Wright

It is alleged that a client was neglected when staff/alleged perpetrator (AP) did not adequately provide Sherburn Otsego 21487 Accurate Home Care LLC NURSING CARE NEGLECT-HEALTH CARE 11/1/2016 12/22/2016 emergency care when the client was unresponsive. The client died three days later. x e

It is alleged that a client was neglected when staff/alleged perpetrator (AP) did not adequately provide Otsego 21487 Accurate Home Care LLC NURSING CARE NEGLECT-HEALTH CARE 11/1/2016 12/22/2016 emergency care when the client was unresponsive. The client died three days later. x Wright

It is alleged that the patient was neglected when s/he was found with an improperly connected ventilator. Sherburn Otsego 21487 Accurate Home Care LLC NURSING CARE NEGLECT-HEALTH CARE 2/2/2016 10/24/2016 Patient's oxygen levels were extremely low and needed to be hospitalized. x e 02/02/2016 and It is alleged that a patient was neglected when s/he was found with an improperly connected ventilator. Otsego 21487 Accurate Home Care LLC NURSING CARE NEGLECT-HEALTH CARE 02/03/2016 10/24/2016 Patient's oxygen levels were extremely low and needed to be hospitalized. x Wright 04/20/2015 and It is alleged that a patient was financially exploited when the alleged perpetrator (AP) took the patient's Otsego 21487 Accurate Home Care LLC ABUSE-EXPLOITATION-DRUG DIVERSION 04/21/2015 6/6/2015 medication for the AP's own use. x Wright It is alleged that a client was abused when the alleged perpetrator grabbed the client by the wrist and PHYSICAL ABUSE BY STAFF EMOTIONAL ABUSE shoved him/her backwards. It is also alleged that the perpetrator spoke to the client in a threatening Owatonna 31944 Birchwood Cottages x BY STAFF 11/9/2017 3/12/2018 manner. x Steele It is alleged that a client was abused when the alleged perpetrator grabbed the client by the wrist and PHYSICAL ABUSE BY STAFF EMOTIONAL ABUSE shoved him/her backwards. It is also alleged that the perpetrator spoke to the client in a threatening Owatonna 31944 Birchwood Cottages x BY STAFF 11/9/2017 3/12/2018 manner. x Steele It is alleged a client was abused when staff/alleged perpetrator (AP) inappropriately touched the client after Owatonna 20851 Brookdale Owatonna x ABUSE-SEXUAL 3/21/2017 9/17/2017 s/he assisted the client with a shower. x Steele

It is alleged that a resident was neglected by a staff member that did not transfer the resident according to Owatonna 644 Koda Living Community x NEGLECT OF HEALTH CARE 11/3/2015 5/24/2016 his/her care plan. Resident was hospitalized and underwent surgery for a distal femoral fracture. x Steele

It is alleged a client was neglected after 15 falls in three weeks due to call lights not being answered timely NEGLECT-HEALTH CARE STAFFING SHORTAGE due to staffing shortages. In addition, it is alleged that medications are being administered by staff that are Owatonna 21085 Park Place Senior Living x NURSING CARE 11/24/2014 6/17/2015 not adequately trained. Also, it is alleged that an on call nurse is not available for staff to contact. x Steele

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 70 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County It is alleged that several clients were financially exploited when a staff, alleged perpetrator, (AP) took client's Owatonna 1439 REM Woodvale Inc Adams ABUSE-EXPLOITATION BY STAFF 9/30/2015 2/5/2016 money for his/her own personal use. x Steele It is alleged that clients were emotionally and physicallly abused when a staff, alleged perpetrator (AP) yelled Owatonna 1439 REM Woodvale Inc Adams ABUSE-PHYSICAL, EMOTIONAL-STAFF 7/16/2015 12/22/2015 and swore at the clients and physically pushed the clients. x Steele

It is alleged that a client was abused when the facility staff caused bruises on the client's forearms. It is also ABUSE-PHYSICAL-STAFF ABUSE-EXPLOITATION- alleged the client was financially exploited when the staff took the client to the bank and had the client close Owatonna 1439 REM Woodvale Inc Adams STAFF 11/22/2016 7/6/2017 the account, without informing the client or the client's family of the disposition of the money. x Steele

It is alleged that a client was abused when the facility staff caused bruises on the client's forearms. It is also alleged the client was financially exploited when the staff took the client to the bank and had the client close Owatonna 1439 REM Woodvale Inc Adams ABUSE-PHYSICAL-STAFF 11/22/2016 7/6/2017 the account, without informing the client or the client's family of the disposition of the money. x Steele It is alleged that a client was neglected when the facility staff, alleged perpetrator #1 and #2, did not initiate cardiopulmonary resuscitation when the client was found with no pulse and was not breathing. The client's Owatonna 24247 Traditions of Owatonna x FAILURE TO DO CPR 11/24/2017 2/7/2018 code status was full code. x Steele

It is alleged that client was neglected when staff failed to provide adequate supervision during meal times. NEGLECT-SUPERVISION-RESIDENT TO Client #1 got into a verbal altercation with Client #2, which lead to Client #2 grabbing Client #1 by the arm Owatonna 24247 Traditions of Owatonna x RESIDENT 5/11/2016 2/5/2018 and right shoulder and throwing Client #1 into a wall and hitting Client #1 in the side. x Steele

It is alleged that a client was neglected when when facility staff failed to provide medical care promptly Owatonna 24247 Traditions of Owatonna x NEGLECT OF HEALTH CARE 5/11/2016 2/5/2018 when the client fell. The client was on the floor for over an hours. Facility staff is also short staffed. x Steele It is alleged that client was neglected when facility staff failed to seek medical care for the client when the NEGLECT OF HEALTH CARE FAILURE TO client was unable to urinate and deficate for four days. The client had increased abdominal pain, called the Owatonna 24247 Traditions of Owatonna x REPORT 5/11/2016 12/27/2017 emergency room twice and got the proper care. x Steele

TOUCHING/FONDLING BY STAFF EMOTIONAL Owatonna 24247 Traditions of Owatonna x ABUSE BY STAFF FAILURE TO REPORT 5/11/2016 12/27/2017 It is alleged a client was sexually abused twice a day by a staff member, alleged perpetrator x Steele

It is alleged that a client was neglected when s/he had an outbreak of bed bugs in his/her apartment and Owatonna 24247 Traditions of Owatonna x NEGLECT-HEALTH CARE 10/5,6/2016 7/11/2017 staff stopped answering his/her call light as staff were fearful of getting bed bugs. x Steele

It is alleged a client had not been provided adequate nursing care by unnamed staff. Client has sores on her Owatonna 24247 Traditions of Owatonna x NEGLECT-HEALTH CARE 5/11/2017 2/5/2018 buttock and in the folds underneath her breasts and is not receiving daily cares of her sores. x Steele

It is alleged that a client was neglected when s/he had a change in condition, with symptoms of weakness NEGLECT-HEALTH CARE MEDICATION and difficulty breathing. The client was hospitalized and found to be dehydrated and had a lack of oxygen. In Owatonna 25424 Traditions of Owatonna II x ADMINISTRATION 10/7/2016 7/13/2017 addition, the client did not receive his/her medications for two days at the facility due to a system error. x Steele

It is alleged that a client was neglected when the facility failed to report and provide care after a fall that led Owatonna 25424 Traditions of Owatonna ii x NEGLECT-FALLS 5/31/2017 3/2/2018 to a brain hemorrhage. The client was also left on the floor for seven hours. x Steele

NEGLECT-HEALTH CARE, SUPERVISION, It is alleged that a client was neglected when the facility failed to report and provide care after a fall that led Owatonna 25424 Traditions of Owatonna ii x FAILURE TO NOTIFY PHYSICIAN 5/31/2017 3/2/2018 to a brain hemorrhage. The client was also left on the floor for seven hours. x Steele

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 71 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County

It is alleged that a client was neglected when s/he left the facility and was found trying to cross a busy interstate highway. In addition, it is alleged that the client was abused when the alleged perpetrator (AP) Owatonna 25301 Valleyview of Owatonna LLC x NEGLECT-SUPERVISION 11/4,5/202015 4/18/2016 came to pick up the client and was yelling at the client. The police returned the client to the facility. x Steele It is alleged that a resident was neglected when staff/alleged perpetrator (AP) did not follow appropriate 12/20/2016 care plan resulting in multiple falls. After the second fall, resident was transferred to the hospital and was and diagnosed with skull fracture with intra cranial bleeding. Resident passed away due to probable Park Rapids 288 Heritage Living Center x NEGLECT-FALLS 12/21/2016 8/22/2017 complications of closed head injury. x Hubbard It is alleged that a resident was neglected when staff/alleged perpetrator (AP) did not follow appropriate 12/20/2016 care plan resulting in multiple falls. After the second fall, resident was transferred to the hospital and was and diagnosed with skull fracture with intra cranial bleeding. Resident passed away due to probable Park Rapids 288 Heritage Living Center x H5052040NEGLECT-FALLS NURSING CARE 12/21/2016 8/22/2017 complications of closed head injury. x Hubbard It is alleged that a resident was neglected when staff transferred him/her in an unsafe manner that caused ABUSE-PHYSICAL the resident pain. The staff left the resident without assessing the pain or injuries. The resident was sent to Park Rapids 288 Heritage Living Center x 3/26/2015 8/10/2015 the emergency room with a large bruise and was in pain. x Hubbard It is alleged that a resident was neglected when staff failed to adequately transfer the resident resulting in the resident falling and requiring stitches and multiple cuts on the resident's legs. The facility failed properly Paynesville 636 Centracare Health Paynesville x NEGLECT-HEALTH CARE NEGLECT-FALLS 12/1/2014 3/23/2015 assess the resident's positino of his/her bed, x Stearns It is alleged that a resident was neglected when the facility did not provide appropriate wound care/dressing and follow-up resulting in the development of level four pressure ulcer. Resident was admitted to the Pelican Rapids 28988 Lilac Homes Corporation x NEGLECT-HEALTH CARE 1/12/2017 8/18/2017 hospital and was seen by the surgeon. x Clay It is alleged that a resident was neglected when the facility did not provide appropriate wound care/dressing and follow-up resulting in the development of level four pressure ulcer. Resident was admitted to the Pelican Rapids 28988 Lilac Homes Corporation x NEGLECT-HEALTH CARE 1/12/2017 8/18/2017 hospital and was seen by the surgeon. x Otter Tail It is alleged that a resident was neglected when the facility did not provide appropriate wound care/dressing and follow-up resulting in the development of level four pressure ulcer. Resident was admitted to the Pelican Rapids 28988 Lilac Homes Corporation x NEGLECT-DECUBITI 1/12/2017 8/14/2017 hospital and was seen by the surgeon. x Clay It is alleged that a resident was neglected when the facility did not provide appropriate wound care/dressing and follow-up resulting in the development of level four pressure ulcer. Resident was admitted to the Pelican Rapids 28988 Lilac Homes Corporation x NEGLECT-DECUBITI 1/12/2017 8/14/2017 hospital and was seen by the surgeon. x Otter Tail

It is alleged that a client was neglected when the facility received an order to collect a stool sample for possible parasites, and the facility failed to do so, while also failing to ensure proper hygiene to prevent Pequot Lakes 21049 Minnesota Heritage House x NEGLECT-HEALTH CARE 2/6,7/2017 7/5/2017 spread of the suspected problem. The client was observed with feces under his/her fingernails. x Crow Wing Pequot Lakes 21049 MN Heritage House x ABUSE-RAPE-STAFF 5/10,11/2016 8/18/2016 It is alleged that a client was sexually assaulted by an employee, alleged perpetrator (AP). x Crow Wing Pequot Lakes 21049 MN Heritage House x ABUSE-RAPE-STAFF 5/10,11/2016 8/8/2016 It is alleged that a client was sexually assaulted by an employee, alleged perpetrator (AP). x Crow Wing Pequot Lakes 21049 MN Heritage House x ABUSE-RAPE-OTHER 5/10,11/2016 8/8/2016 It is alleged that a client was sexually assaulted by an employee, alleged perpetrator (AP). x Crow Wing

It is alleged that a client was neglected when he/she suffered pressure ulcers. Also, the client's care plan is not being followed because the client had water at the bedside instead of thickened liquids, putting him at PEQUOT LAKES 25179 SENIOR CLASS HOME HEALTH CARE X NEGLECT-HEALTH CARE STAFFING SHORTAGE 12/22/2015 2/23/2016 risk of choking. Also, the facility did not use two staff when using the mechanical life to transfer the resident. X Crow Wing It is alleged that a resident was neglected when the facility failed to provide assessment and prevention Perham 29022 7th Heaven Assisted Living x NEGLECT-FALLS, SUPERVISION NURSING CARE 9/23/2016 5/25/2017 resulting in multiple falls and fractures. x Otter Tail

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 72 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County

It is alleged that a resident was neglected when the alleged perpetrator (AP) left the resident on the toilet unattended that resulted in the resident having a fall. Gradually, the resident's condition declined; the facility transferred the resident to a hospital. A computerized tomography (CT) scan indicated the resident had a Perham 438 Perham Living x NEGLECT-HEALTH CARE, SUPERVISION 4/5/2017 7/31/2017 very large left-side subdural hematoma with herniation. x Otter Tail 03/30/2016 and It is alleged that a client was abused when the alleged perpetrators (AP) (night staff at facility, names Perham 24511 Prairie View Assisted Living I x ABUSE-PHYSICAL-STAFF 03/31/2016 6/10/2016 unknown) were rough with the client, leaving several bruises on the client's legs and shoulders. x Otter Tail

It is alleged that a client was neglected when staff failed to provide adequate personal cares to the client. The client was admitted to another facility with blood, dirt, feces and food on his/her clothing, hair and skin. Pierz 20767 Harmony House NEGLECT-HEALTH CARE 2/27/2015 3/26/2015 In addition, the client was physically weak and was observed to have severe chest congestion. x Morrison

It is alleged that a resident was neglected when s/he was administered the incorrect dosage of Warfarin and Pierz 384 Pierz Villa Inc x NEGLECT-MEDICATIONS 6/2/2016 10/18/2016 the resident was sent to the emergency room with significant bruising and persistent bleeding. x Morrison

It is alleged that a resident was neglected when the facility did not provide appropriate monitoring, resulting Pine Island 148 Pine Haven Care Center Inc x NEGLECT-FALLS 12/5/2016 5/16/2017 in a fall. The fall was not reported and the resident died a few days later. x Goodhue It is alleged that abuse occurred when the alleged perpetrator spoke to residents in a derogatory and Pine Island 148 Pine Haven Care Center Inc x EMOTIONAL ABUSE BY STAFF 3/1/2017 2/6/2018 demeaning manner during the shift at the facility. x Goodhue It is alleged that a resident was abused by the AP when the resident reported the AP touch his/her Pine River 58 Good Sam Society Pine River x ABUSE-SEXUAL 3/10/2017 7/31/2017 inappropriately. x Cass It is alleged that a client was abused when staff yanked on his/her arm and slammed the client on the Pine River 22165 Riverside Assisted Living x ABUSE-PHYSICAL-STAFF 1/25/2016 1/25/2016 shower chair during transfers, causing the client to yell in pain. x Cass

Plymouth 27083 Brightstar Healthcare of Wayza X ABUSE-SEXUAL 10/31/2017 12/22/2017 Client was abused when the AP fondled the client. AP watched pornographic shows with the client. X Hennepin

it is alleged that a resident was neglected when s/he fell and staff initially did not discover any injury. The Plymouth 20537 Brookdale Plymouth x Neglect-Falls 6/1/2015 11/25/2015 next day the client was found unresponsive and was hospitalized with a brain bleed. x Hennepin It is alleged that two clients were neglected when staff failed to adequately supervise the two clients and Touching/Fondling by other Neglect of one client climbed into the other client's bed and attempted to touch her/him inappropriately. The client Plymouth 20537 Brookdale Plymouth supervision unexplained injury 5/29/2015 8/28/2015 attempted to get away and fell as a result x Hennepin

Client was neglected when becoming confused and developed slurred speech. Staff discovered a medication error had occurred. The client was hospitalized and died. Hospital death summary toxic encephalopathy due to unintentional medication ingestion, aspiration pneumonia, acute respiratory failure, acute coronary syndrome complicated urinary tract infection, delirium, chronic renal failure, diabetes and hypertension. Plymouth 20297 Copperfield Hill-Phase 2 X NEGLECT-HEALTH CARE 4/30/2015 4/30/2015 Medical Examiner said manner of death was natural. X Hennepin It is alleged that neglect occurred when a resident did not receive medication as ordered, and as a result, had Plymouth 235 Mission Nursing Home x Medication Errors 2/15/2017 12/29/2017 several seizures. x Hennepin It is alleged that a client was neglected when the client had two falls in the three days and the client 9/29/2016 Plymouth 20898 Presbyterian Assisted Living Home x NEGLECT-HEALTH CARE 7/20/2016 sustained injuries, including a broken thumb and abrasions. x Hennepin ABUSE-SEXUAL NEGLECT-SUPERVISION- Princeton 375 Elim Home x RESIDENT TO RESIDENT PATIENT RIGHTS 12/01,02/2016 5/1/2017 It is alleged Resident #1 was not adequately supervised when Resident #1 sexually assaulted Resident #2. x Mille Lacs NEGLECT-SUPERVISION-RESIDENT TO Princeton 375 Elim Home x RESIDENT PATIENT RIGHTS 12/01,02/2016 5/1/2017 It is alleged Resident #1 was not adequately supervised when Resident #1 sexually assaulted Resident #2. x Mille Lacs

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 73 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County It is alleged that a resident was neglected when facility staff failed to provide adequate supervision resulting in 14 falls during the month of May. It is alleged that the facility failed to provide adequate fall interventions to ensure the resident safety. Facility did not self-report any falls to the State Agency. In addition, the staff failed to provide adequate incontinence care leaving the resident in his/her incontinence product for NEGLECT-FALLS, SUPERVISION NEGLECT- extended periods resulting in a yeast infection. In addition, it is alleged that staff retaliated against resident Princeton 375 Elim Home x HEALTH CARE NEGLECT-FAILURE TO REPORT 09/12,13/2017 10/23/2017 for behaviors. x Mille Lacs

It is alleged that a resident was neglected when staff failed to adequately monitor the resident's oxygen Princeton 375 Elim Home x NEGLECT-HEALTH CARE 1/30/2015 4/3/2015 level. The resident was turning blue and needed to be transported to the emergency room. x Mille Lacs It is alleged that a client was neglected when the staff/alleged perpetrator failed to follow the client's care NEGLECT-HEALTH CARE, FALLS DUE TO EQUIP plan that required a mechanical lift w assist of 2 people for transfers. The AP transferred the client with only Princeton 28071 Sterling Pointe Senior Living x FAILURE/INAPPROP USE OF EQUIPMENT 6/23/2017 3/9/2018 a gait belt, which resulted in a fall and femur fracture. x Mille Lacs

NEGLECT OF HEALTH CARE-MEDICATIONS It is alleged that neglect occurred when the client's medications were not ordered in a timely manner. It is Princeton 28071 Sterling Pointe Senior Living x EXPLOITATION BY DRUG DIVERSION 11/27/2017 12/7/2017 also alleged that financial exploitation occurred when the client's medication went missing. x Mille Lacs

It is alleged that neglect occurred when the client's medications were not ordered in a timely manner. It is Princeton 28071 Sterling Pointe Senior Living x ABUSE-EXPLOITATION-DRUG DIVERSION 11/27/2017 12/7/2017 also alleged that financial exploitation occurred when the client's medication went missing. x Mille Lacs It is alleged that client #1 (C1) was neglected when staff did not follow his/her dietary care plan resulting in the client choking and passing away. It is alleged that client #2 (C2) was neglected when staff failed to provide proper wound care and the client needed to have his/her wounds debrided. Staff are not assisting Prior Lake 27091 Assured Care x NEGLECT-HEALTH CARE 3/17/2015 5/14/2015 with or changing the client's colostomy bag. x Scott

It is alleged that a client was neglected when staff would lock the client in the basement due to staffing Prior Lake 29064 Assured Care x NEGLECT-HEALTH CARE 6/25/2015 7/6/2015 shortages. In addition, staff failed to provide adequate wound cares and had numerous medication errors. x Scott

It is alleged that a client was neglected when facility staff left the client's walker out of reach resulting in the Prior Lake 20823 Community Assisted Living Inc x NEGLECT-HEALTH CARE 9/7/2017 10/5/2017 client falling and fracturing hip. The client passed away from complications of hip fracture. x Scott It is alleged that a client was neglected when s/he became almost unresponsive, was unable to hold his/her head up, dehydrated, and had to be hospitalized. In addition, the client was not being re-positioned as the client developed pressure sores. The client's oral care was neglected as the client had sores in his/her mouth Prior Lake 20823 Community Assisted Living Inc x NEGLECT-HEALTH CARE 8/18/2015 2/14/2017 , and his/her dentures were filthy. x Scott

It is alleged that a client with diabetes was neglected when s/he had a sore on his/her toe. The toe became infected and s/he had swelling and redness moving up his/her leg. The facility failed to provide adequate Prior Lake 20823 Community Assisted Living Inc x NEGLECT-HEALTH CARE 2/19,22/2016 7/28/2016 care of the toe and did not seek medical attention. The client has been hospitalized with infection of the toe. x Scott It is alleged that a client was exploited when the alleged perpetrator replaced 21 tablets of oxycodone with Prior Lake 29091 McKenna Crossing x EXPLOITATIN BY DRUG DIVERSION 8/18/2107 10/4/2017 Lorazepam. x Scott It is alleged that a client was abused when a staff, alleged perpetrator (AP) pushed the client, causing the client to fall. The client is currently hospitalized with three broken ribs and a punctured lung. The AP also Prior Lake 29091 McKenna Crossing x ABUSE-PHYSICAL, EMOTIONAL-STAFF 03/21,22/2016 7/28/2016 verbally threatened the client. x Scott

It is alleged that a client was neglected when the client had a change in condition that was not monitored or Prior Lake 29091 McKenna Crossing x NEGLECT-HEALTH CARE 6/5/2015 8/21/2015 treated. The client was then hospitalized and treated with severe dehydration and malnutrition. x Scott

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 74 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County It is alleged that a client was abused on three separate occasions when the alleged perpetrator, unknown staff, touched the resident inappropriately and the resident was scared to report this after the first incident. In addition, the family requested the resident to not have male staff working with him/her on the overnight shift. This document has been re-scanned to the MDH website. The compliance revisit was completed on Prior Lake 29091 McKenna Crossing x SEXUAL ABUSE 12/18/2014 3/30/2015 5/8/2015. x Scott

Diamond Willow Assisted Lving (FULL It is alleged that a client was neglected when the facility positioned the client too close too the fireplace. The Proctor 24424 CIRCLE SENIOR LIVING INC) x NEGLECT-HEALTH CARE 12/5-6/2016 3/28/2017 client sustained reddened and blistered skin. The facility did not notify the physician for nine days. x St. Louis

It is alleged that a client was neglected when staff assisted the client in the bathtub and the client had genital bleeding. The facility transferred the client to the hospital where the bleeding stopped. The client also had Proctor 25952 GOLDEN OAKS ADVANCED ASST LVG x NEGLECT-HEALTH CARE, DECUBITI 4/28/2017 07/24/2017 wounds on the buttocks which greatly increased in size and appearance. x St. Louis 02/01/2018 NEGLECT OF SUPERVISION NEGLECT OF and It is alleged that a client was neglected when the alleged perpetrator did not provide adequate supervision Rainer 20001 Decker's Family Care Inc x HEALTH CARE 02/02/2018 3/9/2018 by sleeping in the bathroom while caring for the client resulting in the client feeling unsafe and fearful. x Koochiching 02/01/2018 NEGLECT OF SUPERVISION NEGLECT OF and It is alleged that a client was neglected when the alleged perpetrator did not provide adequate supervision Rainer 20001 Decker's Family Care Inc x HEALTH CARE 02/02/2018 3/9/2018 by sleeping in the bathroom while caring for the client resulting in the client feeling unsafe and fearful. x Koochiching 02/01/2018 NEGLECT OF SUPERVISION NEGLECT OF and It is alleged that a client was neglected when the alleged perpetrator did not provide adequate supervision Rainer 20001 Decker's Family Care Inc x HEALTH CARE 02/02/2018 3/9/2018 by sleeping in the bathroom while caring for the client resulting in the client feeling unsafe and fearful. x Koochiching It is alleged that a client was financially exploited when a stagf member, AP, took the client's money and gift Ramsey 31331 First Pheonix Ramsey, LLC x EXPLOITATION BY STAFF 5/17/2017 7/7/2017 cards for his/her own personal use. x Anoka It is alleged that a client was neglected she s/he did hot receive his/her medications for 10 days and 7/13/2016 Ramsey 31331 First Pheonix Ramsey, LLC x NEGLECT-MEDICATIONS 3/23/2016 developed labord breathing, swollen feet and legs. The client was hospitalized. x Anoka It is alleged that a client was abused when the alleged perpetrator punched, grabbed and pinched the client. Ramsey 31331 Stoney River of Ramsey Assiste x ABUSE-PHYSICAL 5/24/2016 4/20/2017 The client has bruising on his/her face and arms. x Anoka It is alleged that a client was financially exploited when a stagf member, AP, took the client's money and gift Ramsey 31331 Stoney River of Ramsey Assisted Living x EXPLOITATION BY STAFF 5/17/2017 7/7/2017 cards for his/her own personal use. x Anoka It is alleged that a client was neglected she s/he did hot receive his/her medications for 10 days and 7/13/2016 Ramsey 935 Stoney River of Ramsey Assisted Living x NEGLECT-MEDICATIONS 3/23/2016 developed labord breathing, swollen feet and legs. The client was hospitalized. x Anoka

It is alleged that a client was neglected when the alleged perpetrator did not provide scheduled daily services, resulting in a decline in the conditions of the client's physical and mental status. The client was found being very confused and unkempt appearance in the dialysis center. In addition, client appeared to NEGLECT-HEALTH CARE, SUPERVISION, have significant weight loss, fluid was leaking/crusting from the eye, and strong body odor. Client was Ramsey 31331 Stoney River of Ramsey Assisted Living x FAILURE TO NOTIFY PHYSICIAN 6/30/2017 12/4/2017 transferred to a hospital from the dialysis center for further treatment and care. x Anoka 11/04/2015 and Ramsey 31331 Stoney River of Ramsey Assisted Living x NEGLECT-SUPERVISION 11/05/2015 1/19/2016 It is alleged that clients were not adequately supervised when client #1 was found naked in client #2's room. x Anoka It isi alleged that a client was neglected when the facility staff did not follow medication instruction and administered an overdose of medication. The client's condition declined quickly, s/he was found Red Lake Falls 31622 Hillcrest Senior Living INC x MEDICATION ERRORS 12/29/2016 4/7/2017 unresponsive, and was transferred to the hospital. x Red Lake It is alleged that a client was financially exploited when the alleged perpetrator (AP) took the client's money Red Wing 2048 Accra Home Health Inc ABUSE-EXPLOITATION-OTHER 2/29/2016 6/29/2016 for his/her own personal use. x Goodhue It is alleged that a resident was neglected when s/he developed severe unstageable pressure ulcers and NEGLECT-DECUBITI NURSING CARE Red Wing 149 Red Wing Health Center x 10/3/2016 1/23/2017 Stage IIIIV pressure ulcers while s/he was at the facility. x Goodhue

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 75 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County It is alleged that a resident was financially exploited when a staff, alleged perpetrator (AP) took the resident's Red Wing 149 Red Wing Health Center x ABUSE-EXPLOITATION-DRUG DIVERSION 5/27/2015 2/4/2016 pain medication for his/her own personal use. x Goodhue It is alleged that a resident was neglected when facility staff failed to perform CPR on the resident as Red Wing 149 Red Wing Health Center x NEGLECT-FAILURE TO DO CPR 5/25/2017 1/31/2018 specified on resident's POLST when resident was found unresponsive. x Goodhue It is alleged that a resident was neglected when s/he had a blood sugar reading over 500 and the staff reported they could do nothing about this as the resident was not on sliding scale insulin. The resident also Red Wing 149 Red Wing Health Center x NEGLECT-HEALTH CARE 10/15/2015 3/3/2017 suffered a seizure and was hospitalized. x Goodhue

05/23/2016 It is alleged that a resident was neglected when facility staff failed to follow physician orders for a resident and who was given an incorrect dose of Opium before a nursing procedure. Facility staff also failed to follow Red Wing 149 Red Wing Health Center x NEGLECT OF HEALTH CARE-MEDICATIONS 05/24/2016 10/27/2016 their policy and procedure for contacting the physician when the error was discovered. x Goodhue It is alleged that a resident was neglected when s/he presented to the hospital with stage IV ulcers. In addition, it is alleged that the facility did not provide medication administration as prescribed and call lights Red Wing 149 Red Wing Health Center x NEGLELCT-HEALTH CARE 7/6/2016 7/13/2016 are not answered in a timely manner. x Goodhue 05/23/2016 It is alleged that a resident was abused when the alleged perpetrator (AP) staff would hit the resident around and the face and neck and forcefully put a temperature probe in the resident's mouth. The resident reported Red Wing 149 Red Wing Health Center x ABUSE-PHYSICAL-STAFF 05/24/2016 7/6/2016 being fearful. x Goodhue

It is alleged that a resident was neglected when s/he had physician's orders to start an anticoagulant and the resident did not receive the medication for two weeks. The resident was hospitalized with blood clots in his/her lungs. In addition, it is alleged that call light wait times are excessive, with the resident having to wait Red Wing 149 Red Wing Health Center x NEGLECT-HEALTH CARE 9/28/2015 3/29/2016 up to an hour for call lights to be answered. x Goodhue

06/16/2015 It is alleged that a resident was neglected when staff failed to provide adequate supervision and failed to and adequately assess the resident when the resident had a urinary tract infection and had five falls in six days. Red Wing 149 Red Wing Health Center x NEGLECT-HEALTH CARE, FALLS 06/17/2015 2/19/2016 In addition, the resident's call light was not answered for 80 minutes. x Goodhue

It is alleged that a resident was neglected when staff failed to provide adequate catheter care, resulting in the resident needing emergency treatment at the hospital. In addition, the resident was to have an air mattress at the facility to prevent skin breakdown and was not provided. The resident developed a stage one Red Wing 149 Red Wing Health Center x NEGLECT-HEALTH CARE 9/1/2015 10/26/2015 pressure ulcer. Also, resident did not receive physician ordered peg tube water flushes. x Goodhue

It is alleged that a resident was neglected when staff failed to monitor and provide proper wound cares. The Red Wing 149 Red Wing Health Center x NEGLECT-HEALTH CARE 2/19/2015 3/24/2015 resident has over eight pressure ulcers with some being unstageable requiring hospitalization. x Goodhue Red Wing 149 Red Wing Health Center x ABUSE-SEXUAL 1/24/2017 6/19/2017 It is alleged that a resident was sexually assaulted by staff, unknown alleged perpetrator (AP). x Goodhue Red Wing 149 Red Wing Health Center x ABUSE-SEXUAL PATIENT RIGHTS 1/24/2017 6/19/2017 It is alleged that a resident was sexually assaulted by staff, unknown alleged perpetrator (AP). x Goodhue

It is alleged that a resident was neglected when s/he had a seizure in the dining room and the facility failed to follow his/her seizure protocol. It took several minutes to find staff to assist and then staff failed to give a Red Wing 149 Red Wing Health Center x NEGLECT-HEALTH CARE 12/8/2015 4/7/2017 second dose of diazepam when the client went into grand mal seizure. The resident was hospitalized. x Goodhue 08/25/2014 It is alleged that a resident was neglected. It is alleged that the resident does not receive adequate care and related to his tracheostomy and oral care. The resident has been hospitalized four times in two months Red Wing 149 Red Wing Health Center x NEGLECT-HEALTH CARE 08/26/2014 4/2/2015 related to respiratory issues. x Goodhue It is alleged that a client was neglected when facility staff failed to provide adequate supervision when the Red Wing 1511 REM River Bluffs Park Heights NEGLECT-SUPERVISION 9/1/2017 10/9/2017 client left the facility and crossed a busy street x Goodhue It is alleged that a resident was financially exploited when the alleged perpetrator took the resident's Red Wing 787 St Brigids at HI Park x EXPLOITATION BY OTHER 9/10/2015 11/4/2015 wedding ring and pawned it at a local pawn shop for his/her own use. x Goodhue

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 76 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County It is alleged that client's #1 and #2 were financially exploited when the alleged perpetrator (AP) took the Red Wing 26539 Visiting Angels x ABUSE-EXPLOITATION-STAFF 3/30/2016 5/2/2016 client's jewelry. x Goodhue It is alleged that a client was financially exploited when a staff, alleged perpetrator (AP) took his/her Red Wing 26539 Visiting Angels x ABUSE-EXPLOITATION-DRUG DIVERSION 3/30/2016 5/9/2016 medication for their own use. x Goodhue NEGLECT-FALLS DUE TO EQUIP FAILURE. It is alleged that a resident was neglected when the alleged perpetrator (AP) transferred the resident in a lift Redwood Falls 63 Good Samaritan Society Redwood Falls x INAPPROPRIATE USE OF EQUIPMENT 9/25/2017 12/29/2017 and the resident fell resulting in multiple fractures. x Redwood NEGLECT-FALLS DUE TO EQUIP FAILURE. It is alleged that a resident was neglected when the alleged perpetrator (AP) transferred the resident in a lift Redwood Falls 63 Good Samaritan Society Redwood Falls x INAPPROPRIATE USE OF EQUIPMENT 9/25/2017 12/29/2017 and the resident fell resulting in multiple fractures. x Redwood

It is alleged that a resident was neglected when facility staff did not follow resident's care plan and did not Redwood Falls 63 Good Samaritan Society Redwood Falls x NEGLECT HEALTH CARE-FALLS 3/4/2016 10/18/2016 properly attach sling lift for a transfer. Resident had a fall and sustained a head laceration. x Redwood 01/11/2017 and It is alleged that a client was neglected due to multiple wounds on the client for eight weeks. The client's Redwood Falls 1609 Westwood Home NEGLECT-DECUBITI NURSING CARE 01/12/2017 7/6/2017 wounds continue to be red, raw, and bleeding for the past two weeks. The wounds cause the client pain. x Redwood

It is alleged that a resident was neglected when she had multiple falls with injuries and the facility did not Renville 557 RENVILLA HEALTH CENTER x NEGLECT-FALLS 2/3/2016 2/3/2016 put adequate fall interventions in place and did not place the call light in reach of the resident. x Renville It is alleged that Resident #1 was neglected when the resident was sexually assaulted while in the facility. Resident #1 had asked another resident to help keep Resident #2 away from Resident #1's room because Resident #2 had stated that s/he intended to come to Resident #1's room at night. The other resident gave a 10/16/2017, note to a staff member indicating Resident #1 was afraid of Resident #2 and needed assistance keeping 10/17/2017 Resident #2 out of the room, but the staff member threw away the note and took no action. Later that NEGLECT OF SUPERVISION-RESIDENT TO and evening, Resident #2 entered Resident #1's room and engaged in unwanted sexual penetration of Resident Revere 824 Revere Home RESIDENT 10/18/2017 12/11/2017 #1. x Redwood

It is alleged that a client was neglected when the staff failed to clean the facility, did not provide activities, 10/16/2017, and did not provide appropriate food. It also alleged that other clients were abused when staff members had OTHER PENETRATION BY STAFF NEGLECT OF 10/17/2017 sex with those clients (not named). It is alleged that other clients were neglected when the staff did not HEALTH CARE NEGLECT OF SUPERVISION- and supervise them, and the clients had sex with each other in the facility. It is also alleged that clients have Revere 824 Revere Home RESIDENT TO RESIDENT 10/18/2017 12/22/2017 witnessed staff members having sex with other staff members while on duty. x Redwood

It is alleged that two residents' health care was neglected when a staff brought the residents to his/her home and provided the residents with marijuana and alcohol. It is alleged that a resident was sexually abused by 02/01/2017 staff while passed out after drinking at the AP's home. The resident, along with another resident, snuck out and to drink and do drugs at the AP's home in January 2017. The resident recently became away that while he Revere 824 Revere Home NEGLECT-HEALTH CARE 03/12/2017 10/9/2017 was passed out the AP sexually assaulted him. x Redwood

It is alleged that two residents' health care was neglected when a staff brought the residents to his/her home and provided the residents with marijuana and alcohol. It is alleged that a resident was sexually abused by 02/01/2017 staff while passed out after drinking at the AP's home. The resident, along with another resident, snuck out and to drink and do drugs at the AP's home in January 2017. The resident recently became away that while he Revere 824 Revere Home ABUSE-SEXUAL 03/12/2017 10/9/2017 was passed out the AP sexually assaulted him. x Redwood ABUSE-SEXUAL NEGLECT-SUPERVISION- Revere 824 Revere Home RESIDENT TO RESIDENT 2/1/2017 10/6/2017 It is alleged that a resident was abused when two staff had consensual sexual interaction with the resident. x Redwood

Revere 824 Revere Home ABUSE-EMOTIONAL-STAFF ABUSE-SEXUAL 2/22/2016 9/15/2016 It is alleged that a client was abused when a staff member had a sexual relationship with the client. x Redwood

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 77 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County

Richfield 20226 Avinity Home Care x Abuse-Emotional-Staff 11/6/2017 11/15/2017 It is alleged that abuse occurred when an employee (AP) spoke to a client in a derogatory manner. x Hennepin

Richfield 20226 Avinity Home Care x Abuse-Restraints 5/4/2017 10/27/2017 it is alleged that a client was abused when staff/alleged perpetrator restrained the client to a recliner chair. x Hennepin It is alleged that abuse occurred when an employee/alleged perpetrator (AP) was mean and rude to a client. When the client reported this to administration, the AP retaliated against the client and the situation Richfield 20226 Avinity Home Care x Abuse-Emotional-Staff 11/6/2016 12/20/2017 worsened. x Hennepin

Client was abused by AP. Client has a large purple bruise 4x8 inches on the back of the left thigh, a 4 inch bruise on the pubic bone, a 3.5 inch bruise on the left thigh and groin area, bruise on the outside of the left thigh. Client has been crying and weeping more, acts differently when AP is working with the client. ER visit Richfield 20226 Avinity Home Care X ABUSE-PHYSICAL-STAFF 8/11/2017 11/6/2017 no signs of intentional abuse or other injuries. X Hennepin AP "went completely, unprofessionally off the handle" by screaming and swearing at the client for making a mess in the bathroom. The abuse started elsewhere and continued in the dining area where at least 8 other Richfield 20226 Avinity Home Care X ABUSE-EMOTIONAL-OTHER 10/4/2017 clients could have been affected. X Hennepin

AP was pushing and shaving the client, also screaming at the client. AP was yelling at client while preforming personal cares, yelling to bend forward. Force was used when AP applied lotion to the client's face. Ap pulled Richfield 20226 Avinity Home Care X ABUSE-PHYSICAL, EMOTIONAL 4/20/2016 on the client's arm to transfer, did not use transfer belt while moving client from the toilet to the wheelchair. X Hennepin

It was alleged that the resident was neglected when the resident was found to have multiple bruises of Richfield 253 RICHFIELD HEALTH CENTER x UNEXPLAINED INJURY/FRACTURE 6/12/2017 9/5/2017 unknown origin on his/her body. In addition, the resident was found to have a clavicle fracture. x Hennepin

It is alleged that the resident was neglected when staff alleged perpetrators (AP #1 & AP#2) did not provide Richfield 253 RICHFIELD HEALTH CENTER x NEGLECT-DECUBITI 2/28/2017 3/22/2017 adequate incontinence care. The resident received two open areas on the buttocks due to incontinence. x Hennepin It is alleged that a resident was neglected when she/he had a fall in his/her bathroom and was not found by NEGLECT OF HEALTH CARE - FALLS NEGLECT- facility staff until approx. 7 hours later. In addition facility failed to follow leave of absence protocols and Robbinsdale 890 GOOD SAM SOCTY SPEC CARE COMM x SUPERVISION 12/1/2015 9/27/2016 procedure. x Hennepin

It is alleged that a resident was abused when the alleged perpetrators (AP)s were rough with the resident Robbinsdale 890 Good Sam Socty Spec Care Comm, x Abuse-Physical-Staff Patient rights 8/29/2016 11/28/2016 and physically sat on the resident. The resident became agitated and angry when s/he see the AP x Hennepin It is alleged that a resident was neglected when the alleged perpetrator transferred the resident not in Robbinsdale 890 Good Samaritan Society Specialty Care Communityx NEGLECT-HEALTH CARE 12/18/2017 3/13/2018 accordance with the resident's care plan resulting in clavicle fracture. x Hennepin It is alleged that a client was neglected when staff failed to provide adequate supervision and was left Rocheser 21496 Comfort Health x NEGLECT-SUPERVISION 1/19,20/16 5/6/2016 outside for several hours and passed away. x Olmsted

It is alleged that a client was emotionally abused by staff/alleged perpetrator (AP) when the AP recorded a Rocheser 29354 Cottage Senior Communities x ABUSE-EMOTIONAL-STAFF 3/14/2017 12/29/2017 previous changing interaction w the client and showed the recording to another staff x Olmsted It is alleged that a client was abused by staff/alleged perpetrator(AP) when the AP made verbal sexual Rocheser 29354 Cottage Senior Communities X ABUSE-EMOTIONAL-STAFF PATIENT RIGHT 3/4/2017 12/29/2017 remarks to the client. x Olmsted

It is alleged a client was neglected when the facility failed to provide appropriate care, resulting in failure to thrive. The client was transported to the emergency room and was found to be dehydrated, malnourished, Rocheser 29354 Cottage Senior Communities x NEGLECT-HEALTH CARE 12/20,21/16 3/6/2017 and with pressure ulcers consistent w long term immobilization. x Olmsted It is alleged that a client was abused when an alleged perpetrator (AP) touched the resident inappropriately Rocheser 03299 Madonna Towers of Roch, Inc. X ABUSE-SEXUAL 6/9/2016 8/30/2016 on his/her breast. x Olmsted

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 78 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County

It is alleged that neglect occurred when Resident #1 did not receive the necessary care for a colostomy and urinary catheter. It is alleged that neglect occurred when Resident #2 did not receive the necessary care and Rocheser 00916 Maple Manor Nursing and Rehab LLC x NEGLECT-HEALTH CARE 1/9,10/2017 10/3/2017 developed pressure ulcers, lost weight, and required hospitalization. x Olmsted

It is alleged that a resident was neglected when staff did not follow wound care orders or administer Rocheser 00953 Rochester E Hlth Serv x NEGLECT-HEALTH CARE NURSING CARE 10/18,19/16 7/31/2017 antibiotics for 10 days and the resident developed multiple stage III pressure ulcers. x Olmsted It is alleged that 2 residents were financially exploited by a staff member/alleged perpetrator (AP) when the AP took the resident's narcotic medication from the medication cart, w no record that the medication was Rocheser 00953 Rochester E Hlth Serv x ABUSE-EXPLOITATION-STAFF 10/18,19/16 7/31/2017 administered to either resident. x Olmsted It is alleged that a resident was neglected when facility staff failed to administer Coumadin medication as Rocheser 00953 Rochester E Hlth Serv X NEGLECT-MEDICATIONS 1/4,5/16 9/6/2016 ordered for multiple days. Resident had an unexpected death the next day. x Olmsted It is alleged that a resident has been neglected when staff failed to assist him/her with eating and drinking fluids and the resident was hospitalized with severe dehydration. The resident has a pressure ulcer and the physician's orders in January were for the resident to get a new bed at the facility. The resident has not received a new bed, staff is not repositioning the resident every 2 hrs. and his/her pressure ulcer has Rocheser 00953 Rochester E Hlth Serv X NEGLECT-HEALTH CARE 5/14,15/15 10/21/2015 worsened. x Olmsted

It is alleged that a resident was abused when staff yelled at him/her, spoke to him/her in demeaning ways, ABUSE-PHYSICAL, EMOTIONAL-STAFF NEGLECT- and hit a resident w a TV remote control. The resident is scared and fearful after this occurred. In addition, Rocheser 00953 Rochester E Hlth Serv X HLTH CARE 5/14,15/15 8/24/2015 when the resident first arrived at the facility, s/he laid in bed w/out staff checking on him/her. x Olmsted

10/31, It is alleged that resident was neglected when staff failed to provide catheterization as ordered. The resident Rocheser 00953 Rochester E Hlth Serv X NEGLECT-HEALTH CARE 11/14/14 5/6/2015 was transferred to the emergency room w a urinary tract infection and sepsis. x Olmsted It is alleged that a resident was abused when an alleged perpetrator (AP) physically hit the resident multiple Rocheser 00427 Samaritan Bethany Hm on Eighth X PHYSICALLY ABUSED BY STAFF 3/28,29/16 5/2/2016 times in the back of head causing redness. x Olmsted It is alleged that a resident was neglected when staff failed to provide adequate personal cares. The resident Rocheser 00427 Samaritan Bethany Hm on Eighth x NEGLECT-HEALTH CARE 5/29/2015 8/24/2015 arrived at the hospital soiled w derived feces and urine. x Olmsted

It is alleged that client #1 neglected when client ran out of medication and facility fail to follow up, resulting I Rochester 20864 Arbor Terrace x NEGLECT-HEALTH CARE 8/13/2015 12/24/2015 n client not receiving medication for 13 days. Client had adverse effects-lethargy, seizures and small stroke. x Olmsted It is alleged that a client was neglected when staff did not administer the correct dosage of the client's anti- Rochester 20864 Arbor Terrace X NEGLECT OF HEALTH CARE MEDICATIONS 4/20 &21/16 6/16/2016 epileptic medication. x Olmsted

It is alleged that a resident was neglected when the alleged perpetrators failed to follow the facility policy Rochester 00193 Charter House x NEGLECT-FALLS, HEALTH CARE NURSING CARE 10/19/2017 12/27/2017 and procedure during a transfer and the resident fell from a ceiling lift, sustaining a clavicle and rib fracture. x Olmsted It is alleged that a resident was exploited when the alleged perpetrator took the resident's narcotic medic Rochester 00193 Charter House x ABUSE-EXPLOITATION-DRUG DIVERSION 10/19/2017 12/22/2017 ation for his/her own use. x Olmsted It is alleged that a resident was financially exploited when a large amount of money went missing from the Rochester 00193 Charter House X EXPLOITATION BY OTHER 3/16/2017 6/5/2017 resident's possession. X Olmsted

It is alleged that a client was neglected when the alleged perpetrator (AP) did not provide adequate personal NEGLECT-HEALTH CARE ABUSE-EMOTIONAL- care and health care treatments, resulting in the client developing skin breakdown, and having significant Rochester 21066 CNS Home Health Care STAFF 12/16 & 17/14 4/9/2015 swelling in the legs. In addition, the client has been verbally abused by the alleged perpetrator. x Olmsted

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 79 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County

It is alleged that a client was neglected when staff failed to ensure proper placement of the client's catheter and assessing the client in a timely manner. Also it is alleged the staff failed to show up as scheduled leaving the client in his/her wheelchair from 2pm until 9:00am In addition, the client was w/out food, a working Rochester 21066 CNS Home Health Care NEGLECT- HEALTH CARE, NUTRITION 12/16 & 17/14 3/27/2015 phone, lifeline and power chair was not charged. x Olmsted It is alleged that a client was financially exploited when the alleged perpetrator(AP) took the client's Rochester 29354 Cottagewood Senior Communities x EXPLOITATION BY DRUG DIVERSION 11/16/2016 2/9/2017 medications. x Olmsted

Rochester 29354 Cottagewood Senior Communities x ABUSE-EXPLOITATION-OTHER 6/28/2016 9/2/2016 It is alleged that a client was financially exploited when the alleged perpetrator(AP) took the client's money. x Olmsted

It is alleged that a client was neglected when the facility staff failed to provide adequate supervision and the client left the facility and went to the hospital on a day when s/he did not have a dialysis appointment. Rochester 29354 Cottagewood Senior Communities x NEGLECT-SUPERVISION 2/22/2016 3/31/2016 When the hospital called the facility, the staff were unaware that the client was gone. x Olmsted

It is alleged that a resident was neglected when staff failed to properly assess and provide medical services Rochester 29354 Cottagewood Senior Communities x NEGLECT-FALLS, HEALTH CARE 9/16/2015 1/16/2016 for 8 days after she had a fall. The resident remains in the hospital with a fractured hip. x Olmsted

it is alleged that a client was neglected when facility staff failed to adequately supervise the client. The client Rochester 29354 Cottagewood Senior Communities X NEGLECT OF SUPERVISION 12/18/2017 2/8/2018 was able to make a hole in the fence and exit. The client was located and transported to St. Mary's Hospital. x Olmsted NEGLECT OF HEALTH CARE MEDICATION It is alleged that a client was neglected when his/her medications were administered improperly, resulting in Rochester 29354 Cottagewood Senior Communities X ERRORS 3/14/2017 12/29/2017 the (clients) death. x Olmsted it is alleged that a client was emotionally abused by 2 staff/alleged perpetrators (AP's), when the AP's transported the naked client in a wheelchair from his/her room to the shower area, thereby exposing him/her to other clients. In addition, AP#1 allegedly yelled at the client and also posted a photo of the client Rochester 29354 Cottagewood Senior Communities X ABUSE-EMOTIONAL-STAFF 3/15/2017 12/27/2017 on social media. x Olmsted It is alleged that the client was abused when the alleged perpetrator (AP) (name unknown) hit and punched Rochester 29354 Cottagewood Senior Communities X ABUSE-PHYSICAL-STAFF-NEGLECT-FALLS 2/12/2016 5/2/2016 him/her causing bruising and injuries to the client. x Olmsted It is alleged that a client was neglected when staff failed to provide adequate personal cares and s/he had skin breakdown, yeast in her/his groin and had a strong body odor. The client's dentures were filthy w old Rochester 29354 Cottagewood Senior Communities X NEGLECT- HEALTH CARE 2/22/2016 3/23/2016 food on them. x Olmsted

It is alleged that a client was neglected when staff failed to assess and monitor the client for fall risks after multiple falls. In addition, the facility did not contact emergency services in a timely manner after the client fell and complained of pain. In addition, it is alleged the facility neglected the client's personal cares leaving the client in urine soaked clothing for several hours. It is alleged the facility is short staffed and staff found to Rochester 29354 Gentle Touch Health Initiative X NEGLECT-HEALTH CARE STAFFING SHORTAGE 4/30/2015 9/8/2015 be sleeping while on duty. x Olmsted It is alleged that the resident was abused when s/he was found to have multiple bruising all over his/her body, in different stages of healing and occurred at different times. In addition, it is alleged that the resident was neglected when s/he had 14 falls in yr. lady 3 months. Also, it is alleged that the resident was neglected PHYSICAL ABUSE BY STAFFING NEGLECT OF when staff failed to administer his/her medication for 7 days and as a result, was hospitalized w a complaint Rochester 00953 Golden Living Center Rochester E X HEALTH CARE NURSING CARE 10/18&19/16 5/26/2017 of bloody emesis. x Olmsted

It is alleged that a resident was not provided adequate supervision when s/he was found outside a gas Rochester 00953 Golden Living Center Rochester E x NEGLECT-SUPERVISION 2/4/2016 3/9/2017 station w/out weather approx. clothing. The facility was unaware the resident had left the facility. x Olmsted NEGLECT OF HEALTYH CARE & NEGLERCYT OF It is alleged that a resident was neglected when s/he was found dead in his/her bed and was a full code. Rochester 00953 Golden Living Center Rochester E x SUPERVISION 1/4&5/16 9/6/2016 Facility staff had not checked the resident for 3.5 hrs. x Olmsted

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 80 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County

It is alleged that staff failed to provide adequate supervision when a resident (#1) was sexually assaulting NEGLECT-SUPERVISION-RESIDENT TO another resident (#2). In addition, the facility was aware that Resident #1 had a history of sexualized Rochester 00953 Golden Living Center Rochester E x RESIDENT SEXUAL ABUSE 3/24/2015 6/23/2015 behaviors, upon Resident #1's admission, and did not implement a plan to keep other residents safe. x Olmsted

It is alleged that neglect occurred to a resident when the facility failed to properly care for a resident who had a recent hip replacement surgery. The resident complained of significant pain a week later and was Rochester 00941 Golden Living Center Rochester W x NEGLECT- HEALTH CARE 7/31/2015 2/22/2016 transported to the emergency department for a possible hip dislocation. X Olmsted

Rochester 00941 Golden Living Center Rochester W x SEXUAL ABUSE 12/31/2015 1/19/2016 It is alleged that a resident was abused when s/he was sexually assaulted by an unknown individual. X Olmsted NEGLECT-PAIN MGMT, HEALTH ARE ABUSE- Rochester 00941 Golden Living Center Rochester W x EXPLOITATION-DRUG DIVERSION 1/28/2015 4/2/2015 It is alleged that a resident was neglected when staff failed to adequately manage the resident's pain. X Olmsted

It is alleged that a client was abused when staff/alleged perp posted a picture of the client on social media w Rochester 20566 Madonna Meadows x ABUSE-EMOTIONAL-STAFF PATIENT RIGHTS 8/29/2017 9/16/2017 a description of "This little shit just pulled the fire alarm and now I have to call 911." x Olmsted It is alleged that a resident was neglected when staff found the resident unresponsive and didn’t initiate Rochester 00916 Maple Manor Nursing & Rehab LL x NEGLECT-FAILURE TO DO CPR 10/2 &4/17 12/22/2017 cardiopulmonary resuscitation despite the resident's full code status. x Olmsted

It is alleged that a resident was neglected when the facility did not follow proper care of a resident's stoma area. The resident was found w significant inflammation around the stoma, loose stoma appliance, fecal Rochester 00916 Maple Manor Nursing & Rehab LL x NEGLECT-HEALTH CARE 12/1/2016 6/12/2017 contents were on and around the stoma and his/her pants were soaked w urine. x Olmsted It is alleged that a resident was neglected when staff/alleged perpetrator administered the resident's morning insulin w/out breakfast. The resident left for an appointment and was sent to the emergency room Rochester 00916 Maple Manor Nursing & Rehab LL x NEGLECT OF HEALTH CARE MEDICATIONS 5/2/2017 7/10/2017 and treated for hypoglycemia. x Olmsted

It is alleged that a resident was neglected when the facility failed to provide adequate supervision resulting NEGLECT OF HEALTH CARE-FALLS NEGLECT OF in a fall w a head laceration. In addition, it is also alleged that the facility failed to administer resident's Rochester 00916 Maple Manor Nursing & Rehab LL x HEALTH CARE-MEDICATIONS 1/9&10/17 6/8/2017 medication (diuretic) for 9 days that resulted in acute exacerbation of heart failure and wheezing. x Olmsted

NEGLECT- MEDICATION ERRORS MEDICATIONS It is alleged that a resident was neglected when given the wrong dose of Coumadin for 2 days. Resident was Rochester 00916 Maple Manor Nursing & Rehab LL x ADMINISTRATION 1/9&10/17 6/8/2017 supposed to receive Coumadin 7.5 mg daily but was administered Coumadin 7.5 mg 2x/day for 2 days. x Olmsted It is alleged that the facility failed to provide adequate supervision to a resident when s/he barricaded him/herself in his/her room and had attempted to commit suicide by wrapping the call light cord around Rochester 00916 Maple Manor Nursing & Rehab LL X NEGLECT - SUPERVISION 8/11/1/6 3/21/2017 his/her neck. x Olmsted Rochester 00916 Maple Manor Nursing & Rehab LL X NEGLECT OF HEALTH CARE-FALLS 4/5/2016 2/27/2017 It is alleged that a resident was neglected when s/he had a fall w several fractures. x Olmsted

It is alleged that a resident was neglected when s/he suffered a fall and staff did not adequately assess and monitor the resident for change in condition. After the fall, the resident had increased agitation, behavior changes, was shaking weak and not eating. Six days after the fall, the resident's knees buckled, s/he vomited and requested to go to the hospital and the facility denied the request. The next day, the dialysis center Rochester 00916 Maple Manor Nursing & Rehab LL X NEGLECT- HEALTH CARE 6/12/2015 7/28/2015 called the emergency services and the resident was hospitalized. x Olmsted

It is alleged that a client was neglected when s/he had a change in condition, including symptoms of confusion, weakness, and dizziness and the client fell. The client was hospitalized and hospital staff found Rochester 28279 Oxford Property Mgt LLC x NEGLECT-HEALTH CARE 8/10/2017 12/22/2016 the client had three pain patches on instead of 1. The client had an overdose of fentanyl pain patches. x Olmsted It is alleged that a client was financially exploited when a staff alleged perpetrator (AP) took money from the Rochester 28279 Oxford Property Mgt LLC x EXPLOITATION BY OTHER 6/24/2017 8/15/2017 client's apartment, once around Christmas and the next time in January. x Olmsted

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 81 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County It is alleged that the clients are neglected by the facility due to staff shortage and meals not serv ed consistently. The facility did not serve breakfast most days and the facility ran out of food. The facility only NEGLECT-HEALTH CARE, NUTRITION, STAFFING had one staff on duty who passed medications, provided nursing cares, prepped foods and made meals for Rochester 28279 Oxford Property Mgt LLC x SHORTAGE 2/8&9/17 6/7/2017 all of the clients. x Olmsted

It is alleged that a client was neglected when the facility provided inadequate colostomy care and inadequate housekeeping. The client was found/out attached colostomy bag, and feces, food, and dirty Rochester 28279 Oxford Property Mgt LLC x NEGLECT HEALTH CARE 2/8&9/17 5/31/2017 clothes all over in the apartment. The client was transferred to the hospital w flu-like symptoms. x Olmsted It is alleged that a client was neglected when the facility made multiple medication errors. This included an Rochester 28279 Oxford Property Mgt LLC x NEGLECT-MEDICATION ERRORS 2/8&9/17 4/25/2017 inadequate supply of insulin for the client and antipsychotic medications. x Olmsted It is alleged that several clients were financially exploited when the alleged perpetrator(AP) made unauthorized purchases using the clients' debit card information. In addition, the AP stole personal Rochester 01320 REM River Bluffs Rochester SE ABUSE-EXPLOITATION 12/29/2016 10/4/2017 computers from 2 clients. x Olmsted It is alleged that Client #1 and #2 were neglected when staff failed to provide adequate supervision and Rochester 1464 REM River Bluffs Stone Park NEGLECT - SUPERVISION 11/2/2016 8/1/2017 Client #2 hit #1 in the head with a phone 2 times. x Olmsted

It is alleged that a client was neglected when the client had a change in condition, including symptoms of excessive sleepiness and dehydration and the facility did not assess the change in condition. In addition, the client had a fall and was laying on the ground for an undetermined amount of time. The client was Rochester 31367 River Bend Asst Lving and Mem Care X NEGLECT-HEALTH CARE, FALLS 11/17/2015 2/216 hospitalized w a fractured vertebrae and remains hospitalized after seventeen days. x Olmsted It is alleged that a client was neglected when s/he developed a pressure sore on his/her foot and the facility Rochester 32141 River Bend Asst Lving and Mem Care x NEGLECT HEALTH CARE 1/27, 1/28/16 1/29/2016 failed to provide or obtain adequate treatment for the pressure sore. x Olmsted

It is alleged that a resident was neglected when facility staff failed to provide adequate wound care to Rochester 00953 Rochester East Hlth Services x NEGLECT-HEALTH CARE 9/8/2017 1/22/2018 resident's toe on the right foot. Resident required hospitalization and antibiotics due to infection. x Olmsted

It is alleged that a resident was neglected when facility staff failed to provide adequate wound care to Rochester 00953 Rochester East Hlth Services x NEGLECT-HEALTH CARE 9/8/2017 1/22/2018 resident's toe on the right foot. Resident required hospitalization and antibiotics due to infection. x Olmsted It is alleged that a resident was financially exploited when the alleged perp took the resident's morphine for Rochester 00427 Samaritan Bethany Hm on 8th x EXPLOITATION BY DRUG DIVERSION 10/27 & 28/16 6/19/2017 his/her own personal use. x Olmsted It is alleged that a resident was neglected when s/he had multiple hospitalizations due to neglect of catheter care; had a catheter obstruction and the resident's bladder was perforated, necessitating emergency Rochester 00427 Samaritan Bethany Hm On 8th X NEGLECT HEALTH CARE 2/26/2015 6/3/2015 surgery. x Olmsted

It is alleged that a resident was neglected when the facility failed to toilet the resident according to the residents plan of care. The resident was found incontinent, lying on the floor. The resident was transferred Rochester 00427 Samaritan Bethany HmOn 8th X NEGLECT HEALTH CARE 10/27,28/16 3/24/2017 to the hospital where s/he was found to have a hip fracture. No toileting was documented for 12 hours. x Olmsted It is alleged that a resident was neglected when staff refused to provide emergency medical services when the resident was in pain due to skin ulcers and refused to provide pain medications. It is also alleged that NEGLECT-HEALTH CARE ABUSE-EMOTIONAL- staff were refusing to provide water when requested by the resident and the resident has had previous Rochester 00427 Samaritan Bethany HmOn 8th X STAFF 12/29/2014 4/9/2015 hospital visits due to dehydration. x Olmsted

It is alleged Resident #1 and Resident #2 were abused when an employee, the Alleged Perpetrator (AP), was Rochester 00429 Stewartville Care Center x ABUSE-PHYSICAL, EMOTIONAL 7/30/2015 3/24/2016 yelling at the residents and putting his/her hand and arm around the residents. x Olmsted

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 82 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County

It is alleged that a resident was neglected when staff failed to do nightly checks and shut off resident's alarm and the resident was found in the morning deceased. In addition, it is alleged that multiple residents are being neglected, left unattended while doing personal cares without call buttons and having pressure sores Rochester 00429 Stewartville Care Center x NEGLECT HEALTH CARE 3/5/2015 9/25/2015 due to not being repositioned. These concerns have been brought to the attention of facility w no resolve. x Olmsted It is alleged that several clients (#1,2,3,4 and 5) were financially exploited when the alleged perpetrator took Rochester 24850 The Plumber Home LLC x ABUSE-EXPLOITATION-STAFF 5/18/2016 11/15/2016 their money. x Olmsted It is alleged that a resident was neglected when facility staff/alleged perp administered the wrong medications to the resident. The facility transferred the resident to the hospital. The hospital placed the Rochester 22020 The Shalom Home LLC x NEGLECT-MEDICATION ERRORS 9/17/2017 9/29/2017 resident in the intensive care unit w a breathing tube. x Olmsted It is alleged that a client was exploited by staff/alleged perpetrator when his/her wedding ring and band w Rochester 25044 VOA Home Health at Rochester x ABUSE-EXPLOITATION-STAFF 8/2 &3/17 9/29/2017 approx value of $12,000 went missing. x Olmsted It is alleged that a client was neglected when the staff did not follow up adequately after the client sustained NEGLECT HEALTH CARE-FAILURE TO NOTIFY 2 falls and had facial bruising and other injuries. The client was transferred to the hospital. The hospital Rochester 25044 VOA Home Health At Rochester X PHYSICIAN, FALLS 8/2,3/17 9/29/2017 determined the client had wrist fractures. x Olmsted

NEGLECT-HEALTH CARE PHYSICAL PLANT - It is alleged that a client was neglected by facility when VA had a fall on 3/5/17 at 9:10pm and was found on Rochester 25044 VOA Home Health At Rochester X MAINTENANCE PROBLEMS 8/2,3/17 9/27/2017 the floor on 3/6/17 at 8:42a.m. VA's pendant was not working when VA called for help due to dead battery. x Olmsted It is alleged that a client was neglected when staff, alleged perpetrators (AP #1, AP #2, AP #3, and AP #4) did not respond in a timely manner when the client called out. All AP's refuse to give the client pain medications at night which caused the client to not be able to sleep. AP #4 also refused to suction the client at night. Rogers 22064 Regency Home Healthcare Services NEGLECT OF HEALTH CARE 4/26/2017 8/21/2017 These AP's were temporary staff at night. x Ramsey

It is alleged that a client was neglected when alleged perpetrator closed the client's door at night, which made the client fearful. In addition, the AP refused to suction the client. It is alleged that the client was exploited when the AP switched out the client's narcotic medication at night. The client had pain relief NEGLECT OF HEALTH CARE EXPLOITATION - during the day but not at night. The client had increased pain and was unable to sleep. The client had no way Rogers 22064 Regency Home Healthcare Services DRUG DIVERSION 4/26/2017 6/12/2017 to count and track narcotic medications. x Ramsey It is alleged that a client was neglected when he/she fell in the shower and sustained severe vertebrae ROSEMOUNT 24603 GONDOLA GROUP X NEGLECT-HEALTH CARE 8/16/2016 10/18/2016 fractures. X Dakota It is alleged that six clients were financially exploited when the alleged perpetrator (AP) took the client's Roseville 27952 Eaglecrest Senior Housing LLC x ABUSE-EXPLOITATION-STAFF 10/27/2016 2/2/2017 money. x Ramsey It is alleged that six clients were financially exploited when the alleged perpetrator (AP) took the client's Roseville 27952 Eaglecrest Senior Housing LLC x ABUSE-EXPLOITATION-STAFF 10/27/2016 2/2/2017 money. x Ramsey It is alleged that a client was financially exploited when the alleged perpetrator took the client's pain Roseville 27952 Eaglecrest Senior Housing LLC x ABUSE-EXPLOITATION-DRUG DIVERSION 4/11/2016 8/1/2016 medication for his/her own personal use. x Ramsey It is alleged that clients were financially exploited when a staff, alleged perpetrator (AP), took the client's Roseville 27952 Eaglecrest Senior Housing LLC x EXPLOITATION BY DRUG DIVERSION 6/11/2015 9/16/2015 pain medication for her/his own personal use. x Ramsey 05/16/2017 It is alleged that a client was neglected when the client's care plan was not followed and the client fell. In and addition, it is alleged that the facility is short of staff and that there was an instance of no staff being visible Roseville 27952 Eaglecrest Senior Housing LLC x NEGLECT- HEALTH CARE STAFFING SHORTAGE 05/17/2017 11/20/2017 in the facility for 30 minutes. x Ramsey 05/16/2017 and It is alleged that a client was financially exploited when a staff/alleged perpetrator (AP) took the client's Roseville 27952 Eaglecrest Senior Housing LLC x ABUSE-EXPLOITATION-STAFF 05/17/2017 11/20/2017 credit cared and used it for his/her own personal use without the client's authorization. x Ramsey It is alleged that a resident was neglected when facility staff failed to identify a change in the resident's Roseville 497 Golden LivingCenter Lake Ridge x NEGLECT OF HEALTH CARE 12/15/2017 2/12/2018 baseline resulting in a visit to the emergency room. x Ramsey

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 83 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County It is alleged that a resident was neglected when staff administered medications to the resident that were not his/hers. The resident became unresponsive. The resident was hospitalized in the ICU and needed to be Roseville 497 Golden LivingCenter Lake Ridge x NEGLECT-MEDICATIONS 7/19/2016 3/2/2017 intubated. x Ramsey It is alleged that a resident was neglected when facility staff failed to follow physician orders. Resident was NEGLECT-MEDICATIONS 3/2/2017 Roseville 497 Golden LivingCenter Lake Ridge x 7/19/2016 administered incorrect medication resulting in hospitalization. x Ramsey NEGLECT OF HEALTH CARE NURSING CARE NEGLECT OF HEALTH CARE-FALLS NURSING It is alleged that a resident was neglected when s/he had a fall and an excruciating headache for two days Roseville 497 Golden LivingCenter Lake Ridge x CARE 11/1/2016 12/29/2016 after his/her fall. The resident was hospitalized and diagnosed with a C1 fracture. x Ramsey It is alleged that a resident was neglected when s/he had a pressure ulcer that worsened and became Roseville 497 Golden LivingCenter Lake Ridge x NEGLECT-DECUBITI 4/22/2016 7/18/2016 infected while the resident was at the facility. x Ramsey It is alleged that a resident was abused when staff were rough with him/her, causing bruising. Also, staff Roseville 497 Golden LivingCenter Lake Ridge x ABUSE-PHYSICAL, EMOTIONAL 3/3/2016 3/17/2016 mocked the resident and the resident felt fearful. x Ramsey

It is alleged that a resident (female unknown) was abused when an employee, the Alleged Perpetrator (AP) Roseville 497 Golden LivingCenter Lake Ridge x ABUSE-EMOTIONAL-STAFF 8/14/2015 3/14/2016 yelled at the resident. In addition, the AP yells at several residents at meal times. x Ramsey It is alleged that a resident was neglected when staff failed to provide adequate supervision when s/he left the facility with minimal clothing and skin being exposed to the elements for several hours and also had Roseville 497 Golden LivingCenter Lake Ridge x NEGLECT-SUPERVISION, HEALTH CARE 3/3/2016 3/14/2016 multiple bruises on his/her face. x Ramsey It is alleged that a resident was neglected when s/he had two falls within nine hours and the facility did not access emergency services. When family arrived, the resident appeared to be unconscious, had a large cut Roseville 497 Golden LivingCenter Lake Ridge x NEGLECT-FALLS 11/17/2015 1/8/2016 on his/her face, bruising, etc. x Ramsey it is alleged that a resident was neglected when staff failed to provide adequate personal cares for the resident and the resident sat in urine and feces for long periods of time, developing wounds. In addition, the resident developed pressure sores on his/her feet that caused significant pain due to sitting in the Roseville 497 Golden LivingCenter Lake Ridge x NEGLECT-HEALTH CARE 6/25/2015 12/7/2015 wheelchair for long periods of time. x Ramsey 10/12/2015 and It is alleged that a resident was neglected when s/he was found unresponsive with low oxygen stats and s/he Roseville 497 Golden LivingCenter Lake Ridge x NEGLECT-HEALTH CARE 10/13/2015 11/20/2015 was not sent to the hospital until six hours later. The resident died at the hospital from sepsis. x Ramsey 08/24/2015 It is alleged that a resident was neglected when s/he fell and broke his/her hip. Staff did not adequately NEGLECT-HEALTH CARE and assess the resident when s/he complained of pain when moving and his/her leg was swollen. The resident Roseville 497 Golden LivingCenter Lake Ridge x 08/25/2015 11/4/2015 had a broken hip for a month before the facility discovered this. x Ramsey

3/26/2015 It is alleged that a resident was neglected when staff failed to provide adequate medical attention when the Roseville 497 Golden LivingCenter Lake Ridge x NEGLECT-HEALTH CARE 10/27/2014 resident aspirated and developed pneumonia that resulted in the resident's death. x Ramsey It is alleged that a client was neglected when s/he did not receive his/her medication for five-six days and the client became increasingly disoriented and lost his/her balance several times, resulting in three falls. The facility was aware that the client was not receiving his/her medication yet failed to resolve the issue for Roseville 29562 Keystone Roseville x NEGLECT-FALLS, MEDICATION 9/10/2015 12/10/2015 several days. x Ramsey 06/02/2017 and It is alleged that a resident was neglected when staff found the resident face down with the resident's head Roseville 284 Langton Place x NEGLECT OF HEALTH CARE-ENTRAPMENT 06/05/2017 11/22/2017 between the grab bar and mattress. The resident had no pulse or respirations. x Ramsey

TOUCHING/FONDLING BY OTHER NEGLECT OF It is alleged that Client #1 and Client #2 were neglected when staff failed to supervise them, and Client #2 Roseville 20898 Presbyterian Assisted Living Home x SUPERVISION-RESIDENT TO RESIDENT 4/3/2017 6/10/2017 touched Client #1's breast. x Ramsey It is alleged that Client #1 and Client #2 were financially exploited by an unknown person, after the clients' Roseville 20898 Presbyterian Assisted Living Home x ABUSE-EXPLOITATION-OTHER 4/3/2017 6/2/2017 wallets were stolen and credit cards were used. x Ramsey

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 84 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County 10/27/2016 It is alleged that a client was sexually assaulted when the client awoke while the staff/alleged perpetrator and (AP) digitally penetrated the client while the AP changed the client. The client was transferred to the Roseville 20898 Presbyterian Assisted Living Home x ABUSE-SEXUAL 10/28/2016 8/16/2017 emergency department. The client later returned to the facility. x Ramsey 10/27/2016 It is alleged that a client was sexually assaulted when the client awoke while the staff/alleged perpetrator and (AP) digitally penetrated the client while the AP changed the client. The client was transferred to the Roseville 20898 Presbyterian Assisted Living Home x ABUSE-SEXUAL 10/28/2016 8/16/2017 emergency department. The client later returned to the facility. x Ramsey

It is alleged that a resident was neglected when the facility provided inadequate resident cares. This led to Roseville 00126 Rose of Sharon a Villa Center x NEGLECT-DECUBILI 11/15/2017 3/9/2018 the development of at least seven pressure ulcers on the coccyx and buttocks and severe pain. x Ramsey

It is alleged that a resident was neglected when the facility provided inadequate resident cares. This led to Roseville 00126 Rose of Sharon a Villa Center x NEGLECT-DECUBILI 11/15/2017 3/9/2018 the development of at least seven pressure ulcers on the coccyx and buttocks and severe pain. x Ramsey

It is alleged that a resident was neglected by three staff persons, alleged perpetrators (APs), (A), (B) and (C), when the resident was transferred to a different facility without the knowledge of or approval of the resident's guardian. The resident was sent via cab to an alternate facility with only medications and without NEGLECT-HEALTH CARE, FAILURE TO REPORT additional clothing or possessions. The guardian became aware of the transfer the following day when the Roseville 126 ROSE OF SHARON A VILLA CENTER x DUMPING PATIENT RIGHTS 3/31/2017 3/13/2018 resident called to ask for additional clothing. x Ramsey 12/03/2015 and It is alleged that a resident was financially exploited when the alleged perpetrator (AP) took the resident's Roseville 126 Rose of Sharon Manor x EXPLOITATION BY STAFF 12/04/2015 1/20/2016 money for his/her own personal use. x Ramsey PHYSICAL ABUSE BY STAFF EMOTIONAL ABUSE It is alleged that abuse occurred when an employee/alleged perpetrator (AP) yelled at a resident and was Roseville 126 Rose of Sharon Manor x BY STAFF 11/1/2017 3/7/2018 rough with cares. x Ramsey It is alleged that a resident was sexually abused by an alleged perpetrator when a tube was inserted into Roseville 126 Rose of Sharon Manor x ABUSE-SEXUAL 12/7/2016 7/28/2017 his/her rectum. x Ramsey

04/26/2016 It is alleged that a resident was neglected when s/he developed a urinary tract infection and was hospitalized and for five days. The resident also had developed open sores. In addition, it is alleged that the staff do not take Roseville 126 Rose of Sharon Manor x NEGLECT-HEALTH CARE PATIENT RIGHTS 04/27/2016 5/8/2017 the resident to the toilet and instead have him/her urinate in their brief. x Ramsey It is alleged that a resident was neglected when staff failed to administer proper medication dosages and did 04/26/2016 not assess the resident for adverse effects. The resident was taken to the emergency room and was and diagnosed with a morphine overdose. In addition, the resident has multiple cuts and bruising and a urinary Roseville 126 Rose of Sharon Manor x NEGLECT-HEALTH CARE 04/27/2016 2/27/2017 infection. x Ramsey

NEGLECT-MEDICATION ERRORS MEDICATION It is alleged that a resident was found to have six medication patches on his/her body at one time. The Roseville 126 Rose of Sharon Manor x ERROR 8/18/2016 11/17/2016 resident was supposed to have one patch and the patch was supposed to be changed daily. x Ramsey 12/03/2015 and it is alleged that nurses have been verbally abusive to a resident. In addition, it is alleged that residents have Roseville 126 Rose of Sharon Manor x ABUSE-EMOTIONAL-STAFF 12/04/2015 1/20/2016 been screamed at by a staff member, Alleged Perpetrator (AP). x Ramsey It is alleged that the resident was neglected when staff found the resident entrapped between the bed and NEGLECT-ENTRAPMENT Roseville 22361 Sunrise Assisted Living of Roseville x 1/4/2017 3/30/2017 the transfer device. The resident was deceased. x Ramsey 06/23/2016 and It is alleged that seven clients were financially exploited when staff, alleged perpetrator (AP), took the Roseville 22361 Sunrise Assisted Living of Roseville x ABUSE-DRUG DIVERSION 06/27/2016 11/28/2016 client's medications. x Ramsey It is alleged that a resident was neglected when facility staff failed to identify a change in the resident's Roseville 497 The Estates at Roseville LLC x NEGLECT OF HEALTH CARE 12/15/2017 2/12/2018 baseline resulting in a visit to the emergency room. x Ramsey

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 85 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County It is alleged that a resident was neglected when staff administered medications to the resident that were not NEGLECT-MEDICATIONS his/hers. The resident became unresponsive. The resident was hospitalized in the ICU and needed to be Roseville 497 The Estates at Roseville LLC x 7/19/2016 3/2/2017 intubated. x Ramsey It is alleged that a resident was neglected when facility staff failed to follow physician orders. Resident was Roseville 497 The Estates at Roseville LLC x NEGLECT-MEDICATIONS 7/19/2016 3/2/2017 administered incorrect medication resulting in hospitalization. x Ramsey NEGLECT OF HEALTH CARE NURSING CARE NEGLECT OF HEALTH CARE-FALLS NURSING 12/29/2016 It is alleged that a resident was neglected when s/he had a fall and an excruciating headache for two days Roseville 497 The Estates at Roseville LLC x CARE 11/1/2016 after his/her fall. The resident was hospitalized and diagnosed with a C1 fracture. x Ramsey It is alleged that a resident was neglected when s/he had a pressure ulcer that worsened and became 7/18/2016 Roseville 497 The Estates at Roseville LLC x NEGLECT-DECUBITI 4/22/2016 infected while the resident was at the facility. x Ramsey It is alleged that a resident was abused when staff were rough with him/her, causing bruising. Also, staff Roseville 497 The Estates at Roseville LLC x ABUSE-PHYSICAL, EMOTIONAL 3/3/2016 3/17/2016 mocked the resident and the resident felt fearful. x Ramsey

It is alleged that a resident (female unknown) was abused when an employee, the Alleged Perpetrator (AP) Roseville 497 The Estates at Roseville LLC x ABUSE-EMOTIONAL-STAFF 8/14/2015 3/14/2016 yelled at the resident. In addition, the AP yells at several residents at meal times. x Ramsey It is alleged that a resident was neglected when staff failed to provide adequate supervision when s/he left the facility with minimal clothing and skin being exposed to the elements for several hours and also had Roseville 497 The Estates at Roseville LLC x NEGLECT-SUPERVISION, HEALTH CARE 3/3/2016 3/14/2016 multiple bruises on his/her face. x Ramsey It is alleged that a resident was neglected when s/he had two falls within nine hours and the facility did not 1/8/2016 access emergency services. When family arrived, the resident appeared to be unconscious, had a large cut Roseville 497 The Estates at Roseville LLC x NEGLECT-FALLS 11/17/2015 on his/her face, bruising, etc. x Ramsey it is alleged that a resident was neglected when staff failed to provide adequate personal cares for the NEGLECT-HEALTH CARE resident and the resident sat in urine and feces for long periods of time, developing wounds. In addition, the Roseville 497 The Estates at Roseville LLC x 6/25/2015 12/7/2015 resident developed pressure sores on hi x Ramsey 10/12/2015 NEGLECT-HEALTH CARE and It is alleged that a resident was neglected when s/he was found unresponsive with low oxygen stats and s/he Roseville 497 The Estates at Roseville LLC x 10/13/2015 11/20/2015 was not sent to the hospital until six hours later. The resident died at the hospital from sepsis. x Ramsey 08/24/2015 It is alleged that a resident was neglected when s/he fell and broke his/her hip. Staff did not adequately NEGLECT-HEALTH CARE and assess the resident when s/he complained of pain when moving and his/her leg was swollen. The resident Roseville 497 The Estates at Roseville LLC x 08/25/2015 11/4/2015 had a broken hip for a month before the facility discovered this. x Ramsey

NEGLECT-HEALTH CARE It is alleged that a resident was neglected when staff failed to provide adequate medical attention when the Roseville 497 The Estates at Roseville LLC x 10/27/2014 3/26/2015 resident aspirated and developed pneumonia that resulted in the resident's death. x Ramsey It is alleged that a client was emotionally abused by a staff, alleged perpetrator, when the AP live-streamed Saint Anthony 20047 Chandler Place Home Health Care x ABUSE-EMOTIONAL-STAFF 4/21/2017 7/6/2017 interactions (audio only) between the AP and the client. x Ramsey

It is alleged that a resident was neglected when the facility did not adequately assess, monitor, and supervise the resident. The facility transferred the resident to the hospital where it was determined that the resident Saint Anthony 522 St Anthony Health & Rehab x NEGLECT-FALLS 1/4/2018 1/31/2018 sustained a subdural hematoma (bleeding in the brain). The resident died the next day. x Ramsey

NEGLECT-HEALTH CARE, FALLS DUE TO EQUIP It is alleged that a resident was neglected when the resident fell off a sling during a mechanical lift transfer. Saint Anthony 522 St Anthony Health Center x FAILURE. INAPPROPRIATE USE OF EQUIPMENT 2/3/2017 4/17/2017 The resident hit his/her head, receiving a large cut and was found to have a broken collar bone. x Ramsey NEGLECT-FALLS DUE TO EQUIP FAILURE, INAPPROPRIATE USE OF EQUIPMENT NEGLECT- It is alleged that a resident was neglected when the resident fell off a sling during a mechanical lift transfer. Saint Anthony 522 St Anthony Health Center x SUPERVISION 2/3/2017 4/17/2017 The resident hit his/her head, receiving a large cut and was found to have a broken collar bone. x Ramsey

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 86 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County It is alleged that a resident was neglected when s/he presented to the emergency room with multiple pressure ulcers and non-stageable wounds. S/he also had an elbow wound dressing from a previous injury appearing not to have been changed in several days. In addition, s/he was also observed to have a black and Saint Anthony 522 St Anthony Health Center x NEGLECT-HEALTH CARE 4/11/2016 2/28/2017 swollen tongue. x Ramsey It is alleged that a resident was neglected when staff failed to follow her/his nutrition care plan. The resident Saint Anthony 522 St Anthony Health Center x NEGLECT-HEALTH CARE, NUTRITION 3/31/2016 12/8/2016 aspirated and passed away. x Ramsey It is alleged that a resident was neglected when s/he had symptoms of a stroke and was not taken to the Saint Anthony 522 St Anthony Health Center x NEGLECT-HEALTH CARE 7/22/2016 11/15/2016 hospital until 12 hours after s/he had a stroke. x Ramsey

NEGLECT-HEALTH CARE It is alleged that a resident was neglected when s/he was found unresponsive. The resident had a fever of Saint Anthony 522 St Anthony Health Center x 12/21/2015 5/12/2016 105 degrees and was severely dehydrated. The resident was admitted to the Intensive Care Unit. x Ramsey 11/01/2017 It is alleged that a resident was neglected when alleged perpetrator (AP) failed to follow the resident plant of and care and failed to follow the facility safe patient handling policy resulting in a fall and subsequent Saint Anthony 522 St Anthony Health Center x NEGLECT-FALLS 11/02/2017 5/31/2017 development of a large bruise to his/her back. x Ramsey It is alleged that a resident was neglected when s/he had a fall and sustained a hip fracture and thoracic Saint Charles 942 Golden LivingCenter Whitewater x NEGLECT-FALLS 2/22/2016 7/7/2016 vertebrae fracture. x Winona It is alleged that a resident was neglected when his/her care plant for continuous oxygen was not followed and the resident was not receiving oxygen. The resident was in distress, was gray in color, and was sweating. Also, it is alleged that the resident's catheter bag is not being emptied and cleaned on a regular basis Saint James 697 Good Samaritan Society St James x NEGLECT-HEALTH CARE 11/10/2015 8/23/2016 resulting in several urinary tract infections. x Watonwan

It is alleged that a resident was neglected when s/he had a change in condition. The resident had symptoms of drooling, difficulty speaking, difficulty breathing, and had blood coming out of his/her ear. The resident Saint James 697 Good Samaritan Society St James x NEGLECT-HEALTH CARE 9/28/2015 2/3/2016 had a recent fall also recently had a significant medication error. The resident is hospitalized on life support. x Watonwan It is alleged that a resident was neglected when staff failed to change his oxygen tank when it is low, and when the resident runs out of oxygen s/he experiences chest pain. The resident is upset and cried when Saint James 697 Good Samaritan Society St James x NEGLECT-HEALTH CARE 5/6/2015 10/20/2015 talking about this. x Watonwan Client was neglected when staff were not following the care plan. The client had two falls on two Saint Louis Park 29578 Brightstar of Northern Dakota X NEGLECT-HEALTH CARE 2/26/2016 2/26/2016 consecutive days. The client broke their hip and dies a few days later. X Hennepin

April It is alleged that resident was neglected when facility failed to provide adequate supervision during smoking. Saint Louis Park 943 Golden Living Center-St Louis Park x NEGLECT-SUPERVISION SAFETY HAZARDS 10,11,12,13 6/16/2017 The resident smoked while using oxygen and sustained a superficial burn to face. x Hennepin

It is alleged that a resident was abused when the alleged perpetrator went into the resident's room to assist Saint Louis Park 943 Golden LivingCntr St Louis Pk x Sexual Abuse 2/7/2017 5/12/2017 the resident, but rubbed the resident's back, touched the residents breast and anus. x Hennepin It is alleged that a resident was abused when the alleged perpetrator (AP) grabbed him/her by the arm and Saint Louis Park 943 Golden LivingCntr St Louis Pk x Physical Abuse by Staff 11/3/2016 1/9/2017 slapped him/her in the head. x Hennepin It is alleged that a resident was neglected when it was reported to the facility staff that his/her mattress was flat and four days later the resident's air mattress was still flat and the resident had developed a 10x18 cm Saint Louis Park 943 Golden LivingCntr St Louis Pk x Neglect-Health Care 7/30/2015 12/21/2015 open area on his/her buttocks. x Hennepin

It is alleged that a resident was neglected when staff failed to provide adequate personal cares leaving the Saint Louis Park 943 Golden LivingCntr St Louis Pk x Neglect-Health Care 7/14/2015 7/14/2015 resident in his/her wheelchair all night telling the resident to urinate in his/her wheelchair. x Hennepin

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 87 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County

It is alleged that a resident was abused when the alleged perpetrator said the resident's family did not care Saint Louis Park 253 Sholom Home West x Emotional Abuse by Staff 12/5/2017 2/12/2018 about the resident. x Hennepin 12/21/2015 Saint Louis Park 380 SHOLOM HOME WEST x ABUSE-SEXUAL 12/22/2015 4/11/2016 It is alleged that the resident was abused by the alleged perpetrator (AP). x Hennepin It is alleged that a resident was physically abused when staff put pajamas to the residents face and said "how Saint Louis Park 129 ST LOUIS PARK OPCO II LLC x ABUSE-EMOTIONAL-STAFF 3/27/2017 11/6/2017 do you like that"? Forcing residents arm into pajamas x Hennepin It is alleged that a resident was neglected when he/she was left in pain for two nights when the facilities call NEGLECT-HEALTH CARE NURSING CARE light system was not working properly. The resident sustained a fall approximately 5 hours before their Saint Louis Park 129 ST LOUIS PARK OPCO II LLC x PHYSICAL PLANT-MAINTENANCE PROBLEMS 12/20/2016 5/8/2017 death. x Hennepin

It is alleged that resident was abused and neglected when staff/alleged perpetrator slammed VA's hand down and the facility staff failed to provide VA with adequate personal cares.VA had dried food on face, very Saint Louis Park 144 TEXAS TERRACE A VILLA CENTER x NEGLECT-HEALTH CARE 4/10/2017 1/31/2018 dirty with dried crusted blood on VAs nose. x Hennepin November 30 It is alleged that the resident was neglected when the facility failed to provide appropriate nursing care &December related to IV care and IV medication administration. In addition, facility failed to follow physician's orders for Saint Louis Park 144 TEXAS TERRACE A VILLA CENTER x NEGLECT-HEALTH CARE 1st 2016 11/3/2017 fluid restrictions. x Hennepin It is alleged that a resident was sexually abused when a staff / alleged perpetrator (AP) penetrated the Saint Louis Park 144 TEXAS TERRACE A VILLA CENTER x ABUSE-SEXUAL 8/3/2017 9/13/2017 resident vaginally and attempted oral penetration. x Hennepin

It is alleged that a resident was neglected when the staff failed to adequately supervise the resident allowing Saint Louis Park 144 TEXAS TERRACE A VILLA CENTER x NEGLECT-SUPERVISION 11/3/2014 5/1/2015 the resident to attend a scheduled outing on his/her own. The resident fell broke his/her shoulder. x Hennepin It is alleged that a resident was neglected when s/he had a fall and the facility was unaware of the fall. The Saint Louis Park 144 Texas Terrace Care Center x Neglect-Health Care 12/22/2015 2/10/2016 resident sustained a hip fracture. x Hennepin It is a sexual allegation based on the following: Resident #1 stated that s/he was raped before dinner by an unidentified alleged perpetrator (AP)/staff person. Resident #1 gave a description of heavy-set, curly-haired Saint Louis Park 943 The Estates at Saint Louis Park x RAPE BY STAFF 3/22/2017 3/12/2018 staff. x Hennepin It is alleged that a resident was abused when staff / alleged perpetrator (AP) #1 mocked the resident when AP#1 screamed and flailed their arms after coming out of the residents room. Another staff/AP#2 grabbed PHYSICAL ABUSE BY STAFF EMOTIONAL ABUSE pulled on the residents arms to go back to bed. It was alleged that the resident was neglected when staff left Saint Louis Park 278 THE VILLA AT ST LOUIS PARK x BY STAFF NEGLECT OF HEALTH CARE 12/26/2017 2/13/2018 the resident in wet, soiled clothing after assisting the resident to the bathroom. The resident was still x Hennepin It is alleged that a client was sexually assaulted when the alleged perpetrator (staff) inserted objects into the Saint Paul 28659 A-1 Reliable Home Care x ABUSE-SEXUAL 5/5/2016 6/27/2016 patient's vagina resulting in injury. x Ramsey It is alleged that a client was financially exploited when the alleged perpetrator (AP) took $100 in cash from Saint Paul 24382 Accessible Space (ASI Metro) 3 x EXPLOITATION BY OTHER 11/29/2016 12/7/2016 the client's room. x Ramsey 03/26/2015 and It is alleged that a client was neglected when staff failed to transfer the client correctly and provide adequate Saint Paul 24382 Accessible Space (ASI Metro) 3 x NEGLECT-HEALTH CARE 03/27/2015 1/14/2016 repositioning and the client developed a necrotic pressure ulcer requiring surgery. x Ramsey It is alleged that a client was abused when a staff caregiver/Alleged Perpetrator (AP) spoke to the client in an Saint Paul 24382 Accessible Space (ASI Metro) 3 x ABUSE-EMOTIONAL-STAFF 3/27/2015 10/5/2015 inappropriate manner resulting in the client not feeling safe. x Ramsey It is alleged that a client was financially exploited when cash was taken from the client's room on two Saint Paul 24381 Accessible Space Inc (ASI Metro) x ABUSE-EXPLOITATION-STAFF 2/22/2017 3/10/2017 occasions x Ramsey It is alleged that two clients (Client #1 and Client #2) were financially exploited when the alleged perpetrator Saint Paul 24380 Accessible Space Inc (ASI Metro) x EXPLOITATION BY DRUG DIVERSION 6/13/2016 6/29/2016 (AP) took their narcotic medications. x Ramsey

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 88 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County 10/29/2015 and 12/10/2015 It is alleged that a client was abused when a staff, alleged perpetrator (AP) verbally threatened and Saint Paul 24379 Accessible Space Inc (ASI North) x ABUSE-EMOTIONAL-STAFF 10/30/2015 reprimanded the client. The client reportedly does not feel safe as a result. x Ramsey

It is alleged that a client was sexually assaulted when staff/alleged perpetrator assisted the client with bathing. The AP fondled the client and made inappropriate verbal remarks to the client. It is alleged that the Saint Paul 24382 Accessible Space Inc 3 x ABUSE-SEXUAL 3/30/2017 8/5/2017 client was emotionally abused by staff when the staff got mad at the client. This intimidated the client. x Ramsey

It is alleged that a client was sexually assaulted when staff/alleged perpetrator assisted the client with bathing. The AP fondled the client and made inappropriate verbal remarks to the client. It is alleged that the Saint Paul 24382 Accessible Space Inc 3 x ABUSE-SEXUA; EMOTIONAL-STAFF 3/30/2017 8/3/2017 client was emotionally abused by staff when the staff got mad at the client. This intimidated the client. x Ramsey It is alleged that a client was verbally abused when staff/alleged perpetrator (AP) told the client that s/he Saint Paul 25489 Accessible Space Inc 4 x ABUSE-EMOTIONAL-STAFF 4/6/2017 12/22/2017 might get something if he learns to talk to people properly. x Ramsey It is alleged that a client was abused and exploited by staff due to AP being rough and verbally abusive. AP got up angrily and left without feeding VA. AP and her children moved into VA's home and are eating and Saint Paul 25489 Accessible Space Inc 4 x ABUSE-EXPLOITATION-STAFF, EMOTIONAL 4/6/2017 12/22/2017 using VA's belongings. x Ramsey It is alleged that a client was financially exploited when an alleged perpetrator (AP) took money from the Saint Paul 25489 Accessible Space Inc 4 x ABUSE-EXPLOITATION-STAFF 10/5/2017 11/6/2017 client for their own personal use. x Hennepin

It is alleged that financial exploitation occurred when two resident's (Client #1 and Client #2) money went Saint Paul 25489 Accessible Space Inc 4 x EXPLOITATIN BY OTHER 4/7/2017 9/17/2017 missing. x Hennepin It is alleged that a client was abused when the alleged perpetrator was rough with the client, causing deep Saint Paul 25489 Accessible Space Inc 4 x ABUSE-PHYSICAL-STAFF 2/5/2016 6/6/2016 hematoma. x Hennepin It is alleged that a client was abused when the alleged perpetrator (AP) spoke to the client in a threatening and demeaning manner by raising their voice and telling the client s/he is to demanding and in the past the EMOTIONAL ABUSE BY STAFF NEGLECT OF client has been afraid of the AP. In addition, it is alleged the AP has made the client intentionally wait for an Saint Paul 25489 Accessible Space Inc 4 x HEALTH CARE 10/19/2015 12/24/2015 extended period to provide personal cares. x Hennepin

It is alleged that a client was abused when the alleged perpetrator was rough with him/her during transfers Saint Paul 24381 Accessible Space Inc Metro - Valley Hi Rise x ABUSE-PHYSICAL, EMOTIONAL 6/28/2016 2/6/2017 and personal cares. In addition, the alleged perpetrator was verbally abusive to the client. x Ramsey It is alleged that a client was financially exploited by the alleged perpetrator (AP) who stole the client's credit Saint Paul 25489 ASI Metro x EXPLOITATION BY STAFF 9/19/2016 12/20/2016 card and made purchases without the client's permission x Ramsey It is alleged that a client was financially exploited when the alleged perpetrator (AP) took the client's alcohol Saint Paul 25489 ASI Metro 4 x ABUSE-EXPLOITATION-STAFF PATIENT RIGHTS 9/19/2016 5/9/2017 for his/her own use. x Ramsey

It is alleged that a client was neglected when the facility power went out for 12 hours and the staff did not 9/14/2015 ensure the client's wound vacuum and air mattress were working during that time. The clients wound Saint Paul 25489 ASI Metro 4 x NEGLECT-HEALTH CARE, SUPERVISION 8/4/2015 worsened, with significant amount of bloody drainage and foul smell. x Ramsey 07/24/2017 NEGLECT OF SUPERVISION NEGLECT OF and It is alleged that a resident was neglected when facility staff failed to provide adequate supervision during an Saint Paul 913 Bethel Care Center x HEALTH CARE 07/25/2017 12/19/2017 activity and the resident's ventilator became disconnected resulting in the resident's death. x Ramsey 05/07/2015, 05/08/2015 and It is alleged that a resident was neglected when the staff did not attach the resident's ventilator during the Saint Paul 913 Bethel Care Center x NEGLECT-HEALTH CARE 05/11/2015 9/2/2015 night. The resident suffered brain damage as a result of lack of oxygen is not expected to survive. x Ramsey It is alleged that the resident was emotionally abused by the alleged perpetrator (AP) when the AP revealed Saint Paul 913 Bethel Care Center x PHYSICAL ABUSE BY OTHER 4/3/2017 8/21/2017 that she was in love with the resident. x Ramsey

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 89 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County It is alleged that a resident's healthcare was neglected by unnamed staff/alleged perpetrator (AP) when she was not given adequate pain medication as ordered by the physician. The AP decreased pain medication and Saint Paul 913 Bethel Care Center x NEGLECT-HEALTH CARE, MEDICATIONS 4/3/2017 8/1/2017 the resident was in a lot of pain. x Ramsey It is alleged that a resident was neglected when the facility staff failed to provide adequate supervision when s/he was smoking inside the bathroom. Smoke was noted coming from the resident's bathroom. Staff Saint Paul 913 Bethel Care Center x NEGLECT-SUPERVISION NURSING CARE 8/9/2016 3/10/2017 investigated and found fire in the waste basket. x Ramsey 02/04/2015 and It is alleged that a resident was neglected when her/his trach tubing became pinched and the resident did Saint Paul 913 Bethel Care Center x NEGLECT-HEALTH CARE 02/05/2015 11/7/2016 not receive oxygen. The resident is hospitalized in ICU. x Ramsey 06/22/2016 and It is alleged that a resident was neglected when his/her ventilator was found disconnected and s/he was Saint Paul 913 Bethel Care Center x NEGLECT-SUPERVISION 06/23/2016 10/10/2016 pulseless. The resident passed away the next day. x Ramsey It is alleged that a resident was neglected when his/her ventilator tubing became disconnected and the Saint Paul 913 Bethel Care Center x NEGLECT OF HEALTH CARE 4/13/2015 2/10/2016 alarm did not sound. The resident was found unresponsive and died. x Ramsey

It is alleged that a resident was neglected when the resident was not given medications or food three days. Saint Paul 913 Bethel Care Center x NEGLECT-HEALTH CARE 4/6/2015 10/29/2015 In addition, the resident's feeding tube fell out, fluid leaked out and s/he was lying in a wet bed. x Ramsey

It is alleged that a resident was neglected when staff refused to provide personal cares resulting in the resident not being toileted for 20 hours, missing doses of seizure medication and not monitoring the 12/23/2014 resident's oxygen levels. The resident's care plan was not developed in a timely manner to ensure and consistency of care. In addition, the resident does not feel safe in the facility. These concerns have been Saint Paul 913 Bethel Care Center x NEGLECT-HEALTH CARE 12/28/2014 6/10/2015 brought to the attention of administration and are not being addressed. x Ramsey

It is alleged that a resident was neglected when staff was not adequately caring for pressure ulcers according to doctor's orders: did not update the resident's care plan with wound orders and the resident's wounds worsened resulting in severe damage. In addition, the resident was not consistently receiving his/her Saint Paul 913 Bethel Care Center x NEGLECT-HEALTHCARE 2/23/2015 4/16/2015 medications and has been observed wearing dirty clothing and unkempt. x Ramsey

It is alleged that a resident was neglected when his/her fistula dressings were not changed in between dialysis appointments. The resident developed two ulcers with drainage in his/her fistula; there was Saint Paul 913 Bethel Care Center x NEGLECT-HEALTH CARE NURSING CARE 10/24/2016 2/23/2017 significant damage to the fistula and the dialysis center was unable to complete dialysis. x Ramsey 02/04/2015 and It is alleged that a resident was neglected when the alleged perpetrator (AP) was not following the care plan Saint Paul 913 Bethel Care Center x NEGLECT-HEALTH CARE 02/05/2015 11/7/2016 when transferring the resident, causing the resident pain and to feel fearful. x Ramsey

It is alleged that three residents were exploited when the alleged perpetrator (AP) took the residents' Saint Paul 498 Capitol View Transitional Care x ABUSE-EXPLOITATION-STAFF DRUG DIVERSION 10/25/2016 3/2/2017 narcotic medication several times a week that resulted in residents not getting their pain medication. x Ramsey

It is alleged that a patient was financially exploited when $480 went missing from her purse when alleged Saint Paul 3323 Caremate Home Health Care Inc ABUSE-EXPLOITATION-STAFF 4/25/2017 6/9/2017 perpetrator was in her apartment cleaning. x Ramsey It is alleged that a resident was neglected when resident slipped off bed after being transferred by facility Saint Paul 27189 Carondelet Village Care Center x NEGLECT HEALTH CARE-FALLS 7/7/2016 12/8/2016 staff. Resident sustained left femur and right hip fractures. x Ramsey 03/27/2017 and It is alleged that a resident was financially exploited when staff/alleged perpetrator signed out narcotics for Saint Paul 354 Cerenity - Marian St Paul LLC x ABUSE-EXPLOITATION-STAFF 03/28/2017 12/29/2017 the residents but never administered it. x Ramsey

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 90 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County 03/27/2017 and It is alleged that a resident was financially exploited when staff/alleged perpetrator signed out narcotics for Saint Paul 354 Cerenity - Marian St Paul LLC x NEGLECT-MEDICATION ERRORS 03/28/2017 12/29/2017 the residents but never administered it. x Ramsey 03/27/2017 and It is alleged that a resident was financially exploited when staff/alleged perpetrator signed out narcotics for Saint Paul 354 Cerenity - Marian St Paul LLC x ABUSE-EXPLOITATION-STAFF 03/28/2017 12/29/2017 the residents but never administered it. x Ramsey It is alleged that a resident was abused when staff, alleged perpetrator, roughly pulled the resident into a Saint Paul 354 Cerenity - Marian St Paul LLC x PHYSICAL ABUSE BY STAFF 8/21/2017 12/22/2017 sitting position. This resulted in a bruise and pain to the resident. x Ramsey It is alleged that a resident was sexually abused by an employee, Alleged Perpetrator (AP), during the Saint Paul 354 Cerenity - Marian St Paul LLC x ABUSE-SEXUAL 12/21/2016 3/23/2017 evening shift. x Ramsey

06/08/2016 and It is alleged that several clients (#1, #2, #3, #4, #5, #6, #7, #8 and #9) were financially exploited when the Saint Paul 20167 Cerenity Care Center - Marian x EXPLOITATION BY DRUG DIVERSION 06/14/2016 1/3/2017 alleged perpetrator (AP) took the client's narcotic medications for his/her own personal use. x Ramsey 12/05/2016 NEGLECT-MEDICATION ERRORS MEDICATION and It is alleged that a resident was neglected when the alleged perpetrator administered 100 units of insulin to Saint Paul 354 Cerenity Care Center Marian x ADMINISTRATION 12/06/2016 12/29/2016 the resident when the order indicated two units. x Ramsey It is alleged that the facility is not adequately supervising a resident. As a result, the resident is chemically impaired when s/he returns to the facility from approved leaves of absences and the resident is also smoking Saint Paul 538 Cerenity Care Center on Humboldt x NEGLECT-SUPERVISION 11/15/2016 8/16/2017 cigarettes unsafely in the facility. x Ramsey 09/19/2016, 09/20/2016 and It is alleged that a resident was provided the wrong diet texture for evening dinner, causing the resident to Saint Paul 538 Cerenity Care Center on Humboldt x NEGLECT-SUPERVISION 09/21/2016 2/14/2017 choke on food. x Ramsey It is alleged that a client was financially exploited when staff/alleged perpetrator (AP) charged $719.74 from Saint Paul 20167 Cerenity Senior Care - Marian x EXPLOITATION BY STAFF 7/11/2017 1/26/2018 client's debit card without the client's authorization. x Ramsey It is alleged that a resident was neglected when the facility failed to provide adequate nursing care resulting NEGLECT OF HEALTH CARE FALLS NURSING in a fall. Resident's family reported that s/he tried to use pendant call light but got no answer and s/he was Saint Paul 29952 Dellwood Gardens x CARE 12/22/2016 5/4/2017 on the floor for two hours. x Ramsey It is alleged that a client was verbally abused and neglected when the alleged perpetrator refused to assist PATIENT RIGHTS VERBAL REMARKS BY STAFF the client, prevented the client from using the bathroom, and told the client that any attempt to help the Saint Paul 1368 Dungarvin Tikvah NEGLECT OF HEALTH CARE 4/3/2017 6/28/2017 client "always ends in disaster." x Ramsey 01/03/2017 It is alleged that a resident was neglected when the resident got up to use the toilet and fell. The resident and complained of arm pain. An x-ray revealed the resident had a fracture and the resident was transferred to Saint Paul 30004 Episcopal Church Home Gardens x NEGLECT, FALLS, HEALTH CARE NURSING CARE 01/05/2017 2/9/2017 the hospital. x Ramsey It is alleged that a resident was neglected when staff failed to provide adequate wound care for his/her pressure ulcers and subsequently required surgery. Also, the staff failed to provide personal care leaving the resident in soiled clothing for several hours. In addition, call lights are not being answered timely, taking over Saint Paul 30004 Episcopal Church Home Gardens x NEGLECT-HEALTH CARE 4/17/2015 2/19/2016 an hour to respond. x Ramsey It is alleged that a resident has been verbally and physically abused by staff. The resident has many different bruises on her shoulders, arms, and hands. The resident has been yelled at and feels intimidated. The Saint Paul 30004 Episcopal Church Home Gardens x ABUSE-PHYSICAL, EMOTIONAL 7/21/2015 8/7/2015 resident is concerned and nervous about being in the facility. x Ramsey It is alleged that a resident was abused when the alleged perpetrator (AP) grabbed the resident by the shoulders and was shaking the resident. The AP also yelled at the resident making the resident feel fearful Saint Paul 30004 Episcopal Church Home Gardens x ABUSE-PHYSICAL, EMOTIONAL-STAFF 4/1/2016 8/18/2016 and nervous. x Ramsey

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 91 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County

It is alleged that a resident was neglected when staff failed to provide adequate personal care, failed to follow prescribed wound care leading to deterioration of wound to a stage-three pressure sore on sacral area and failed to provide the prescribed medications for five days. Facility staff turned off the resident's call Saint Paul 486 Episcopal Church Home of MN x NEGLECT-HEALTH CARE, DECUBITI 2/3/2017 1/22/2018 light and took the call light away from the resident. x Ramsey

It is alleged that a resident was neglected when staff failed to provide adequate personal care, failed to 1/22/2018 follow prescribed wound care leading to deterioration of wound to a stage-three pressure sore on sacral NEGLECT OF HEALTH CARE EMOTIONAL ABUSE area and failed to provide the prescribed medications for five days. Facility staff turned off the resident's call Saint Paul 486 Episcopal Church Home of MN x BY STAFF 2/3/2017 light and took the call light away from the resident. x Ramsey ABUSE-SEXUAL NEGLECT-SUPERVISION- It is alleged that a resident was raped in the morning three times and had vaginal bleeding. The resident 10/4/2017 Saint Paul 486 Episcopal Church Home of MN x RESIDENT TO REST 3/24/2017 described the alleged perpetrator as another resident. x Ramsey

6/11/2017 It is alleged that a resident was sexually abused when the alleged perpetrator (AP) inappropriately touched a Saint Paul 486 Episcopal Church Home of MN x ABUSE-SEXUAL 4/7/2017 resident. x Ramsey It is alleged that a resident was sexually abused when the alleged perpetrator (AP) inappropriately touched a Saint Paul 486 Episcopal Church Home of MN x ABUSE-SEXUAL 4/7/2017 6/11/2017 resident. x Ramsey

PHYSICAL ABUSE BY STAFF EMOTIONAL ABUSE It is alleged that a resident was emotionally and physically abused when an employee, the Alleged Saint Paul 486 Episcopal Church Home of MN x BY STAFF 4/18/2016 5/18/2016 Perpetrator (AP), called the resident by derogatory names and physically abused the resident's face and lips. x Ramsey It is alleged that a resident was neglected when the resident smoked with oxygen and sustained burns to the Saint Paul 480 Galtier Health Center x NEGLECT OF SUPERVISION 6/6/2017 11/6/2017 face. x Ramsey It is alleged that a resident was neglected when staff alleged perpetrator (AP) #1 and AP #2 failed to provide Saint Paul 480 Galtier Health Center x NEGLECT-HEALTH CARE, FAILURE TO DO CPR 2/9/2017 7/3/2017 CPR to a resident. x Ramsey

It is alleged that two residents were neglected and possibly overdosed with narcotics when the alleged perpetrator failed to provide supervision resulting in residents found unresponsive, pinpoint pupil, lethargic NEGLECT OF SUPERVISION NEGLECT- and not responding to verbal command. Residents were transferred to the ER. Residents were administered Saint Paul 480 Galtier Health Center x MEDICATIONS 2/17/2017 5/1/2017 Narcan, required sternal rub, and airway intervention, including intubation. x Ramsey

It is alleged that a resident was neglected and the facility failed to provide adequate supervision when the alleged perpetrator followed the resident into her room, closed the door, inappropriately fondled her breast, Saint Paul 480 Galtier Health Center x NEGLECT-SUPERVISION ABUSE-SEXUAL 11/2/2016 3/13/2017 kissed the resident on the mouth and cheek, and forced himself on the resident. x Ramsey It is alleged that a resident was neglected when staff failed to provide him/her with a diabetic diet and did not adequately monitor his/her diabetes while in the facility. The resident developed a kidney issue as a Saint Paul 480 Galtier Health Center x NEGLECT-HEALTH CARE, NUTRITION 6/18/2015 3/14/2016 result, and was hospitalized. x Ramsey It is alleged that a resident was neglected when he developed a stage three pressure ulcer on his lower spine while he was at the facility, and staff did not inform his group home about the ulcer. In addition, the resident Saint Paul 480 Galtier Health Center x NEGLECT-HEALTH CARE, DECUBITI 8/19/2015 10/14/2015 lost twenty pounds while he was at the facility. x Ramsey 09/28/2016 It is alleged that a resident was neglected when the facility failed to provide adequate assistance and NEGLECT-HEALTH CARE and supervision while s/he was off of the facility grounds resulting in being hit by a slow moving light rail train. Saint Paul 945 Golden LivingCenter Lynnhurst x 09/29/2016 1/20/2017 The resident sustained a hematoma on his/her forehead. x Ramsey

09/28/2016 It is alleged that two residents were neglected when the facility staff failed to provide adequate supervision NEGLECT-SUPERVISION-RESIDENT TO and and Resident #1 called Resident #2 names, taunted him/her and ran into him/her with his/her wheelchair Saint Paul 945 Golden LivingCenter Lynnhurst x RESIDENT NURSING CARE 09/29/2016 1/3/2017 causing the resident to fall over. Resident #2 is fearful of Resident #1. x Ramsey

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 92 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County It is alleged that a client was financially exploited when a staff, alleged perpetrator (AP) took the client's pain Saint Paul 2303 Integrated Home Care EXPLOITATION BY DRUG DIVERSION 7/22/2015 4/11/2016 medication for his/her own personal use. x Ramsey

It is alleged that a client was neglected when the facility failed to follow the physician's orders regarding wound care and also did not provide adequate personal cares for the client. The facility was not tracking the Saint Paul 29564 Keystone Highland Park x NEGLECT-HEALTH CARE 10/14/2015 6/24/2016 treatment of the wound care. The client's wound has worsened. x Ramsey It is alleged that a client was neglected when staff failed to follow the care plan and the client had a fall ABUSE-PHYSICAL-STAFF NEGLECT-HEALTH resulting in lacerations and contusions. In addition, it is alleged that the client was abused when staff were Saint Paul 29564 Keystone Highland Park x CARE 3/1/2016 3/21/2016 rough with him/her and the client had bruising around her/his wrists. x Ramsey 07/12/2016 and It is alleged that a resident was financially exploited when alleged perpetrator took resident's pain Saint Paul 501 Lyngblomsten Care Center x EXPLOITATION-DRUG DIVERSION 07/13/2016 11/7/2016 medications. x Ramsey It is alleged that the resident was neglected when the facility staff did not respond timely when the resident voiced and exhibited symptoms of a stroke. The facility transferred the resident to the hospital over one and a half hours later. The resident arrived at the hospital two and a half hours after the resident complained of Saint Paul 501 Lyngblomsten Care Center x NEGLECT-HEALTH CARE 3/31/3017 9/19/2017 symptoms to the facility staff. x Ramsey

It is alleged that the resident was neglected when the facility staff did not respond timely when the resident voiced and exhibited symptoms of a stroke. The facility transferred the resident to the hospital over one and NEGLECT-FAILURE TO NOTIFY PHYSICIAN, a half hours later. The resident arrived at the hospital two and a half hours after the resident complained of Saint Paul 501 Lyngblomsten Care Center x HEALTH CARE 3/31/2017 9/19/2017 symptoms to the facility staff. x Ramsey It is alleged that a resident was neglected when the facility failed to provide supervision and the resident Saint Paul 501 Lyngblomsten Care Center x NEGLECT-SUPERVISION 3/31/2017 8/11/2017 eloped from the facility. The resident was found by law enforcement. x Ramsey It is alleged that a resident was neglected when the resident developed pressure sores on his/her buttocks Saint Paul 501 Lyngblomsten Care Center x NEGLECT OF HEALTH CARE 1/11/2016 9/8/2016 and foot. In addition, the resident has many cuts on his/her face. x Ramsey

It is alleged that a resident was neglected when staff did not check on him/her during the overnight shift and 11/6/2015 the resident was found in distress, incontinent and dehydrated. In addition, there was no food or water Saint Paul 501 Lyngblomsten Care Center x NEGLECT-HEALTH CARE 7/6/2015 available for the resident and s/he is supposed to drink every two hours according to the care plan. x Ramsey 06/22/2017 and 2/12/2018 It is alleged that a resident was abused when an unknown alleged perpetrator sexually assaulted the Saint Paul 501 Lyngblomsten Care Center x RAPE BY OTRHER 06/23/2017 resident. x Ramsey 06/22/2017 and It is alleged that a resident was abused when an unknown alleged perpetrator sexually assaulted the Saint Paul 501 Lyngblomsten Care Center x ABUSE-SEXUAL 06/23/2017 2/12/2018 resident. x Ramsey 06/22/2017 and It is alleged that a resident was abused when an unknown alleged perpetrator sexually assaulted the Saint Paul 501 Lyngblomsten Care Center x ABUSE-SEXUAL 06/23/2017 2/12/2018 resident. x Ramsey It is alleged that a resident was neglected when s/he had an unexplained injury when x-ray results in the 3/10/2017 Saint Paul 492 New Harmony Care Center x UNEXPLAINED INJURY/FRACTURE 2/6/2017 hospital showed several fractures to the left and right ribs. x Ramsey It is alleged that a resident was neglected when s/he had an unexplained injury when x-ray results in the Saint Paul 492 New Harmony Care Center x UNEXPLAINED INJURY 2/6/2017 3/10/2017 hospital showed several fractures to the left and right ribs. x Ramsey

It is alleged that a resident was neglected when nursing staff failed to provide adequate assessment when Saint Paul 492 New Harmony Care Center x NEGLECT-HEALTH CARE 6/22/2016 7/14/2016 the resident's bile drainage tubes became dislodged. The resident was hospitalized. x Ramsey

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 93 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County

It is alleged that approximately 20 residents do not have their medications properly set up so they received the wrong dosage of medications with multiple medication errors. Some medications are not ordered. Medications are not set up by a nurse. Some staff administered medications have not been trained. A resident received sliding scale insulin when the resident had scheduled insulin ordered by the physician. The NEGLECT-MEDICATIONS, MEDICATION 02/02/2017, resident had elevated blood sugars and the staff/alleged perpetrator (AP) declined to send the resident to ERRORS, HEALTH CARE MEDICATION 02/03/2017 the hospital. The resident was later taken to the hospital by family after they saw the insulin pen and noted ADMINISTRATION MEDICATION ERROR and the wrong dose of insulin. The AP is disrespectful to the residents. Another resident was found slouched over Saint Paul 24993 Peaceful Living Services x NURSING CARE PATIENT RTS 02/06/2017 10/3/2017 outside. The oxygen tank was later found to be empty. The resident died. x Ramsey

It is alleged that a client was neglected when s/he had two falls on two consecutive days and has a brain Saint Paul 24993 Peaceful Living Services x NEGLECT-HEALTH CARE 1/27/2016 3/25/2016 bleed. In addition, the client received the wrong medications on the same day as one of her/his falls. x Ramsey 12/30/2015 and It is alleged that a client was neglected when s/he had several falls with injuries. After the last fall, the client Saint Paul 24993 Peaceful Living Services x NEGLECT-FALLS 12/31/2015 6/6/2016 was hospitalized with a knee injury requiring surgery. x Ramsey

It is alleged that a client was neglected when s/he was hospitalized and was found to be very dirty, smelled Saint Paul 24993 Peaceful Living Services x NEGLECT-HEALTH CARE 1/27/2016 3/28/2016 strongly of body odor, and had bruising and abrasions on multiple areas of his/her body. x Ramsey It is alleged that a client was neglected when s/he did not receive his/her scheduled psychotropic medication injection and had increased paranoia and delusions. The client hadn't received the injection until 12 days Saint Paul 24993 Peaceful Living Services x NEGLECT-MEDICATIONS 9/15/2015 2/9/2016 after the date s/he was schedule to receive it. x Ramsey

It is alleged that a client was neglected when the facility staff neglected to properly secure the client with the seatbelt strap in the client's wheelchair when s/he was going to be transported to an appointment. The Saint Paul 24993 Peaceful Living Services x NEGLECT-HEALTH CARE 8/13/2015 9/11/2015 client fell out of his/her wheelchair while the vehicle was in motion and sustained a spinal cord injury. x Ramsey

It is alleged that a client was neglected when s/he had bleeding wounds and staff did not provide wound care. In addition, it is alleged that the client was not receiving adequate personal cares and the staff were Saint Paul 24993 Peaceful Living Services x NEGLECT-HEALTH CARE 1/5/2016 3/17/2016 unable to get the client out of bed, as the facility did not have a mechanical lift. x Ramsey

It is alleged that a client was financially exploited when the cash for his/her rent payment left on the table Saint Paul 2672 People Incorporated EXPLOITATION BY STAFF 5/25/2017 11/1/2017 was missing after the unnamed staff alleged perpetrator (AP) left after providing services. x Ramsey EMOTIONAL ABUSE BY STAFF PHYSICAL ABUSE It is alleged that a client was abused when the alleged perpetrator (AP) yelled at the client to sit down and Saint Paul 31559 Ramsey Hill Senior Living LLC x BY STAFF 8/25/2017 10/24/2017 also a slapping noise was heard over a surveillance camera recording. x Ramsey 05/02/2017 and It is alleged that a patient was sexually abused by the alleged perpetrator (AP) while the patient received Saint Paul 527 Regions Hospital PATIENT RIGHTS SEXUAL ABUSE 05/03/2017 6/5/2017 treatment at the hospital. x Ramsey It is alleged that a client was financially exploited when the alleged perpetrator (AP) used the client's debit Saint Paul 1056 Rem Ramsey Inc Mississippi EXPLOITATION BY STAFF 5/24/2017 10/23/2017 card for personal use without the client's authorization. x Ramsey

It is alleged that a resident was abused when alleged perpetrator (AP), an unlicensed caregiver, squeezed the Saint Paul 26210 Scenic Hills Alternative Care x ABUSE - PHYSICAL - STAFF 9/1/2017 1/18/2018 resident's face with both the AP's hands and pushed resident into a chair. x Ramsey It is alleged that a client has been abused when a staff, alleged perpetrator has yelled at the client. The client 11/20/2015 Saint Paul 20169 Shepard Park Home x ABUSE-EMOTIONAL-STAFF 9/17/2015 feels threatened and intimidated by the AP. x Ramsey

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 94 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County

It is alleged that a client was neglected when staff failed to respond to a change in the client's condition. The Saint Paul 20169 Shepard Park Home x NEGLECT-HEALTH CARE 12/7/2015 2/4/2016 client was taken to the hospital and suffered a heart attack and multiple organ damage. x Ramsey

It is alleged that a resident was neglected when staff did not assist the resident to toilet when requested. Staff also left the resident in wet clothing before supper and was not changed until later in the evening at bedtime. It is alleged that the resident was emotionally abused when staff told the resident not to use the 03/13/2017 call light until an hour later. The resident cried and was afraid to use the call light. It is alleged that the NEGLECT-HEALTH CARE, MEDICATION ERRORS and resident was neglected when staff did not ensure the resident received seizure medication. The resident Saint Paul 496 Shirley Chapman Sholom Home East x ABUSE-EMOTIONAL-STAFF PATIENT RIGHTS 03/14/2017 1/26/2018 sustained a grand mal seizure. The facility transferred the resident to the hospital. x Ramsey 02/12/2016 and It is alleged that a resident was neglected when s/he was found to be dehydrated, anemic, and malnourished Saint Paul 997 St Anthony Park Home x NEGLECT OF HEALTH CARE 02/16/2016 10/10/2016 with a broken arm. The resident was hospitalized. x Ramsey It is alleged that a resident was neglected when facility staff failed to develop a proper care plan to prevent NEGLECT OF HEALTH CARE AND NEGLECT OF the resident from falling, and failed to ensure the resident was assessed after a fall before s/he was moved. HEALTH CARE - FALLS Saint Paul 997 St Anthony Park Home x 2/26/2016 6/16/2016 The resident was admitted to the hospital with a re-fractured left femur. x Ramsey It is alleged that a resident was financially exploited when a staff, alleged perpetrator took the resident's pain Saint Paul 997 St Anthony Park Home x ABUSE-EXPLOITATION-DRUG DIVERSION 6/18/2015 8/7/2015 medication for his/her own personal use. x Ramsey It is alleged that a resident was neglected when the resident smoked with oxygen and sustained burns to the Saint Paul 480 St Paul Opco LLC x NEGLECT OF SUPERVISION 6/6/2017 11/6/2017 face. x Ramsey It is alleged that a resident was neglected when staff alleged perpetrator (AP) #1 and AP #2 failed to provide Saint Paul 480 St Paul Opco LLC x NEGLECT-HEALTH CARE, FAILURE TO DO CPR 2/9/2017 7/3/2017 CPR to a resident. x Ramsey

It is alleged that two residents were neglected and possibly overdosed with narcotics when the alleged perpetrator failed to provide supervision resulting in residents found unresponsive, pinpoint pupil, lethargic NEGLECT OF SUPERVISION NEGLECT- and not responding to verbal command. Residents were transferred to the ER. Residents were administered Saint Paul 480 St Paul Opco LLC x MEDICATIONS 2/17/2017 5/1/2017 Narcan, required sternal rub, and airway intervention, including intubation. x Ramsey

It is alleged that a resident was neglected and the facility failed to provide adequate supervision when the alleged perpetrator followed the resident into her room, closed the door, inappropriately fondled her breast, Saint Paul 480 St Paul Opco LLC x NEGLECT-SUPERVISION ABUSE-SEXUAL 11/2/2016 3/13/2017 kissed the resident on the mouth and cheek, and forced himself on the resident. x Ramsey It is alleged that a resident was neglected when staff failed to provide him/her with a diabetic diet and did not adequately monitor his/her diabetes while in the facility. The resident developed a kidney issue as a Saint Paul 480 St Paul Opco LLC x NEGLECT-HEALTH CARE, NUTRITION 6/18/2015 3/14/2016 result, and was hospitalized. x Ramsey It is alleged that a resident was neglected when he developed a stage three pressure ulcer on his lower spine 10/14/2015 while he was at the facility, and staff did not inform his group home about the ulcer. In addition, the resident Saint Paul 480 St Paul Opco LLC x NEGLECT-HEALTH CARE, DECUBITI 8/19/2015 lost twenty pounds while he was at the facility. x Ramsey It is alleged that neglect occurred when the facility failed to ensure staff were knowledgeable about infection 12/20/2017 Saint Paul 28604 Summit Hill Senior Living x NEGLECT-HEALTH CARE 11/14/2017 control needs of a client resulting in the spread of infections. x Ramsey It is alleged that a client was neglected when the client who was unable to ambulate independently, was 6/16/2016 found in the bathroom with a broken knee and a twisted foot. The client is now hospitalized and needs Saint Paul 28604 Summit Hill Senior Living x NEGLECT-HEALTH CARE 11/23/2015 surgery for his/her knee. x Ramsey It is alleged that a client was neglected when the client developed a urinary tract infection, became sick and Saint Paul 28604 Summit Hill Senior Living x NEGLECT-HEALTH CARE NEGLECT-FALLS 10/28/2014 3/26/2015 weak, and fell. x Ramsey

It is alleged that a client was neglected when facility staff failed to administer his/her antipsychotic Saint Paul 27035 Sunlight Senior Living x NEGLECT-MEDICATIONS 6/30/2016 8/21/2016 medications and the client's mental health severely declined. The client was hospitalized. x Ramsey

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 95 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County It is alleged that a client was neglected when facility staff failed to monitor the client. The client committed Saint Paul 27035 Sunlight Senior Living x NEGLECT OF SUPERVISION 11/2/2017 12/20/2017 suicide at the facility. x Ramsey It is alleged that a client was neglected when s/he was dropped by staff while being transferred. The client was hospitalized and died a week after the fall. In addition, there are alleged safety concerns as the facility Saint Paul 27035 Sunlight Senior Living x NEGLECT-FALLS SAFETY HAZARDS 12/23/2015 7/25/2016 has only one exit. x Ramsey It is alleged that a client was neglected when s/he was prescribed a new medication following a significant change in mental health, and the alleged perpetrator did not assess the resident or implement the Saint Paul 23761 Sunlight Services LLC x NEGLECT OF HEALTH CARE 12/13/2016 7/7/2017 medication for over two days. In addition, it is alleged that the client was financially exploited when a x Ramsey It is alleged that a client was abused when the alleged perpetrator (AP) inappropriately touched the client's body and got into bed with the client. The client was afraid to report the incident because s/he was told not Saint Paul 23761 Sunlight Services LLC x ABUSE-SEXUAL 11/3/2016 11/15/2016 to tell anyone. x Ramsey 09/22/2016 and It is alleged that client was neglected when staff failed to provide adequate supervision and the client Saint Paul 23761 Sunlight Services LLC x NEGLECT-SUPERVISION NURSING CARE 09/23/2016 11/7/2016 attempted suicide. The client was found in his/her room in a pool of blood with slash marks on his/her body. x Ramsey

It is alleged that resident was neglected when the facility failed to provide adequate supervision to the NEGLECTY OF SUPERVISION-RESIDENT TO resident. Resident had sexual interaction with other resident. Unknown if it was consensual or not. In Saint Paul 21707 Supportive Living Solutions x RESIDENT 7/5/2017 12/7/2017 addition it is alleged that facility staff delivered condoms to the resident. x Ramsey It is alleged that clients were neglected when staff failed to provide adequate supervision and one client Saint Paul 21707 Supportive Living Solutions x NEGLECT-SUPERVISION SEXUAL ABUSE 8/9/2016 10/27/2016 sexually assaulted another client. x Ramsey It is alleged that clients were neglected when staff failed to provide adequate supervision and one client Saint Paul 21707 Supportive Living Solutions x NEGLECT-SUPERVISION 8/9/2016 10/27/2016 sexually assaulted another client. x Ramsey It is alleged that a resident was emotionally abused when an alleged perpetrator (AP) verbally abused the Saint Paul 945 The Estates at Lynnhurst LLC x ABUSE-EMOTIONAL-STAFF 2/10/2017 2/6/2018 resident. x Ramsey It is alleged that a client was neglected when facility staff did not provide adequate supervision for the client, Saint Paul 20812 Wilder Assisted Living Program x NEGLECT-SUPERVISION 3/6/2017 7/21/2017 and the client engaged in sexual intercourse with a stranger. x Ramsey It is alleged that a client was financially exploited when the alleged perpetrator (AP) took the client's wallet Saint Paul 20812 Wilder Assisted Living Program x ABUSE-EXPLOITATION-STAFF 10/18/2016 11/4/2016 that included money, bank cards, and other items. x Ramsey It is alleged that a client was neglected when staff failed to assess him/her and update his/her care plan when the client stopped eaten, subsequently the resident lost 15 pounds in 2 wks. It was brought to the Sartell 627 Country Manor HLTH & REHA x NEGLECT-FALLS, HEALTH CARE 6/21/2017 8/16/2017 attention of the facility R.N. and no action was taken. x Benton It is alleged that a resident was neglected when s/he rolled out of bed and hit his/her bead. The resident was taken to the hospital and admitted with a brain bleed and facial lacerations and passed away less than 24 Sartell 627 Country Manor HLTH & REHA x NEGLECT-HEALTH CAREBE 4/5/2016 4/6/2017 hours later. x Benton

Sartell 627 Country Manor HLTH & REHA x NEGLECT-HEALTH CARE 3/24/2016 6/13/2016 It is alleged that resident was neglected when s/he had a fall resulting in a brain bleed and neck fracture. x Benton It is alleged that a client was neglected when the facility stopped the client's medication for one week and then restarted the client on it without the physician's order and the client subsequently became unconscious Sartell 28073 Welcome Home Health Care Inc x NEGLECT-HEALTH CARE 3/10/2015 1/21/2016 and was hospitalized. x Stearns It is alleged when client #1 was abused by a staff, alleged perpetrator (AP), was touching the client inappropriately. In addition, the AP touched clients #2 and #3 inappropriately. This has been reported to the Sartell 28073 Welcome Home Health Care Inc x SEXUAL ABUSE 3/30/2015 6/27/2015 facility on two occasions and no action has been taken. x Stearns NEGLECT OF HEALTH CARE NEGLECT OF HEALTH CARE FALLS EMOTIONAL ABUSE BY It is alleged that a resident was neglected when s/he had a fall in his/her room and the alleged perpetrator Sartell 28073 Welcome Home Health Care Inc x STAFF 9/28/2015 12/28/2015 (AP) left the resident on the floor while in the room. x Stearns

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 96 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County

It is alleged that a resident was neglected when s/he had blood sugars over 300 and facility failed to update on-call physician per facility protocol. Resident was transported to the hospital and admitted to the Intensive Sauk Centre 640 Centracare Health System x NEGLECT OF HEALTH CARE 12/1,2/2015 6/29/2016 Care Unit for increased blood sugars and decreased blood pressure. x Stearns It is alleged that a client was neglected when the faciility failed to provide adequate assistance and NEGLECT OF HEALTH CARE-FALLS NEGLECT OF supervision resulting in multiple falls and skin abrasion/bruise. Resident had total four falls in the last three Sauk Centre 640 Centracare Health System x HEALTH CARE NURSING CARE 11/29,30/2016 8/22/2017 months. Stearns

Sauk Centre 24072 Getty Street Assisted Living x ABUSE-EXPLOITATION-OTHER 12/28/2016 1/23/2017 It is alleged that two clients personall items and money were stolen. x Stearns It is alleged that a client was neglected when staff failed to provide adequate cares and s/he had two stage 2 pressure ulcers on the coccyx, abraded areas on the inner thighs, fecal matter in the perineal area and an Sauk Rapids 27306 Cherrywood Advanced Living x NEGLECT-HEALTH CARE 8/6/15 8/6/2015 odor. x Benton It s alleged that a client was neglected when a staff failed to folowthe care plan and the client fell out of his/her wheelchair. The client was not assessed and sent to the hospital until the next day and subsequently Sauk Rapids 27306 Cherrywood Advanced Living x NEGLECT-SUPERVISION 1/8/15 3/16/2015 died. x Benton It is alleged that a client was neglected when staff failed to provide adequate supervision. The client wandered outside, was in subzero temperature for 25 minutes and was found with blisters on his/her fingers Sauk Rapids 27306 Cherrywood Advanced Living x NEGLECT-HEALTH CARE 4/6, 4/7/2015 6/16/2015 and was admitted to the hospital with hypothermia. x Benton

It is alleged that a client was neglected when the alleged perpetrator (AP) failed to assess the client or contact emergency medical services when the client was hypertensive and asked to be sent to an emergency room and when direct care staff asked the AP to send the client to the emergency room. The next day, the Sebeka 32493 Serenity Lvg Solutions Sebeka x NEGLECT-HEALTH CARE 1/19/2018 3/9/2018 client was found to have suffered a heart attack and the client died within a week of the incident. x Wadena

It is alleged that a client was neglected when the alleged perpetrator (AP) failed to assess the client or contact emergency medical services when the client was hypertensive and asked to be sent to an emergency room and when direct care staff asked the AP to send the client to the emergency room. The next day, the Sebeka 32493 Serenity Lvg Solutions Sebeka x NEGLECT-HEALTH CARE 1/19/2018 3/9/2018 client was found to have suffered a heart attack and the client died within a week of the incident. x Wadena It is alleged that two clients were neglected when staff failed to provide adequate supervision and client #1 Shakopee 29508 All Saints Senior Living of Sh x NEGLECT-SUPERVISION ABUSE-SEXUAL 12/18/2018 5/9/2016 sexually assaulted client #2. x Scott It is alleged that a client was neglected when failed to provide adequate supervision and s/he ingested dishwasher detergent. The client was hospitalized. Client subsequently died from complications of the Shakopee 29327 Augustana Emerald Crest Shakop x NEGLECT-SUPERVISION 3/10/2016 1/3/2017 injestion. x Scott It is alleged that a client was neglected when failed to provide adequate supervision and s/he ingested dishwasher detergent. The client was hospitalized. Client subsequently died from complications of the Shakopee 29327 Augustana Emerald Crest Shakop x NEGLECT-SUPERVISION 3/10/2016 1/3/2017 injestion. x Scott NEGLECT-SUPERVISION-RESIDENT TO It is alleged that neglect of supervision occurred Clients' #1 and #2 were inappropriately touched another Shakopee 1228 Delphi RESIDENT 10/13/2107 1/22/2018 Client #3. x Scott NEGLECT-FALLS DUE TO EQUIP FAILURE. INAPPROPRIATE USE OF EQUIPMENT NURSING It is alleged that a resident was neglected when the resident fell from a mechanical lift from the height of Shakopee 820 Shakopee Friendship Manor x CARE 11/15/2016 1/26/2017 his/her bed and sustained an injury on his/her head. x Scott NEGLECT-FALLS DUE TO EQUIP. FAILURE. It is alleged that a resident was neglected when the resident fell from a mechanical lift from the height of Shakopee 820 Shakopee Friendship Manor x INAPPROPRIATE USE OF EQUIPMENT 11/15/2016 1/26/2017 his/her bed and sustained an injury on his/her head. x Scott It is alleged that a resident was abused when s/he present with bruising on left eye, forehead and face area. The resident reported a facility staff that s/he was getting abused by an unknown perpetrator and facility did Shakopee 820 Shakopee Friendship Manor x ABUSE-PHYSICAL-STAFF 5/12/2016 9/14/2016 not believe the resident. x Scott

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 97 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County It is alleged that a client was neglected when staff failed to monitor the resident's change in condition after receiving a medication that was not prescribed by his/her physician. The resident was sent to the intensive care unit and passed away. This document has been re-scanned to the MDH website. The compliance revisit Shakopee 459 St Gertrudes Hlth & Rehab Ctr x NEGLECT-HEALTH CARE, MEDICATIONS 3/4/2015 3/31/2015 was completed on 5/14/2015. x Scott It is alleged that a resident was neglected when staff failed to follow the resident's care plan, resulting in a Shakopee 459 St Gertrudes Hlth & Rehab Ctr x NEGLECT-HEALTH CARE 9/19/2016 7/31/2017 fall. The resident was hospitalized with a cervical fracture. x Scott

Shakopee 29508 Tealwood Management LLC EXPLOITATION BY DRUG DIVERSION188 8/1/2016 8/1/2016 Six clients were financially exploited when AP took the clients narcotic medication for their own use. X Scott 12/10/2015 and It is alleged that a patient was neglected when s/he was left unsupervised by a nurse and was found by Shoreview 27763 Bayada Home Health Care Inc NEGLECT-SUPERVISION 12/11/2015 3/28/2016 family after a fall. The patient was hospitalized for a traumatic brain injury related to the fall. x Ramsey 09/07/2016, 09/08/2016 and It is alleged that facility staff failed to provide adequate supervision and two clients engaged in sexual Shoreview 831 Lake Owasso Residence NEGLECT OF SUPERVISION NURSING CARE 09/09/2016 2/3/2017 activity with each other. x Ramsey 09/07/2016, 09/08/2016 and It is alleged that facility staff failed to provide adequate supervision and two clients engaged in sexual Shoreview 831 Lake Owasso Residence NEGLECT OF SUPERVISION NURSING CARE 09/09/2016 2/3/2017 activity with each other. x Ramsey It is alleged that a client was abused when staff restrained the client. The client sustained bruising and Shoreview 831 Lake Owasso Residence PATIENT RIGHTS RESTRAINTS 9/19/2017 1/30/2018 multiple abrasions. x Ramsey It is alleged that a client was abused when staff restrained the client. The client sustained bruises to the Shoreview 831 Lake Owasso Residence RESTRAINTS PATIENT RIGHTS 9/19/2017 1/30/2018 cheek and abrasions to the elbow and left lower back. x Ramsey

Shoreview 831 Lake Owasso Residence NEGLECT-HEALTH CARE ABUSE-RESTRAINTS 2/16/2017 11/28/2017 It is alleged that clients are neglected, abused, and restrained by unknown staff members. x Ramsey

It is alleged that a client was neglected when facility staff did not adequately supervise the client. The client picked up a coffee pot, raised it up, and poured coffee on his/her left arm and left side of back. The facility Shoreview 831 Lake Owasso Residence NEGLECT-SUPERVISION 6/13/2017 7/31/2017 transferred the client to the emergency room for burn treatment. x Ramsey It is alleged that a client was neglected when staff failed to properly assess and provide treatment after the Shoreview 831 Lake Owasso Residence NEGLECT-HEALTH CARE 6/16/2016 6/26/2017 client had a fall with bruising and fractured his/her arm. x Ramsey It is alleged that a client was abused when the alleged perpetrator (AP) slapped the client's hands away and Shoreview 1287 WINGSPAN LIFE RESOURCES ABUSE-PHYSICAL, EMOTIONAL 2/1-2/2018 3/6/2018 raised his/her voice to the client, and swore at the client. x Ramsey

It is alleged that Resident #1 was abused when Resident #2 entered his/her room, tried to take off his/her oxygen mask and was in the process of taking off bed sheet. Resident #1 is bed ridden, blind and was ABUSE-PHYSICAL-OTHER NEGLECT- screaming in fear. In addition, it is alleged that several other residents' #3, #4, #5, #6 (unknown residents) Silver Bay 381 MN Veterans Home Silver Bay x SUPERVISION-RESIDENT TO RESIDENT 3/1/2017 12/15/2017 were also physically abused by Resident #2, due to his behavioral outburst issue. x Lake

It is alleged that Resident #1 was abused when Resident #2 entered his/her room, tried to take off his/her ABUSE-PHYSICAL-OTHER NEGLECT- oxygen mask and was in the process of taking off bed sheet. Resident #1 is bed ridden, blind and was SUPERVISION NEGLECT-SUPERVISION- screaming in fear. In addition, it is alleged that several other residents' #3, #4, #5, #6 (unknown residents) Silver Bay 381 MN Veterans Home Silver Bay x RESIDENT TO RESIDENT 3/1/2017 12/15/2017 were also physically abused by Resident #2, due to his behavioral outburst issue. x Lake

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 98 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County

It is alleged that Resident #1 was abused when Resident #2 entered his/her room, tried to take off his/her oxygen mask and was in the process of taking off bed sheet. Resident #1 is bed ridden, blind and was screaming in fear. In addition, it is alleged that several other residents' #3, #4, #5, #6 (unknown residents) Silver Bay 381 MN Veterans Home Silver Bay x PHYSICAL ABUSE BY OTHER 3/1/2017 12/15/2017 were also physically abused by Resident #2, due to his behavioral outburst issue. x Lake It is alleged that a resident was neglected when facility staff failed to provide adequate supervision. The resident strikes at residents and staff. It is also alleged that facility is short staffed and nine falls resulting in Silver Bay 381 MN Veterans Home Silver Bay x NEGLECT-SUPERVISION 3/30/2017 9/25/2017 injuries occurred due to lack of supervision. x Lake

It is alleged that a resident was neglected when facility staff failed to have an adequate care plan in place to Silver Bay 381 MN Veterans Home Silver Bay x NEGLECT OF HEALTH CARE-FALLS 3/1/2016 11/18/2016 keep the resident safe. The resident fell and was hospitalized with a left hip fracture. x Lake NEGLECT OF HEALTH CARE/FALLS DUE TO It is alleged that a resident was neglected when facility staff transferred a resident in a lift and resident fell Silver Bay 381 MN Veterans Home Silver Bay x EQUIPMENTT FAILURE 10/2/2017 2/6/2018 resulting in a head laceration. x Lake

It is alleged that a client and several other clients were neglected when staff alleged perpetrators (AP1, AP2 NEGLECT-HEALTH CARE PATIENT RIGHTS and AP3) failed to provide personal care to residents, used illicit drugs, and left clients in beds for hours Slayton 1520 Prairie View Inc INADEQUATE HOUSEKEEPING 4/18/2017 11/27/2017 causing pressure sores on bottoms and feet. It is also alleged the shower room is covered with black mold. x Murray

It is alleged that a client was fincially exploited when a staff, alleged perpetrator (AP) #1, asked for and ABUSE-EXPLOITATION-OTHER received $100 from the client. It is also alleged that the client was finacially exploited by AP #2 when AP #2 Sleepy Eye 20718 Sleepy Eye Area Home Health In x 8/14/2017 9/25/2017 asked the client to withdraw $1000 from the client's bank account. x Brown

It is alleged that a resident was neglected when staff failed to follow the wound care guidelines as ordered nby the physician and the resident's wound worsened. In addition, it is alleged that the resident was Sleepy Eye 776 Sleepy Eye Care Center x NEGLECT-HEALTH CARE 7/8/2015 7/8/2015 neglected when s/he suffered a 53 lb weight loss in seven months. x Brown It is alleged that a client was financially exploited when the alleged perpetrator stole the client's gift card and SOUTH ST PAUL 29863 EVERYDAY LIVING LLC X EXPLOITATION BY STAFF 11/10/2016 11/23/2016 used it for personal use. X Dakota It is alleged that a client was financially exploited when the alleged perpetrator stole the client's gift card and SOUTH ST PAUL 29863 EVERYDAY LIVING LLC X EXPLOITATION BY STAFF 11/10/2016 11/23/2016 used it for personal use. X Dakota NEGLECT-FALLS DUE TO EQUIP FAILURE. It is alleged that a resident was neglected when a staff, alleged perpetrator improperly attached a lift strap x Spring Grove 285 Tweeten Lutheran Health C C X INAPPROPRIATE USE OF EQUIPMENT 1/25/2016 3/24/2016 causing the resident fall, hitting his/her head. Houston It is alleged that staff failed to respond to the resident's change in condition. The resident's face was numb, s/he was running into walls and had a hard time seeing. The facility identified the resident was administered Spring Grove 285 Tweeten Lutheran Health Care Center x NEGLECT-HEALTH CARE, MEDICATIONS 11/24/2015 11/7/2016 an overdose of insulin and suffered brain trauma. x Houston It is alleged that two clients were finacilally exploited when the alleged perpetrator (AP) took the clients Springfield 23595 Home Care Services x ABUSE-EXPLOITATION-DRUG DIVERSION 7/28/2016 9/19/2016 narcotic medications. x Brown It is alleged that a resident was neglected when the facility staff failed to monitor for medication side effects and did not assess a change in condition when the resident had five suicide attempts after starting a medication that has suicidal indications as a known side effect. In addition, the facility failed to notify the Springfield 45 St John Lutheran Home X NEGLECT-HEALTH CARE 5/6/2016 5/6/2016 family of these incidents. x Brown

Springfield 45 St John Lutheran Home x ABUSE-PHYSICAL-STAFF 6/6/2017 10/23/2017 It is alleged that a resident was abused when an alleged perpetrator (AP) slapped the resident's face. x Brown It is alleged that a resident was abused when the alleged perpetrator (AP) sent email to the resident St Paul 494 Highland Chateau HCC x ABUSE-EMOTIONAL-STAFF 12/29/2017 3/1/2018 requesting to advocate on the AP's behalf regarding the AP's employment. x Ramsey It is alleged that a resident was neglected when facility staff failed to provide adequate supervision and the resident eloped from the facility for up to three hours. It is alleged the facility staff did not identify that the St Paul 494 Highland Chateau HCC x NEGLECT-SUPERVISION 12/27/2017 2/26/2018 resident left the facility. x Ramsey

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 99 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County

It is alleged a client was abused when staff/alleged perpetrators (AP#1, AP#2, AP#3) verbally threatened to ABUSE-EMOTIONAL-STAFF NEGLECT- strangle the client if s/he attempted to leave the unit at the facility. It is also alleged the APs barricaded the St Peter 27944 Ecumen Prairie Hill x ENTRAPMENT 9/25/2017 2/12/2018 exit with a mechanical lift to prevent the client from leaving the unit. x Nicollet It is alleged that clients were financially exploited when the alleged perpetrator (AP) took the client's money St Peter 20719 Ecumen Sand Prairie x ABUSE-EXPLOITATION-OTHER 9/13/2017 2/16/2018 and jewelry. x Nicollet It is alleged that clients were financially exploited when the alleged perpetrator (AP) took the client's money St Peter 20719 Ecumen Sand Prairie x ABUSE-EXPLOITATION-STAFF 9/13/2017 2/16/2018 and jewelry. x Nicollet It is alleged that clients were financially exploited when the alleged perpetrator (AP) took the client's money St Peter 20719 Ecumen Sand Prairie x ABUSE-EXPLOITATION-STAFF 9/13/2017 2/16/2018 and jewelry. x Nicollet

It is alleged that a resident (Resident #1) was not supervised adequately when another resident (Resident #2) ABUSE-EMOTIONAL-OTHER ABUSE- threatened Resident #1 over a period of one to two months. Resident #1 was fearful of Resident #2. It is RESTRAINTS, SELF ABUSE NEGLECT- alleged that Resident #1 was abused when staff inappropriately restrained Resident #1 in a restraint chair. It SUPERVISION NEGLECT-SUPERVISION- is alleged that Resident #1 was inadequatelly supervised when Resident #1 had feelings of suicidal ideation St Peter 1418 Forensic Services RESIDENT TO RESIDENT 2/15/2017 5/1/2017 and had objects hidden for self abuse. x Nicollet It is alleged that a resident was neglected when facility staff failed to provide adequate supervision resulting St Peter 25494 So Psychiatric NF - St Peter x ABUSE-SEXUAL NEGLECT-SUPERVISION 2/15/2017 5/2/2017 in sexual touching by another resident. x Nicollet

It is alleged that client was neglected when staff were not trained on ventilator care and the client's oxygen December 6&7 saturations dropped requiring emergency services and the client was left in pain for multiple days before St. Anthony 26906 PROVIDENT HOME HEALTHCARE NURSING CARE NEGLECT-HEALTH CARE 2016 4/17/2017 being sent for emergency services. The client was found to have a torn ligament and fractured femur. x Hennepin It is alleged that a patient was abused when a staff member, alleged perpetrator (AP) sexually assaulted the St. Cloud 2185 Centracare Health Home Care SEXUAL ABUSE 3/4,5/2015 5/27/2015 patient. x Stearns It is alleged that a client was neglected when the client did not get scheduled warfarin for 10 days. The Sherburn St. Cloud 20550 Nature's Point Assisted Living x MEDICATION ERRORS 7/25/2017 9/25/2017 client's condition declined and the client was transported to the hospital. x e It is alleged that a client was financially exploited when a staff/alleged perpetrator (AP) took ten tablets of Vicodin/acetaminophen 10/325 milligrams (mg) for personal use. The AP admitted to taking the medication Sherburn St. Cloud 20550 Nature's Point Assisted Living x ABUSE-EXPLOITATION-DRUG DIVERSION 6/21/2017 8/28/2017 and resigned. x e

It is alleged that a patient was neglected when a staff/alleged perpetrator worked with the patient while impaired. The patient's ileostomy and urostomy bags were overflowing. The patient was fearful and had difficulty sleeping since the night of the incident. It is alleged that a patient was financially exploited when AP took a variety of the patient's medications. It is alleged that a patient was abused when blood was found on NEGLECT-HEALTH CARE ABUSE-SEXUAL ABUSE- syringes in the nurses' room, counter, floor and sofa. The patient had bleeding noted in the patient's St. Cloud 2312 Recover Health PHYSICAL-STAFF PATIENT RIGHTS 6/7,8/2017 12/27/2017 underwear later that night. x Stearns It is alleged that a patient was neglected when when a staff/alleged perpetrator worked with patient while St. Cloud 2312 Recover Health NEGLECT-HEALTH CARE PATIENT RIGHTS 6/7,8/2017 12/27/2017 impaired. x Stearns

It is alleged that a resident was abused when the alleged perpetrators AP #1 and AP #2, used excessive force St. Cloud 1514 REM Central Lakes Inc Fernwood ABUSE-PHYSICAL-STAFF 9/19/2016 8/4/2017 when providing personal cares. The resident was crying and bleeding and bruising on his/her face. x Stearns It is alleged that a resident was abused when the resident was found to be restrained to his/her wheelchair Sherburn St. Cloud 774 St Benedict's Senior Community x ABUSE-RESTRAINTS 7/6/2017 12/29/2017 with a gait belt. x e It is alleged that five clients were financially exploited when the alleged perpetrator (AP) took the client's Sherburn St. Cloud 20711 St Benedict's Senior Community x ABUSE-EXPLOITATION-STAFF 10/5/2016 1/5/2017 money. x e It is alleged that five clients were financially exploited when the alleged perpetrator (AP) took the client's Sherburn St. Cloud 20711 St Benedict's Senior Community x ABUSE-EXPLOITATION-OTHER 10/5/2016 1/5/2017 money. x e

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 100 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County It is alleged that Client #1 was not adequately supervised by the facility when Client #2 pushed Client #1 NEGLECT-SUPERVISION-RESIDENT TO during a verbal and physical altercation. Client #1 fell and was taken to the hospital for a fractured hip that Sherburn St. Cloud 20711 St Benedict's Senior Community x RESIDENT PATIENT RIGHTS 1/13/2017 3/1/2017 required surgical intervention. x e It is alleged that Client #1 was not adequately supervised by the facility when Client #2 pushed Client #1 NEGLECT-SUPERVISION-RESIDENT TO during a verbal and physical altercation. Client #1 fell and was taken to the hospital for a fractured hip that Sherburn St. Cloud 20711 St Benedict's Senior Community x RESIDENT PATIENT RIGHTS 1/13/2017 3/1/2017 required surgical intervention. x e

It is alleged that a client was neglected when the client had a change in condition, including being increasingly sleepy and lethargic, and the client was being overmedicated. The client was not assessed for a Sherburn St. Cloud 20711 St Benedict's Senior Community x NEGLECT-HEALTH CARE, MEDICATIONS 12/7/2015 6/6/2016 change in condition by the staff and later suffered a fall, broke his/her back and was hospitalized. x e It is alleged that resident was sexually abused staff/alleged perpetrator (AP) inappropriately touched the Sherburn St. Cloud 774 St Benedict's Senior Community x ABUSE-SEXUAL 3/8,9/2017 12/14/2017 resident. x e It is alleged that a resident was neglected when Alleged Perpetrator (AP) did not transfer the resident per Sherburn St. Cloud 774 St Benedict's Senior Community x NEGLECT-HEALTH CARE 3/24/2016 8/16/2016 his/her care plan. The resident sustained a left femur fracture. x e It is alleged that neglect occurred when a resident's foot was fractured; it is unclear as to how the fracture Sherburn St. Cloud 774 St Benedict's Senior Community x UNEXPLAINED INJURY/FRACTURE 9/11/2015 6/10/2016 occurred. Care was delayed for a week resulting in increased pain and suffering. x e

NEGLECT OF SUPERVISION-RESIDENT TO It is alleged that Resident #1was neglected when facility staff failed to provide adequate supervision that Sherburn St. Cloud 614 Talahi Nursing & Rehab Center x RESIDENT 7/28/2017 1/3/2018 resulted in a resident to resident altercation, Resident #2 pushed Resident #1 resulting in a fractured arm. x e

NEGLECT-SUPERVISION-RESIDENT TO It is alleged that Resident #1was neglected when facility staff failed to provide adequate supervision that Sherburn St. Cloud 614 Talahi Nursing & Rehab Center x RESIDENT 7/28/2017 1/3/2018 resulted in a resident to resident altercation, Resident #2 pushed Resident #1 resulting in a fractured arm. x e

It is alleged that a resident was neglected when s/he had a change in condition with stroke like symptoms and the facility did not provide adequate nursing care and assessment. The client was not sent to the Sherburn St. Cloud 614 Talahi Nursing & Rehab Center x NEGLECT OF HEALTH CARE 3/22/2016 5/18/2017 emergency room until eight hours after staff noticed the change in condition. X e

It is alleged that a resident was neglected when the staff failed to provide personal cares in a timely manner. Sherburn St. Cloud 614 Talahi Nursing & Rehab Center x NEGLECT OF HEALTH CARE - FALLS 1/22/2015 6/24/2015 The resident fell during a self-transfer to the bathroom after a prolonged period of waiting for assistance. x e It was alleged that client was neglected when staff failed to provide the client's scheduled medications, NEGLECT-MEDICATION ERRORS NEGLECT- which was prescribed for client's multiple myeloma, resulting in worsening pain and increased clinic visits. St. Michael 27112 The Legacy of St. Michael x HEALTH CARE 7/6/2015 9/15/2017 The client's missing medications has been an ongoing issue. x WRIGHT

It is alleged that Resident #1 and Resident #2 were abused when the alleged perpetrator (AP) recorded two St. Paul 30004 EPISCOPAL CHURCH HOME GARDENS x ABUSE-EMOTIONAL-STAFF PATIENT RIGHTS 9/19/2017 3/7/2018 videos of the residents and was laughing. It is alleged that the AP posted the videos to social media. x Ramsey It is alleged that a resident was abused when the alleged perpetrator pinched the resident's thigh in St. Paul 494 Highland Chateau HCC x ABUSE-PHYSICAL-STAFF 12/28/2017 3/2/2018 retaliation for the resident's behaviors. x Ramsey It is alleged that a client was neglected by the alleged perpetrator (AP) when medications were not given to Washingt St. Paul 24993 Peaceful Living Services x NEGLECT-MEDICATIONS 1/25/2018 3/6/2018 the client causing withdrawal. x on It is alleged that a client was neglected by the alleged perpetrator (AP) when the facility failed to assess the Washingt St. Paul 24993 Peaceful Living Services x NEGLECT-MEDICATIONS, HEALTH CARE 1/25/2018 3/6/2018 client's condition and when medications were not given to the client. x on It is alleged that a client was financially exploited when the alleged perpetrator (AP) used the client's debit St. Paul 24993 PEACEFUL LIVING SERVICES x ABUSE-EXPLOITATION-STAFF 1/25/2018 3/9/2018 card to pay for the AP's lunch and did not pay back the client the full amount. x Ramsey It is alleged that a client was neglected when the client had an emesis after receiving a tube feeding. It is St. Paul 23482 Phoenix At Douglas NEGLECT-HEALTH CARE 12/14,18/2017 3/2/2018 alleged that the client aspirated resulting in death. x Ramsey

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 101 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County 04/20/2015 It is alleged that a resident was neglected when staff failed to adequately monitor the resident's health when and the resident had not urinated in 3 days, developed a trach infection, was dehydrated and had pneumonia Staples 667 Lakewood Health System x NEGLECT OF HEALTH CARE 04/21/2015 5/21/2015 and was sent to the hospital per the family's request. x Wadena 06/22/2017 and It is alleged that a resident was neglected when staff/alleged perpetrator failed to follow the care plan for Stillwater 947 Golden Living Center Greeley AKA The Estates xat Greeley LLCNEGLECT - HEALTH CARE 06/23/2017 12/11/2017 tracheostomy care. The resident was found 20 minutes later in respiratory distress. x Washington 12/11/2015 It is alleged that a resident was neglected when s/he developed a change in condition and had multiple falls and in a six-hour period. The resident was on Lovenox and had difficulty holding utensils, behavior changes, was Stillwater 947 Golden Living Center Greeley AKA The Estates xat Greeley LLCNEGLECT - HEALTH CARE, FALLS 12/15/2015 5/10/2016 hospitalized, and died the following day. x Washington NEGLECT OF HEALTH CARE NEGLECT OF It is alleged that a resident was neglected. The resident had an allergic reaction to an antibiotic and Stillwater 947 Golden Living Center Greeley AKA The Estates xat Greeley LLCHEALTH CARE-MEDICATIONS 12/1/2015 1/29/2016 subsequently passed away. x Washington It is alleged two residents were financially exploited when the alleged perpetrator took money from both Stillwater 948 Golden Living Center Linden AKA The Estates atx Linden LLCABUSE - EXPLOITATION - OTHER 11/28/2017 2/2/2018 residents. x Washington

It is alleged that a resident was neglected when s/he was found unresponsive and the facility did not follow the resident's advance directive. The facility waited several hours before addressing the resident's change in Stillwater 948 Golden Living Center Linden AKA The Estates atx Linden LLCNEGLECT - HEALTH CARE 12/4/2015 2/6/2017 condition, as the facility mistakenly thought the resident's advance directive was DNR/DNI. x Washington It is alleged that a resident was neglected when staff failed to provide necessary personal cares and wound care. The facility was aware of these concerns for years and has not implemented measures to provide Stillwater 948 Golden Living Center Linden AKA The Estates atx Linden LLCNEGLECT - HEALTH CARE 2/23/2015 3/27/2015 adequate personal cares. x Washington It is alleged that a resident was neglected when staff failed to provide necessary personal cares and wound care. The facility was aware of these concerns for years and has not implemented measures to provide Stillwater 948 Golden Living Center Linden AKA The Estates atx Linden LLCNEGLECT - HEALTH CARE 2/23/2015 3/27/2015 adequate personal cares. x Washington NEGLECT OF HEALTH CARE-NUTRITION It is alleged that a resident was neglected when the resident spilled soup at dinnertime and sustained blisters Stillwater 903 Good Samaritan Society Stillwater x NEGLECT OF SUPERVISION 3/14/2017 12/6/2017 to the right chest and arm. x Washington

It is alleged that a resident was neglected when staff failed to adequately assess him/her when s/he was having a change in condition and she was coughing up phlegm and blood. Family informed staff of this change and asked that the resident be assessed and nothing was done on two separate occasions. The Stillwater 903 Good Samaritan Society Stillwater x NEGLECT - HEALTH CARE 7/16/2015 2/19/2016 resident was hospitalized twice for pneumonia in a two month time period. x Washington It is alleged that several residents were exploited when the alleged perpetrator took resident's narcotics for Stillwater 903 Good Samaritan Society Stillwater x EXPLOITATION BY DRUG DIVERSION 11/14/2017 11/14/2017 personal use. x Washington

It is alleged that a resident was neglected when facility staff failed to notify the resident's guardian s/he was Stillwater 948 The Estates at Linden LLC x NEGLECT - SUPERVISION 2/2/2017 4/28/2017 leaving the facility. The resident has not returned and has now been gone for multiple days. x Washington

It is alleged that neglect occurred when Client #3 missed nine doses of medication for high blood pressure. Client #4 was not given Coumadin and was hospitalized. Neglect is alleged when Client #1 and Client #2 had NEGLECT-HEALTH CARE, FALLS LACK OF falls and staff failed to assess their fall risks and revise the care plan accordingly. In addition, it is alleged that Thief River Falls 23224 Minnesota Greenleaf x TRAINING 2/5/2015 6/9/2015 staff are not receiving necessary training, including emergency preparedness. x Pennington It is alleged that facility staff did not provide adequate supervision of a client and the client smoked while Tower 24173 GOLDEN HORIZONS x SELF ABUSE NEGLECT-SUPERVISION 7/25-26/2017 11/21/2017 using oxygen. The client sustained burns to his/her face. x St. Louis

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 102 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County

It is alleged that a client was neglected when the facility had cares provided by untrained, unlicensed personnel, when the facility assigned an individual with a known substance abuse problem as the sole UNLICENSED PERSONNEL STAFFING SHORTAGE overnight staff member. The facility failed to investigate unexplained bruising on the client's shins and upper NURSING CARE NEGLECT OF HEALTH CARE arms. In addition, the facility failed to ensure call lights were answered, repositioning was completed, Tower 24173 GOLDEN HORIZONS x UNEXPLAINED INJURY 4/3/2017 06/02/2017 catheter care was appropriate, and bathing was accomplished. x St. Louis It is alleged that abuse occurred when an employee/alleged perpetrator (AP) told a client she would not assist the client with toileting and the client would have urinate on him/herself. The client was "humiliated" Tower 24173 GOLDEN HORIZONS x ABUSE-EMOTIONAL-STAFF 12/4-5/2017 2/7/2018 and afraid to ask for help. x St. Louis It is alleged that facility staff did not provide adequate supervision to Client #1 who was smoking and Tower 24173 GOLDEN HORIZONS x NEGLECT-SUPERVISION SAFETY HAZARDS 7/25-26/2017 11/21/2017 endangered the safety of Client #2. x St. Louis

It is alleged that abuse occurred when an employee/alleged perpetrator (AP) put the client in a "headlock" in Tower 24173 GOLDEN HORIZONS x ABUSE-PHYSICAL, EMOTIONAL 12/4-5/2017 02/07/2018 the middle of the dining room and yelled at the client. The client yelled and screamed. x St. Louis It is alleged that a resident was abused when the alleged perpetrator (AP) hit the resident. In addition, it is PHYSICAL ABUSE BY STAFF NEGLECT OF alleged call lights are not being answered in a timely manner. The resident had to wait for 1 hour and 45 Trimont 365 Trimont Healthcare Center x HEALTH CARE 05/23,24/2016 5/17/2016 minutes for assistance. x Martin NEGLECT-SUPERVISION-RESIDENT TO It is alleged that Resident #1 was neglected when facility staff failed to provide adequate supervision and Truman 361 Truman Senior Living x RESIDENT 2/27/2017 7/13/2017 Resident #2 kissed and touched Resident #1 inappropriately. x Martin NEGLECT-SUPERVISION-RESIDENT TO It is alleged that neglect of supervision occurred when Client #2 inappropriately rubbed his penis on Client Truman 22125 Truman Senior Living Inc x RESIDENT 1/17/2017 9/1/2017 #1's neck and face. x Martin

It is alleged that a resident was emotionally abused when staff confined the resident to his/her room for NEGLECT-HEALTH CARE ABUSE-EMOTIONAL- several days and did not allow the resident to do activities. In addition, it is also alleged that staff made the Truman 23692 Vista Prairie At Goldfinch Est x STAFF 04/17,18/2017 10/24/2017 resident walk downstairs despite the fact s/he is wheelchair bound and has a sore on the foot. x Martin

NEGLECT-SUPERVISION-RESIDENT TO It is alleged that a client (Client #1) was neglected when staff heard a scream and found another client (Client Truman 23692 Vista Prairie At Goldfinch Est x RESIDENT 04/17,18/2017 10/24/2017 #2) with his/her hands around Client #1's neck. Client #1 had reddened marks on both sides of the neck. x Martin

It is alleged that clients at Vista Prairie at Goldfinch Est. are being neglected when staff failed to provide adequate personal care. Clients don't get showered; teeth don't get brushed. There are multiple UTI's, skin Truman 23692 Vista Prairie At Goldfinch Est x NEGLECT-HEALTH CARE STAFFING SHORTAGE 04/17,18/2017 10/24/2017 breakdown, and infection due to lack of care. Facility is also short staffed. x Martin It is alleged that a resident was neglected when s/he developed a pressure ulcer on his/her foot while residing at the facility. In addition, the facility failed to provide adequate nursing care when a resident fell Twin Valley 414 Twin Valley Living Center x NEGLECT-DECUBITI 5/16,17/2016 9/6/2016 out of his/her wheelchair and obtained bruising. x Norman It is alleged that a resident was sexually abused when the alleged perpetrator (AP) (unknown) had sex with Two Harbors 844 Ecumen Scenic Shores x 2/15/2017 3/5/2018 the resident. Resident mentioned it was the C.N.A. of his/her care team. x Lake It is alleged that neglect occurred when staff failed to implement interventions to address falls. As a result a Tyler 338 Avera Sunrise Manor x NEGLECT-HEALTH CARE NEGLECT-FALLS 5/23/2016 9/2/2016 resident fell and sustained facial injuries. x Lincoln It is alleged that 5 clients were sexually abused when 3 facility staff/alleged perpetrators forced clients to Victoria 20815 Augustana Emerald Crest of Victoria X ABUSE-SEXUAL, ABUSE-EMOTIONAL 3/13/2017 6/10/2017 have sex with other facility clients in the shower room. X Carver

NEGLECT-SUPERVISION-RESIDENT TO It is alleged that two clients were neglected when staff failed to provide adequate supervision when one Victoria 1022 Mount Olivet Rolling Acres RESIDENT SEXUAL ABUSE 8/20/2015 12/11/2015 client exposed himself to another client and touched the lient inappropriately. X Carver It is alleged that a client was abused when the alleged perpetrator punched the client and put him into a Victoria 1022 Mount Olivet Rolling Acres ABUSE-PHYSICAL,EMOTIONAL PATIENT RIGHTS 8/25/2016 12/20/2016 head lock. X Carver

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 103 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County It is alleged that a client was abused when the alleged perpetrator punched the client and put him into a Victoria 1022 Mount Olivet Rolling acres ABUSE-PHYSICAL,EMOTIONAL PATIENT RIGHTS 8/25/2016 12/20/2016 head lock. X Carver It is alleged that a client was abused when the alleged perpetrator (AP) applied too much pressure during Virginia 21353 EDGEWOOD VIRGINIA I SENIOR LVG x ABUSE-PHYSICAL-STAFF 6/19-20/2017 11/23/2017 care and left a bruise mark on the client's arm, approximately 14 cm by 9.5 cm. x St. Louis

It is alleged that a client was neglected when staffed failed to assess the client when the client had a change Virginia 21353 EDGEWOOD VIRGINIA I SENIOR LVG x NEGLECT-HEALTH CARE 12/18/2014 06/17/2015 in condition after a fall. The client subsequently passed away several days later. x St. Louis It is alleged that a resident was neglected when a staff/alleged perpetrator (AP) failed to follow the resident's care plan which states two person for transfer with mechanical lift. The AP transferred the NEGLECT-FALLS DUE TO EQUIP FAILURE, 4/11,12,13/20 resident alone leading to the resident slipping off the sling and falling onto the floor. The resident sustained Virginia 582 ST MICHAELS HLTH & REHAB CTR x INAPPROPRIATE USE OF EQUIPMENT 17 12/13/2017 a closed humerus fracture. x St. Louis It is alleged that a resident was neglected when facility staff failed to follow physician's orders and correctly change the resident's Fentanyl patch. Resident developed suicidal thoughts because of pain and needed Virginia 582 ST MICHAELS HLTH & REHAB CTR x NEGLECT OF HEALTH CARE-MEDICATIONS 5/12-13/2016 10/10/2016 hospitalization. x St. Louis

It is alleged that a resident was neglected when the staff failed to provide adequate assessment when s/he complained of leg pain and his/her leg continued to swell over a period of a week. The resident had a blood Virginia 603 ESSENTIA HEALTH VIRGINIA CARE x NEGLECT-HEALTH CARE 4/21/2016 8/1/2016 clot in his/her leg and died of a pulmonary embolism. x St. Louis It is alleged that a resident was neglected when a staff/alleged perpetrator (AP) failed to follow the resident's care plan which states two persons for transfer with mechanical lift. The AP transferred the NEGLECT-FALLS DUE TO EQUIP FAILURE, 04/11,12,13/2 resident alone leading to the resident slipping off the sling and falling onto the floor. The resident sustained Virginia 582 St Michaels Hlth & Rehab Ctr x INAPPROPRIATE USE OF EQUIPMENT 017 12/13/2017 a closed humerus fracture. x St. Louis It is alleged that a resident was not provided adequate supervision during mealtime. The resident choked on Wabasha 675 St Elizabeth Medical Center x NEGLECT-SUPERVISION 7/14/2016 6/27/2017 his/her food and died. x Wabasha It is alleged that a resident was neglected when nursing staff failed to properly assess and provide medical services for multiple facial fractures, multiple rib fractures, a hemothorax, and a right hip fracture that Wabasha 675 St Elizabeth Medical Center x NEGLECT-HEALTH CARE-FALLS 2/1/2016 3/18/2016 occurred allegedly from a fall. x Wabasha 06/01/2015, 06/02/2015 and Wabasso 949 Golden LivingCenter Wabasso x ABUSE-TOUCHING/FONDLING/STAFF 06/03/2015 12/30/2015 It is alleged that a staff member sexually abused a client. x Redwood

It is alleged that a client was neglected when staff failed to mionitor oxygen equipment, resulting in Waconia 23848 Lighthouse at Waconia X NEGLECT-HEALTH CARE, MEDICATIONS 10/1/2015 2/9/2016 aspiration of fluid and pneumonia. Alos, medications ran out, leaving the client in pain. X Carver PHYSICAL ABUSE BY STAFF EMOTIONAL ABUSE It is alleged that clients were abused when two alleged perpetrators threw one client onto the bed and Waconia 23848 Lighthouse at Waconia X BY STAFF 7/7/2015 12/15/2015 threw things at the client and another client was verbally abused. X Carver

It is alleged that a client was neglected when staff/alleged perpetrators inappropriately transcribed the Waconia 32695 Nagel Assisted Living X NEGLECT-MEDICATIONS 9/20/2017 12/5/2017 client's medication after a hospital stay, missing 13 days of anti-psychotic medication. X Carver

It is alleged that a resident has been abused when the alleged perpetrator (AP) screamed and swore at the Wadena 20221 Comfort Care Cottages x EMOTIONAL ABUSE BY STAFF 9/8/2015 9/17/2015 client. In addition, the AP has chased the resident. The resident is fearful and afraid. x Wadena It is alleged that a resident was financially exploited when the Alleged Perpetrator (AP) took three checks Wadena 679 Fair Oaks Lodge x ABUSE-EXPLOITATION-STAFF 12/19/2016 3/1/2017 from the resident's checkbook. x Wadena It is alleged that a resident was neglected when staff failed to properly monitor and assess his/her infection and s/he had a change in condition. The resident was sent by life flight and had full amputation due to Wadena 679 Fair Oaks Lodge x NEGLECT-HEALTH CARE 10/16/2015 5/31/2016 infection. x Wadena

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 104 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County 01/21/2015 and It is alleged that neglect occurred when the facility failed to respond in a timely manner to a resident's Wadena 679 Fair Oaks Lodge x NEGLECT-HEALTH CARE 01/22/2015 7/21/2015 change in condition. In addition, medications and treatments were delayed. x Wadena

It is alleged that a resident was neglected when the alleged perpetrator (AP) failed to adequately assess the 01/21/2015 resident after s/he had a change in condition. The resident was experiencing pain in his/her upper thigh and and groin, had a swollen leg and foot, and a fever. The resident was transported to the emergency room and Wadena 679 Fair Oaks Lodge x NEGLECT-HEALTH CARE 01/22/2015 7/20/2015 found to have a blood clot in his/her leg. x Wadena ABUSE-EXPLOITATION-EXPLOITATION-DRUG It is alleged that a client was exploited when staff/alleged perpetrator (AP) took client's narcotics for Waite Park 20596 Sterling Park Commons x DIVERSION 6/20/2017 9/6/2017 personal use. x Stearns It is alleged that a resident was neglected when the Alleged Perpetrator (AP) failed to provide the resident pain medications when the resident exhibited signs of pain, and failed to respond when the resident had Waite Park 643 Sterling Park HCC x NEGLECT-PAIN MANAGEMENT NURSING CARE 8/31/2016 2/28/2017 seizures. The patient died the next day. x Stearns It is alleged that a resident choked in the dining room and it took facility staff seven minutes to get the crash cart, as it was covered in boxes. Also, another resident with eating difficulties is being left unsupervised in the dining area. In addition, it is alleged that some licensed nursing staff come to work under the influence of Waite Park 643 Sterling Park HCC x NEGLECT-SUPERVISION OTHER 8/24/2015 8/28/2015 alcohol. x Stearns It is alleged that a resident was neglected. The resident presented to ER with high blood sugar and the Walker 995 Walker Rehab & HCC x NEGLECT OF HEALTH CARE-DECUBITI 6/20/2017 8/1/2017 resident was also observed to have new pressure ulcers on the buttocks. x Cass NEGLECT-FALLS, PAIN MANAGEMENT, Walker 995 Walker Rehab & HCC x DEHYDRATION 1/17/2017 6/16/2017 It is alleged that neglect occurred when a resident developed a fracture, dehydration and experienced pain. x Cass It is alleged that a resident was neglected when the allged perp;etrator (AP) applied splints to the resident's hand causing much pain and distress to the resident. The AP took 45 minutes to place the splint. In addition, resident's therapist was not notified about the split or the application. A week later, therapist NEGLECT-HEALTH CARE NEGLECT-FAILURE TO checked the resident and found two pressure ulcers on the right hand and one pressure ulcer on the left Walker 995 Walker Rehab & HCC x REPORT 3/14/2017 4/17/2017 hand. x Cass It is alleged that a resident was neglected when s/he was found to have multiple pressure sores on his/her Walker 995 Walker Rehab & Health Care Center x NEGLECT-DECUBITI 1/29/2018 3/7/2018 body. x Cass Warren 356 Good Samaritan Society Warren x NEGLECT-FALLS 3/22/2016 6/30/2016 It is alleged that a resident was neglected when s/he had a fall with injuries. x Marshall

It is alleged that a client was neglected when the alleged perpetrator failed to provide adequate care to the Waseca 20207 Colony Court x NEGLECT-HEALTH CARE, FALLS 8/10/2017 3/9/2018 client, left the client on the toilet unattended. The client had a fall and a right hip fracture. x Waseca

It is alleged that a client was neglected when the alleged perpetrator failed to provide adequate care to the Waseca 20207 Colony Court x NEGLECT-HEALTH CARE, FALLS 8/10/2017 3/9/2018 client, left the client on the toilet unattended. The client had a fall and a right hip fracture. x Waseca 02/12/2016 and It is alleged that a resident was financially exploited when a staff, alleged perpetrator took resident's Waseca 682 Lakeshore Inn Nursing Home x ABUSE-EXPLOITATION-DRUG DIVERSION 02/13/2016 8/1/2016 narcotics. x Waseca 02/12/2016 and It is alleged that a resident was financially exploited when a staff, alleged perpetrator took resident's Waseca 682 Lakeshore Inn Nursing Home x EXPLOITATION - DRUG DIVERSION 02/13/2016 8/1/2016 narcotics. x Waseca

It is alleged that a resident was neglected when s/he had a change in condition, including breathing problems, drooping face and an inability to track with his/her eyes. The family called for emergency services Waseca 682 Lakeshore Inn Nursing Home x NEGLECT-HEALTH CARE 11/24/2015 8/29/2016 and the resident was unresponsive when the EMT's arrived. The resident was hospitalized. x Waseca It is alleged that a resident was neglected when the staff administered the wrong dose of clozapine to the Watertown 51 Elim Home Watertown X MEDICATION ERRORS 3/6/2017 9/25/2017 resident. The resident was sent to the emergency room for evaluation. X Carver

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 105 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County It is alleged that clients were neglected when staff failed to adequately supervise them while smoking in the NEGLECT-SUPERVISION SAFETY HAZARDS facility, causing a fire in the building. It is also alleged that the fire alarm system and alarm panel weren't Watertown 20063 Westwood Place Inc. X PHYSICAL PLANT-MAINTENANCE PROBLEMS 10/27/2015 12/24/2015 working for months. X Carver It is alleged that a client was abused when the alleged perpetrator pushed the client down on a couch, Watertown 20063 Westwood Place Inc. X PHYSICAL ABUSE BY STAFF 9/29/2015 10/20/2015 fracturing the client's arm. X Carver

It is alleged that a client was abused when a staff person, the alleged perpetrator (AP) grabbed the client's Wayzata 21172 Hammer Sheridan Abuse-Physical-Staff 7/5/2016 6/7/2017 face and forcefully removed the client's undergarments while assisting the client to the restroom x Hennepin It is alleged that nine clients were financially exploited when the alleged perpetrator (AP) took narcotic Wayzata 29081 Meridian Manor x Exploitation by Drug Diversion 7/12/2017 9/14/2017 medications for his/her own personal use. x Hennepin It is alleged that a client was neglected when the facility administered an incorrect medication to the client NEGLECT-MEDICATION ERRORS MEDICATION 1/19/2017 and the client developed severe respiratory distress. The client was hospitalized and needed to be West Concord 20055 Circle Drive Manor Assisted Li x ERROR 10/20/2016 intubated. x Dodge

West Saint Paul 1633 LIVING WELL EAST EMERSON NEGLECT-FALLS NURSING CARE 1/5/2017 6/5/2017 It is alleged that a client was neglected when she fell from the bed. The client's fingers were fractured. X Dakota

It is alleged that a client was neglected when the staff failed to provide adequate supervision, resulting in a West Saint Paul 1633 LIVING WELL EAST EMERSON NEGLECT-FALLS, HEALTH CARE 1/5/2017 4/21/2017 fall while being transferred with a gait belt and assist. The client sustained two fractured bones. X Dakota It is alleged that a client was neglected when the facility staff failed to maintain the client's methadone prescription resulting in the client not having enough pain medication. Client required emergency medical West Saint Paul 32476 Sanctuary WSP Operations LLC x NEGLECT OF HEALTH CARE 1/18/2018 2/26/2018 services for pain management. x Dakota It is alleged that a client was financially exploited when an alleged perpetrator was found with the resident's West Saint Paul 32476 SANCTUARY WSP OPERATIONS LLC X EXPLOITATION BY STAFF 4/10/2017 11/6/2017 credit card in their possession. The perpetrator was fired. X Dakota It is alleged that a client was financially exploited when an alleged perpetrator was found with the resident's West Saint Paul 32476 SANCTUARY WSP OPERATIONS LLC X EXPLOITATION BY STAFF 4/10/2017 11/6/2017 credit card in their possession. The perpetrator was fired. X Dakota West Saint Paul 32476 SANCTUARY WSP OPERATIONS LLC X NEGLECT-MEDICATIONS MEDICATION 3/2/2017 5/11/2017 It is alleged that a client was neglected when the staff did not reorder the client's medication. X Dakota

NEGLECT-MEDICATION ERRORS, MEDICATIONS West Saint Paul 32476 SANCTUARY WSP OPERATIONS LLC X MEDICATION ADMINISTRATION 3/2/2017 5/11/2017 It is alleged that a client was neglected when medication were not administered properly. X Dakota It is alleged that a client was financially exploited by staff when 260 of the client's narcotics could not be accounted for. The logbook page recording the times the medication was provided to the resident was West Saint Paul 32476 SANCTUARY WSP OPERATIONS LLC X ABUSE-EXPLOITATION-DRUG DIVERSION 4/10/2017 11/6/2017 missing. X Dakota West Saint Paul 102 SOUTHVIEW ACRES HLTH CARE CTR X NEGLECT OF SUPERVISION 4/7/2015 7/16/2015 It is alleged that residents were neglected when staff failed to stop a sexual assault. X Dakota It is alleged that a client was financially exploited when the staff/alleged perpetrator admitted to swapping out oxycodone with metoprolol in a drug tray. The staff member refused to take a drug test and admitted to West Saint Paul 24035 SOUTHVIEW SENIOR LIVING X ABUSE-EXPLOITATON-DRUG DIVERSION 6/12/2017 9/15/2017 an oxycodone addiction. X Dakota It is alleged that a client was neglected when the facility did not provide adequate toileting assistance and required escort. The client fell and sustained multiple fractures. The facility transferred the client to the West Saint Paul 24035 Southview Senior Living x NEGLECT-FALLS 9/22/2017 3/7/2018 hospital where the client died three days later. x Dakota

It is alleged that a resident was neglected when a perpetrator failed to transcribe hospital discharge orders West Saint Paul 27996 WALKER METH WESTWOOD RIDGE II X NEGLECT-HEALTH CARE 4/18/2017 1/3/2018 resulting in the resident not receiving medications and a decline in condition. X Dakota NEGLECT OF HEALTH CARE AND NEGLECT OF It is alleged that a resident was neglected when an alleged perpetrator failed to follow a care plan and the West Saint Paul 27996 WALKER METH WESTWOOD RIDGE II X HEALTH CARE - FALLS 2/17/2016 2/28/2017 resident fell, fracturing a femur. X Dakota It is alleged that neglect occurred when facility staff did not provide the resident adequate pain relief or West Saint Paul 27996 WALKER METH WESTWOOD RIDGE II x NEGLECT-PAIN MANAGEMENT 11/8/2017 3/16/2018 follow-up regarding the pain. x Dakota

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 106 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County It is alleged that a resident was neglected when the facility staff failed to send the resident to the ER. The West Saint Paul 27996 WALKER METH WESTWOOD RIDGE II X X NEGLECT OF HEALTH CARE 12/4/2017 2/12/2018 resident died the next day. X Dakota It is alleged that a client was emotionally abused by a staff member when the staff member made fun of the West Saint Paul 20448 WALKER METHODIST WESTWOOD RIDG X ABUSE-EMOTIONAL-STAFF 10/23/2017 11/21/2017 client. X Dakota

It is alleged that a client was exploited when an alleged perpetrator took the client's narcotic medication for West Saint Paul 20448 WALKER METHODIST WESTWOOD RIDG X ABUSE-EXPLOITATION-STAFF 8/7/2017 10/20/2017 personal use. There were discrepancies in the log book and the perpetrator was fired. X Dakota

WESTBROOK 82 GOOD SAM SOCIETY WESTBROOK X NEGLECT-FALLS 5/18/2015 11/24/2015 It is alleged that a resident was neglected when the resident fell on the floor and died four days later. X Cottonwood It is alleged that a resident was neglected when the faciity staff failed to follow the resident's care plan. Staff WESTBROOK 82 GOOD SAM SOCIETY WESTBROOK X UNEXPLAINED INJURY - FRACTURE 2/16/2016 4/11/2016 incorrectly repositioned the resident and he/she sustained a hip fracture. X Cottonwood It is alleged that a resident was neglected when the facility accepted the resident and was unable and unequipped to meet his/her needs. The resident had a change in condition, including worsening wounds and overall health. The resident requested to see a wound specialist and this was not granted. The resident Wheaton 669 Traverse Care Center x NEGLECT OF HEALTH CARE 10/13/2015 8/2/2016 had a fall and died the next day. x Traverse It is alleged that a resident was abused when the AP was rough with the resident causing him/her pain to the point of crying. The resident was crying and reporting she did not want to be at the facility due to the rough Wheaton 669 Traverse Care Center x ABUSE-PHYSICAL-STAFF 5/27/2015 12/18/2015 treatment. x Traverse

NEGLECT OF HEALTH CARE-FALLS NEGLECT OF 8/31/2015 It is alleged that a resident was neglected when the alleged perpetrator transferred the resident in a manor White Bear Lake 923 Cerenity Care Center White Bear Lake x HEALTH CARE 1/28/2015 not in accordance with his/her care plan causing the resident to fall, resulting in an injury. x Ramsey

It is alleged that a resident was neglected when the alleged perpetrator (AP) failed to provide appropriate NEGLECT-HEALTH CARE, FAILURE TO NOTIFY health care and failed to notify the resident's critical condition to his/her physician on time. The resident was White Bear Lake 923 Cerenity Care Center White Bear Lake x PHYSICIAN 2/14/2018 3/21/2018 transferred to the ER in critical condition, worsening kidney function, and passed away. x Ramsey It is alleged that a resident was neglected when the Alleged Perpetrator (AP) failed to fasten the resident in his/her wheelchair, then pushed the wheelchair, and the resident fell out of the wheelchair hitting his/her head on the floor. The resident was hospitalized with a large brain bleed, skull fractures, and bruising on the White Bear Lake 923 Cerenity Care Center White Bear Lake x NEGLECT-HEALTH CARE, FALLS 10/14/2015 7/13/2016 spinal cord. x Ramsey It is alleged that a resident was abused by the alleged perpetrator (AP) when the AP was physically rough with the resident and the resident subsequently had a leg fracture. In addition, the AP verbally abused the White Bear Lake 923 Cerenity Care Center White Bear Lake x ABUSE-EMOTIONAL, PHYSICAL-STAFF 5/5/2015 4/27/2016 resident and spoke to her/him in a demeaning way. x Ramsey

NEGLECT-HEALTH CARE It is alleged that a client was neglected when staff failed to follow the physician's medication orders. The White Bear Lake 28288 Vision Quest Property Management x 4/4/2016 12/29/2016 client did not receive prescribed medication for 11 days, suffered a stroke, and was hospitalized. x Ramsey

It is alleged that a client was neglected when staff failed to follow the physician's medication orders. The White Bear Lake 28288 Vision Quest Property Management x NEGLECT-MEDICATIONS 4/4/2016 12/29/2016 client did not receive prescribed medication for 11 days, suffered a stroke, and was hospitalized. x Ramsey PATIENT RIGHTS SAFETY HAZARDS NEGLECT OF It is alleged that a resident was neglected when s/he eloped twice from the secure unit due to facility White Bear Lake 28288 Vision Quest Property Management x SUPERVISION 1/10/2017 4/26/2017 security system and video cameras not in working order. x Ramsey It is alleged that a client was neglected when facility staff did not consistently administer medications and White Bear Lake 28288 Vision Quest Property Management x NEGLECT-MEDICATION ERRORS 1/10/2017 4/26/2017 also had multiple medication errors. x Ramsey It is alleged that a client was sexually assaulted at the facility. The client reported to staff that s/he was White Bear Lake 28288 Vision Quest Property Management x RAPE BY OTHER 1/10/2017 4/13/2017 sexually assaulted. x Ramsey It is alleged that the facility failed to provide adequate supervision when the client was found dead and had White Bear Lake 28288 Vision Quest Property Management x NEGLECT-SUPERVISION 2/24/2016 4/22/2016 committed suicide. x Ramsey

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 107 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County

It is alleged that a client was abused when the alleged perpetrator (AP) verbally degraded and threatened White Bear Lake 28288 Vision Quest Property Management x EMOTIONAL ABUSE BY STAFF 9/18/2015 11/2/2015 the client. The client is emotionally distressed and is fearful to report this abuse to the facility. x Ramsey It is alleged that abuse occurred when a staff repeatedly yelled and swore at client. The staff member also White Bear Lake 28288 Vision Quest Property Management x ABUSE-EMOTIONAL-STAFF 6/27/2017 12/8/2017 told the resident to shut up. The client reported this to the management. x Ramsey PATIENT RIGHTS PHYSICAL ABUSE BY STAFF It is alleged that a client was abused by the Alleged Perpetrator (AP). The AP pushed the client's hands into a White Bear Lake 28288 Vision Quest Property Management x EMOTIONAL ABUSE BY STAFF 1/10/2017 4/13/2017 soiled brief and forced the client to wipe the client's face with the hand. x Ramsey It is alleged that a client was abused by the Alleged Perpetrator (AP). The AP pushed the client's hands into a White Bear Lake 28288 Vision Quest Property Management x ABUSE-PHYSICAL, EMOTIONAL PATIENT RIGHTS 1/10/2017 4/13/2017 soiled brief and forced the client to wipe the client's face with the hand. x Ramsey It is alleged that a client was abused by the Alleged Perpetrator (AP). The AP pushed the client's hands into a White Bear Lake 28288 Vision Quest Property Management x ABUSE-PHYSICAL-EMOTIONAL 1/10/2017 4/13/2017 soiled brief and forced the client to wipe the client's face with the hand. x Ramsey It is alleged that a client was abused by the Alleged Perpetrator (AP). The AP pushed the client's hands into a White Bear Lake 28288 Vision Quest Property Management x ABUSE-EMOTIONAL, PHYSICAL PATIENT RIGHTS 1/10/2017 4/13/2017 soiled brief and forced the client to wipe the client's face with the hand. x Ramsey It is alleged that a client was neglected when the facility provided a client with the wrong diet and the client White Bear Lake 24613 White Bear Lake COH Care LLC x NEGLECT-NUTRITION 10/3/2017 12/29/2017 choked. The client was hospitalized for treatment of aspiration. x Ramsey

It is alleged that a client was neglected when staff failed to follow the client's care plan and did not check on White Bear Lake 24613 White Bear Lake COH Care LLC x NEGLECT-HEALTH CARE 3/30/2016 7/12/2016 him/her every two hours during the overnight. S/he was found on the floor deceased the next morning. x Ramsey

It is alleged that a client was neglected when s/he was not adequately secured in his/her wheelchair and the White Bear Township 1325 Axis on Seneca NEGLECT-HEALTH CARE 5/9/2016 9/12/2016 client fell off the wheelchair ramp, falling head first. The client sustained head injuries and a fractured femur. x Ramsey

It is alleged that a client was neglected when staff failed to correctly use the mechanical lift and did not properly hook the sling to the lift prior to transferring the client from the bed to the wheelchair. The client fell from the sling, approximately two feet to the floor. The client sustained injuries that included bleeding in White Bear Township 1325 Axis on Seneca NEGLECT-FALLS 9/11/2014 9/10/2015 his brain and a fracture of an existing shunt in his head. x Ramsey It is alleged that a resident was neglected when s/he had a fall resulting in facial fractures and subsequently Willmar 312 Bethesda Heritage Center x NEGLECT OF HEALTH CARE - FALLS 4/14/2016 3/22/2017 passed away two days later. x Kandiyohi

It is alleged that a resident was neglected when staff failed to properly assess and provide medical services after the resident suffered a fall and waited on the floor for assistance for two hours. The resident passed Willmar 312 Bethesda Heritage Center x NEGLECT-HEALTH CARE,FALLS 7/21/2015 5/2/2016 away the following morning at 10:00 a.m. In addition, staff failed to answer call lights in a timely manner. x Kandiyohi

It is alleged that a resident was neglected when staff failed to provide adequate supervision when the Willmar 792 Bethesda Nursing Home Pleasantview x NEGLECT OF SUPERVISION 8/15/2016 3/22/2017 resident was found seriously injured in the facility parking lot. The resident died at the scene. x Kandiyohi

It is alleged that a resident was neglected when he had a fall requiring hospitalization for multiple facial fractures. In addition, facility staff failed to provide proper nursing assessments, as the resident was Willmar 792 Bethesda Nursing Home Pleasantview x NEGLECT-HEALTH CARE,FALLS 12/23/2015 3/17/2016 diagnosed with a urinary tract infection and severe sepsis upon admission to the hospital. x Kandiyohi

It is alleged that a resident was neglected when the alleged perpetrator (AP) did not provide adequate Willmar 313 Carris Health Care Center Therapy Suites x NEGLECT OF HEALTH CARE 1/24/2018 2/2/2018 supervision while eating in the dining room resulting in a burn from soup to right wrist and bilateral thighs. x Kandiyohi It is alleged that a client was financially exploited when the alleged perpetrator (AP) took the client's money Willmar 20855 Central Minnesota Senior Care x ABUSE-EXPLOITATION-STAFF 2/17/2016 3/16/2016 for his/her own personal use. x Kandiyohi EXPLOITATION BY STAFF EXPLOITATION BY It is alleged that clients were financially exploited when a staff member (alleged perpetrator) took clients' Willmar 20855 Central Minnesota Senior Care x DRUG DIVERSION 8/6/2015 9/30/2015 narcotic medications and clients' money for his/her own personal use. x Kandiyohi

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 108 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County 04/10/2017 and It is alleged that a client was abused when the alleged perpetrator (AP) took money from the client for Willmar 22025 Divine Home Care Inc EXPLOITATION BY STAFF 04/11/2017 7/3/2017 gasoline and charged cigarettes and money for a television. x Kandiyohi

It is alleged that a client was neglected when staff failed to ensure the client attended medical Willmar 20854 Divine House Inc x NEGLECT-HEALTH CARE 11/19/2015 3/6/2017 appointments. In addition, it is alleged that the facility gave incorrect dose of insulin for two weeks. x Kandiyohi It is alleged that Client #1 was sexually abused by alleged perpetrator (AP) when the client stated the AP touched Client #1 inappropriately. In addition, Client #2 was sexually abused when the AP inappropriately Willmar 20579 Prairie Senior Cottages of Wil x SEXUAL ABUSE 4/25/2017 12/29/2017 touched him/her. x Kandiyohi It is alleged that a client was exploited when a staff person, the alleged perpetrator, took the client's WINDOM 3754 GOOD SAM SOCIETY HOME CARE OF WINDOM ABUSE-EXPLOITATION-DRUG DIVERSION 10/17/2017 1/31/2018 medication for his own use. X Cottonwood It is alleged that a resident was abused when the alleged perpetrator hit the resident, pushed the resident's WINDOM 85 GOOD SAM SOCIETY WINDOM X ABUSE-PHYSICAL-STAFF PATIENT RIGHTS 8/26/2016 4/11/2017 face into a pillow and jerked the arm. X Cottonwood NEGLECT-HEALTH CARE NEGLECT- UNEXPLAINED INJURY/FRACTURE NURSING It is alleged that a resident was abused when the facility noted that the resident had a change in condition WINDOM 1194 HOME FOR CREATIVE LIVING CARE 10/31/2016 10/23/2017 and was transferred to a hospital. The resident had a broken jaw. X Cottonwood

WINDOM 1194 HOME FOR CREATIVE LIVING ABUSE-PHYSICAL-STAFF PATIENT RIGHTS 10/31/2016 2/7/2017 It is alleged that a client was abused when an alleged perpetrator pulled the client's hair and head. X Cottonwood It is alleged that five clients were exploited when the alleged perpetrator took the clients' medications for Winnegago 20270 Parker Oaks Communities Inc x ABUSE-EXPLOITATION-DRUG DIVERSION 9/14/2017 1/2/2018 their own personal use. x Faribault It is alleged that five clients were exploited when the alleged perpetrator took the clients' medications for Winnegago 20270 Parker Oaks Communities Inc x ABUSE-EXPLOITATION-DRUG DIVERSION 9/14/2017 1/2/2018 their own personal use. x Faribault It is alleged that a client was financially exploited when the alleged perpetrator (AP) used the client's debit Winona 29387 Callistra Court x ABUSE-EXPOITATION STAFF 1/3/2018 3/9/2018 card for their own personal use. x Winona NEGLECT-FALLS DUE TO EQUIP FAILURE, 01/03/2017 It is alleged that a resident was neglected when the resident was left unattended while seated on an INAPPROPRIATE USE OF EQUIPMENT NEGLECT- and unlocked commode and suspended in the ceiling lift. The resident had a fall and suffered fractures to both Winona 20873 Lake Winona Manor x HEALTH CARE SAFETY HAZARDS 01/04/2017 5/25/2017 legs. x Winona NEGLECT-FALLS DUE TO EQUIPMENT FAILURE, 01/03/2017 It is alleged that a resident was neglected when the resident was left unattended while seated on an INAPPROPRIATE USE OF EQUIPMENT NURSING and unlocked commode and suspended in the ceiling lift. The resident had a fall and suffered fractures to both Winona 20873 Lake Winona Manor x CARE 01/04/2017 4/25/2017 legs. x Winona

It is alleged that a resident was abused when an employee, the Alleged Perpetrator (AP) hit the resident in Winona 20873 Lake Winona Manor x ABUSE-EMOTIONAL, PHYSICAL-STAFF 12/17/2015 2/16/2017 the mouth with a closed fist and also was yelling, swearing, and calling the resident names. x Winona It is alleged that a resident was neglected when facility staff failed to check the resident's INR according to physician order. It is alleged that the resident developed a blood clot in his heart and required Winona 20873 Lake Winona Manor x MEDICATION ERRORS 10/6/2017 12/29/2017 hospitalization. x Winona It is alleged that a resident was neglected when s/he fell from his/her wheelchair sustaining facial lacerations Winona 955 Saint Anne Extended Healthcare x NEGLECT HEALTH CARE-FALLS 5/18/2016 7/21/2016 and a left hip fracture. The resident passed away 3 days later. x Winona Winona 705 Sauer Health Care x NEGLECT-HEALTH CARE 5/31/2016 7/26/2016 It is alleged that a resident was neglected when s/he had a fall with injuries. x Winona

It is alleged that a client was neglected when the facility failed to provide appropriate assessment and care of Winona 28895 Sugar Loaf Senior Living x NEGLECT-HEALTH CARE NURSING CARE 2/9/2017 10/9/2017 the client's feet. As a result, the client experienced fungal growth and skin cracking. x Winona It is alleged that a resident was neglected when facility staff failed to provide adequate medical assessment NEGLECT-HEALTH CARE; FALLS; FAILURE TO and emergency medical service after a resident fell. The resident was diagnosed with a severely fractured hip Winthrop 961 Good Samaritan Society Winthrop x REPORT 11/8/2017 1/8/2018 the following day. x Sibley

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 109 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County It is alleged that a resident was neglected when facility staff failed to provide adequate supervision and assessments for a resident who smokes outside of the facility. The resident came back from smoking and Winthrop 961 Good Samaritan Society Winthrop x NEGLECT OF SUPERVISION 5/19/2016 10/31/2016 his/her sock was on fire. x Sibley NEGLECT-FALLS, HEALTH CARE VIOLATION OF Winthrop 961 Good Samaritan Society Winthrop x ACT-FAILURE TO REPORT 1/25/2017 7/21/2017 It is alleged a resident was neglected when the resident fell out of a sit to stand lift. x Sibley

NEGLECT OF HEALTH CARE-PAIN It is alleged that a client was neglected when staff failed to properly assess the client's pain and administer as MANAGEMENT NEGLECT OF HEALTH CARE- needed pain medication. In addition, after the as needed pain medication was changed to a scheduled Woodbury 28270 Community Living Options Inc x MEDICATIONS 12/5/2014 3/20/2015 medication the client did not receive the medication as prescribed. x Washington

It is alleged that a client was neglected by staff when the client's physical condition has continued to decline Woodbury 28270 Community Living Options Inc x NEGLECT - HEALTH CARE 3/3/2015 4/13/2015 since August 2014 and the client is not receiving the appropriate care to meet needs. x Washington It is alleged that a client was financially exploited when two staff, alleged perpetrators (AP) #1 and AP #2 Woodbury 21116 Senior Care Woodbury LLC x ABUSE-EXPLOITATION-STAFF 1/4/2016 4/25/2016 took the client's money for his/her own personal use. x Washington It is alleged that resident was neglected when facility staff failed to provide adequate nursing care and NEGLECT OF HEALTH CARE PATIENT RIGHTS protect the resident's rights during his/her stay at the facility. In addition, staff emotionally abused the ABUSE-EMOTIONAL-STAFF Woodbury 31025 St Therese of Woodbury LLC x 8/31/2017 12/18/2017 resident at the facility. x Washington It is alleged that three clients were financially exploited when staff, alleged perpetrator (AP), stole the client's Woodbury 27949 Stonecrest x EXPLOITATION BY STAFF 4/15/2016 7/13/2016 credit cards. x Washington NEGLECT-FALLS DUE TO EQUIPMENT FAILURE, It is alleged that a resident was neglected when the alleged perpetrators failed to crisscross the sling, which INAPPROPRIATE USE OF EQUIPMENT LACK OF resulted in the resident falling from a mechanical lift. The resident experienced pain, bruising, and a black Woodbury 803 Woodbury Health Care Center x TRAINING 12/30/2016 3/3/2017 eye. x Washington It is alleged that a resident was neglected when staff failed to provide adequate medical care resulting in the Woodbury 803 Woodbury Health Care Center x NEGLECT OF HEALTH CARE 8/30/2017 11/6/2017 resident requiring hospitalization. x Washington It is alleged that a resident was neglected. The resident had falls and sustained injuries to the knees, a cut on left foot, and a broken big toe on the left foot. The resident also had another fall and lost the ability to Woodbury 803 Woodbury Health Care Center x NEGLECT - HEALTH CARE 6/22/2017 7/14/2017 swallow. x Washington It is alleged that a resident was neglected when facility staff failed to provide adequate supervision and the Woodbury 803 Woodbury Health Care Center x NEGLECT - SUPERVISION 2/9/2017 4/10/2017 resident lit him/herself on fire while smoking. x Washington

It is alleged that a resident was neglected when s/he had a change in condition, including symptoms of having high levels of pain, and the facility failed to adequately assess the resident. The resident was Woodbury 803 Woodbury Health Care Center x NEGLECT - HEALTH CARE 1/4/2016 6/29/2016 hospitalized where s/he remains with an infection in his/her kidney that may require surgery. x Washington

It is alleged that a resident was neglected when staff failed to monitor his/her wounds when there was a change in condition and staff also failed to provide compression socks to prevents wounds from worsening. Woodbury 803 Woodbury Health Care Center x NEGLECT - HEALTH CARE 5/20/2015 2/11/2016 Also, the resident is having water build up around his/her heart as a result of swelling. x Washington

It is alleged that a resident was neglected when staff failed to follow physician's orders in changing the Woodbury 803 Woodbury Health Care Center x NEGLECT - HEALTH CARE 3/24/2015 12/14/2015 resident's wound care after an amputation resulting in an infection and delay in physical therapy. x Washington NEGLECT-SUPERVISION-RESIDENT TO It is alleged that Resident #1 (R1) was neglected when staff failed to provide adequate supervision that Woodbury 803 Woodbury Health Care Center x RESIDENT SEXUAL ABUSE 10/15/2015 3/20/2015 resulted in another resident (R2) touching R1 inappropriately. x Washington It is alleged, neglect of supervision occurred when a fire in the building resulted in the death of a client and Woodbury 21870 Woodbury Villa x NEGLECT - SUPERVISION 3/27/2015 5/27/2015 serious injury to two other clients. x Washington

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 110 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints. Elder Voice Family Advocate Minnesota Office of Health Facility Complaints Website Data - ALL Resolved Complaint Findings As of 4/3/2018 Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates. The information contained in this document was compiled by Elder Voice Family Advocates in March 2018. It represents the dedicated work and advocacy of family members who have experienced the injury or death of a loved one due to abuse or neglect in a long term care setting and who want to prevent the same from happening to other residents. The data was compiled by sifting through every individual maltreatment findings available on the Minnesota Department of Health website.

City Provider # Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl County

It is alleged that a resident was neglected when staff failed to properly assess the resident when s/he had a change in condition. When the resident was finally sent to the hospital s/he was admitted and was very ill. It Worthington 885 South Shore Care Center x NEGLECT-HEALTH CARE NURSING CARE 4/21/2015 9/24/2015 is also alleged call lights are not answered in a timely manner and staff do not wash their hands. x Nobles It is alleged that a client was sexually assaulted on two separate occasions by two unknown alleged Wrenshall 24256 Garden Terrace Assisted Living x TOUCHING/FONDLING BY STAFF 10/12/2017 12/26/2017 perpetrators. x Carlton

It is alleged that a client was bused when the alleged perpetrator (AP) is rough with him/her during personal Wrenshall 24256 Garden Terrace Assisted Living x ABUSE-PHYSICAL, EMOTIONAL 1/14/2016 2/12/2016 cares, causing the client pain. Also, it is alleged that the AP yells at him/her and retaliates against him/her. x Carlton 01/12/2015 It is alleged that a client was abused when the alleged perpetrator (AP) was rough with the client during and transfers and personal cares and the client sustained a sprained ankle. This rough treatment has been Zumbrota 23577 Cascade Care Services Inc x ABUSE-PHYSICAL-STAFF 01/13/2015 7/16/2015 reported to the owner of the agency with no resolution. x Goodhue It is alleged that a client was abused when staff, alleged perpetrator (AP) would physically throw the client 3/15/2016 and up against his/her metal bed and speak to him/her in a demeaning and threatening manner. The client has Zumbrota 23577 Cascade Care Services Inc x ABUSE-PHYSICAL, EMOTIONAL-STAFF 03/16/2016 5/26/2016 been crying and reports being scared of the AP. x Goodhue It is alleged that a resident was neglected when staff/alleged perpetrator did not unplug the resident's lift chair according to the resident's plan of care. The resident fell and sustained head hematomas. The facility Zumbrota 917 Zumbrota Care Center X NEGLECT-FALLS 10/23/2017 1/17/2018 transferred the resident to the hospital. x Goodhue It is alleged that a resident was neglected when staff/alleged perpetrator did not unplug the resident's lift NEGLECT-FALLS DUE TO EQUIP chair according to the resident's plan of care. The resident fell and sustained head hematomas. The facility Zumbrota 917 Zumbrota Care Center X FAILURE/INAPPROPRIATE USE OF EQUIP 10/23/2017 1/17/2018 transferred the resident to the hospital. x Goodhue

Zumbrota 917 Zumbrota Care Center x NEGLECT-FALLS 3/22/2016 3/23/2016 It is alleged that a resident was neglected when s/he had a fall resulting in a subdural hematoma. x Goodhue

* Per the OLA 2018 Report: We estimate that the website may be missing up to 19% of reports that should be posted. Page 111 of 111 * Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints.