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MALTREATMENT INVESTIGATION MEMORANDUM Minnesota Statutes, section 626.557, subdivision 1 states, “The legislature declares that the public policy of this state is to protect adults who, because of physical or mental disability or dependency on institutional services, are particularly vulnerable to maltreatment.”
License Number and Program Type: 1070419-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Emily Kearns 651-431-6513 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) had a rash and open sores in his/her groin area, that the facility staff persons were not completing the VA’s personal cares, that facility staff persons would close the bathroom doors at the facility resulting in the VA needing to wear adult absorbent undergarments, that the VA smelled of urine, and that the VA was sent to his/her day program with very little food. Date of Incident(s): Ongoing Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (b), and Minnesota Statutes, section 626.5572, subdivision 15, and subdivision 17, paragraph (a): The failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct. Summary of Findings: Pertinent information was obtained during a site visit conducted on August 1, 2024; from documentation at the facility, medical records, a law enforcement (LE) report; and through seven interviews conducted with three supervisory facility staff persons (P1, P2, and P3), two facility staff persons (P4 and P5), a day program staff person (DP), and the VA’s guardian (G) who was also a family member. This investigator met with the VA, but the VA was unable to provide information for this investigation. P3 no longer worked at the facility. The VA was diagnosed with autism spectrum disorder and Pica (a disorder where a person eats non-food items), and did not communicate verbally. The VA was not able to communicate when s/he did not feel well or experienced pain. The VA depended on staff persons for “full assistance” with cares, showering, and drying after showers. The VA’s Support Plan Addendum stated, “[The VA] often self-initiates using the toilet but does not always do so appropriately. [S/he] has a pattern of urinating on [his/her] bedroom floor . . . and relies on staff [persons] to help wipe after bowel movements. [The VA] will not indicate if [s/he] needs to use the restroom when in unfamiliar settings,” so reminders were to be given before leaving the facility. The VA relied upon staff persons to select clothing for him/her and for getting dressed. Staff persons were also to ensure that the VA’s personal space was “kept clean.” The VA liked walking around, drinking coffee, going for short walks, and going for car rides. The VA enjoyed quiet surroundings and was happy just to be “left alone.” The VA attended day program Mondays through Fridays from about 8 a.m. until 2 p.m. Transportation to and from was provided by the day program. The VA lived at the facility with three other clients. The main floor consisted of a large living and dining space, a kitchen, four bedrooms, an office, two bathrooms, a door leading to a basement, a cleaning closet, a staff person bathroom, a stairway leading upstairs with a landing with a locked door at the top, and a stairwell leading downstairs to the lower level. The lower level consisted of a laundry room, a storage room, and an open area. When this investigator arrived for the site visit on August 1, 2024, six to seven window screens were bent and hanging from the window frames, visible from the exterior. On the interior, there was a shredded disposable undergarment with feces on the floor of one of the bedrooms, and there were feces smeared on the walls of that bedroom and on one of the bathroom toilet seats that the clients used. There were feces in the living room on the floor and there were portions of a disposable torn undergarment with feces upstairs on the landing area. Of the two bathrooms that clients used, both were locked. There was no soap in the wall dispenser in the bathroom that clients were to use to go to the bathroom. Surfaces and floors throughout the facility had a sticky residue. Minimal furniture was observed throughout the facility and minimal or no bedding was observed throughout the four bedrooms, to include pillows. The basement storage space had mold on the wall and full laundry baskets were present in the laundry area. The medication cabinet in the office was not locked, but the lower half office door, where the medication cabinet was located was locked. The kitchen had an uncovered bowl with dried pasta on the counter and the kitchen area was in disarray, in general. P4 and P5 were present when this investigator arrived and P5 was in the process of leaving the facility with two clients to drive to pick up disposable gloves so that s/he could clean up the fecal matter and torn undergarment. There were no disposable gloves in the facility at that time. P5 stated that it would take him/her approximately 20 to 30 minutes one way to drive to get the gloves. The VA was at his/her day program at the time. The G provided the following information: · The G checked in “often” on the facility when s/he visited the VA. Frequently, there were open windows with no screens, disposable undergarments left outside, and in general, the facility was dirty. The G was concerned that cares were not being completed for the VA. The VA often had dirty fingernails, unclean hands, needed a haircut, and no one would cut his/her toenails. The VA was missing laundry and clothing. One time when the VA’s bedding was missing, it was stuck in the laundry chute and the bedding had the odor of urine. The G thought that other clients urinated on the VA’s items. If the G did not visit the facility, s/he did not think that any of these issues would be “noticed.” · Staff persons closed the bathrooms and then the VA could not find the bathroom to use it on his/her own. The VA did not have impaired vision. Staff persons started putting disposable adult absorbent undergarments on the VA and leaving them on without changing. As a result, the VA had a “sore groin area,” and a rash with a red and irritated appearance located on his/her thighs, but not on his/her buttocks. It did not appear as though staff persons were bathing or washing the VA properly. There were open sores on the VA’s groin area the size of a “dime to a quarter.” The sores had been “weeping,” but they had been “crusting up” which then allowed them to heal. The sores were present for the last seven to ten days prior to this interview. As of July 30, 2024, the G had not heard anything from the facility since July 25, 2024, which was after the rash was discovered. · The G had also learned that sometimes the VA arrived at day program with dried feces in his/her disposable undergarment. · The G had just purchased a fourth mattress for the VA because staff persons would remove bedding without putting it back on, so the mattresses would get “ruined.” The new mattress had not yet arrived and was ordered on July 8, 2024. · The G had concerns that the VA was not getting nutritious meals at the facility or sent to day program with his/her lunch. The G did not think that staff persons did any sort of meal-planning and were maybe not trained on how to make “nutritious” meals. The VA once got three puddings and six cookies for lunch at his/her day program. P2 began working for the facility within the past year or so and things had “not been so great” since his/her arrival. P2 had “yet to do something” about some of the complaints. Facility staff persons did not seem to be “trained properly.” · The VA was “non-verbal” and was not able to provide information. Sometimes the VA would “push” or “shout” to get out of a “loud room.” The VA did not always cooperate with staff persons when they were cutting his/her hair. The DP provided the following information: · The DP worked at the VA’s day program and was “worried” about the VA’s personal cares not being “taken care of” by the facility. On July 23, 2024, the VA had three open sores on his/her right hip with “discharge” present with additional “rashes” and “skin irritations” on the VA’s groin area. The DP described the sores as “pressure sores.” There were three “concerning” spots that were white, purple, and black in color with “yellow discharge.” One spot was the size of a “dime” and the other two were the size of “pencil erasers.” · The DP contacted P2 and the next day, P2 arrived at the day program on July 24, 2024, to look at the VA’s hip. The DP showed P2 a “new red rash” that was on top of the other rash. The new rash looked like a lot of “red spots” located “all over” the VA’s upper right leg, from the knee to the hip area. The rash was on the inside of the VA’s thighs on both legs and genital area and had a “wrinkly” and “irritated” appearance. The rash was not on the VA’s bottom. The VA would “pull away” if the sores or rash were touched. P2 said that s/he would contact the VA’s primary care physician and let the DP know if there was anything that the DP needed to do. P2 then left. The DP stated that s/he never heard anything additional from P2 until s/he sent an email to P2 on August 2, 2024, and P2 replied back to say that the VA was being treated with a powder which was applied at the facility in the morning and before going to bed. · According to the DP, on August 2, 2024, the rashes were still present with the ones on the VA’s inner thigh area “turning redder.” The sores on the side of the VA’s right hip were still present, but there was no discharge. The red spots and rash from July 24, 2024, were “worse.” The DP contacted P2 about the changes to the marks via email. The DP did not feel like the VA’s “needs were being addressed” by the facility. · The VA had always worn absorbent undergarments in the time that the DP had known the VA but was able to independently use the bathroom. Sometimes, when the VA had a bowel movement, staff persons would go with the VA to make sure s/he was “dry and clean,” “wiping [his/her] bottom” in the morning and afternoon, if needed. · While the VA did not usually arrive with wet clothing but came in at times wearing clothing that was “two to three sizes too big.” The DP was concerned for the VA’s “personal cares” in general and the VA usually had “sticky” or dirty fingernails. The VA had “discolored” lower legs on both legs and day program staff persons monitored the color to make sure it did not get darker in appearance. · The VA arrived at the day program with pudding and cookies for his/her lunch one day and on other days, did not seem to have enough food in his/her lunch. The VA was the only client who did not come to the day program with an ice pack in his/her lunch bag. The G would regularly drop off “snacks” for the VA to have on hand so that there was additional food for the VA. P2 provided the following information: · P2 was informed of the “breakdown of skin” on the VA’s groin area by the DP on July 23, 2024. P2 told the DP that they needed to “clean the area really good” and on July 24, 2024, P2 went to the VA’s day program to observe the area. P2 said, “It was only reddened at that time,” and was “not open skin.” P2 called the VA’s physician and nystatin powder was ordered for the VA. P2 later stated that the sores s/he saw on the VA’s hip were “scabbing” by the time s/he saw them on July 24, 2024 · According to P2 in the facility’s internal review, the pharmacy was unable to deliver the nystatin powder until the following day due to the order being placed at about 1 p.m. Corn starch was suggested as a “fill in” until the powder arrived. · P2 denied knowledge that s/he saw or heard of sores on the VA’s hip prior to the DP bringing it to P2’s attention. P2 went to the facility to explain to staff persons how to apply the powder since s/he would not be at the facility when the pharmacy delivered the prescription. · The VA’s skin was looking “good” after staff persons left the disposable undergarment off for periods of time and assisted the VA to use the bathroom “more consistently.” · Staff persons were to assist the VA with a shower twice per day when s/he was willing. Soaking in the bathtub was also an option to soothe the area, but the VA did not “like change.” Although the VA’s goal was to participate with his/her cares, they did not want to “stress out” the VA. P2 was told by staff persons that they did morning and evening cares with the VA. · The VA was able to use the bathroom independently but would not do any additional care or wiping of him/herself after using the bathroom and needed assistance from staff persons. The VA had always worn absorbent undergarments while living at the facility. · P2 had eight facility locations to oversee and was only at this facility location once per week with an occasional extra stop during the week. P2 was told by staff persons that personal cares were being done daily. The VA was supposed to participate in routine cares and the VA’s “team” had not brought it to P2’s attention that they were not being done daily in the morning and evening hours. · P2 was “working with staff persons” to tell them that the bathroom and bedroom doors could not be locked. P2 stated that the smaller bathroom “needed to be unlocked” and when P2 went to the facility, it was “always unlocked.” There was a tool on top of the doorframe to the smaller bathroom for staff persons to use to unlock the door and it was “just a twist lock.” · The facility had ordered the VA a new mattress that was due to arrive on August 26, 2024, because the VA sometimes was incontinent overnight, and the current mattress was no longer clean. The facility had placed a plastic cover on as a “layer” to protect the mattress. The VA’s family was purchasing the mattress protector while the facility provided linens. The G told P2 that the facility could not launder the mattress pad that the G purchased because the G would wash it. P2 purchased additional mattress covers for the VA after the mattress was soiled. It was cleaned the “best we could” at the time. P2 denied ever smelling urine on the VA. The VA was assisted with using the bathroom, with showering, with cleaning, and with dressing on a daily basis and then his/her bedding would be washed “almost” daily. The VA’s pillows were also washed daily. The VA had two sets of bedding and pillows. · Staff persons at the facility had cleaning supplies and disposable gloves had been ordered, arriving one day after this investigator’s site visit. (Investigator’s note: On the day of the site visit, when there were feces throughout the facility, P5 drove to the facility headquarters where P2 gave P5 one box of 100 count cleaning gloves). According to P2, staff persons were to only use disposable gloves when doing “personal cares with individuals” or cleaning. P2 stated, “Staff [persons] feel like they need to wear them all day long and they replace them several times a day.” This facility location specifically went through three times more gloves than they should be. P2 did not know why staff persons felt that they needed to wear gloves more often during the shift. · When asked by this investigator, P2 stated that s/he only gave P5 one box of gloves because the order was due to arrive and that it “took a little longer” for a bigger box of gloves to arrive. P2 denied saying in May 2024 that the facility could not place another cleaning supply order until October 2024. · P2 denied saying that clients had to pay for gloves out of their own pockets, but instead stated that the facility had “tried to utilize other resources to help get gloves and wipes and briefs” to reduce what the facility had to spend on those items. · As long a staff persons told P2 that they were low on laundry soap, P2 would order it. P2 had to check with his/her supervisor about “larger purchases” such as mattresses. · After this investigator’s site visit, P2 showed staff persons where a five-gallon bucket of cleaning solution was located. P2 did not think that staff persons were “understanding” that “all they had to do was fill up the spray bottles.” · When asked why s/he told a facility administrator that the upstairs area that had feces smeared into the carpet was cleaned on August 2, 2024, when it had not been cleaned, P2 implied that staff persons did not listen to all of the areas that P2 told them to clean. when asked. P2 stated it was cleaned on August 9, 2024. P2 requested that a gate be installed “months ago” for the bottom of the stairway leading upstairs, as the upstairs was not an area of the facility for clients and there was only a short hallway with a locked door at the top, but it was P2’s supervisor’s “belief” that the facility could not do that. The gate was recently installed after that was clarified with another licensor. · “There was a time” when a “newer” staff person mixed up another client’s clothing with the VA’s clothing and the VA was not dressed correctly for day program. P2 labeled all the clients’ clothes with their initials to make sure that they were each wearing their own clothing. · Staff persons from a nearby facility location went to this facility location to “take food” from them for the clients at the other location. Those staff persons were told they could not do that. P2 did not have his/her own credit card to do grocery orders and had to run those purchases through his/her supervisor. Staff persons had to make sure to let P2 know that food needed to be ordered. Food was “typically ordered” every two weeks. · Evening staff persons were to make lunches for the following day and overnight staff persons were to “verify” that the meal was “well-balanced” before sending it along with the VA for day program. P2 had not heard that the VA was not getting ice packs in his/her lunches. P3 provided the following information: · P3 no longer worked at the facility because it was “impossible” to do his/her job. Some of the ongoing “issues” at the facility included the cleanliness of the facility, not having the products for cleaning, and not having the support that was needed to successfully operate the facility. · P3 was unaware of any rash or injuries to the VA’s groin. Staff persons assisted the VA with personal cares and the VA was assisted to shower daily when P3 worked at the facility. The VA was dressed in “nice clothing” for day program. When P3 worked at the facility, staff persons always made sure that the VA had “proper hygiene” and was “presentable.” · The clients each had two sets of bedding, to be washed daily, and pillows, which were washed as needed. The VA’s bedding was always washed daily because even though s/he did not have incontinence “accidents” each night, s/he “sweat” a lot while sleeping. The VA’s mattress had the manufacturing plastic still on it per the G’s request and then sheets were placed over the plastic. Staff persons continued to do that at the G’s request, but another client tore the plastic off. The G told P3 that s/he was not going to purchase another mattress protector for the VA because staff persons did not keep them clean. · One facility client would defecate and wipe feces “anywhere” in the facility if staff persons were not “paying attention.” Staff persons needed products to clean the bathrooms, walls, and the facility in general. The facility was “constantly” out of disposable gloves, disinfectant wipes, laundry soap, dishwashing soap, wet wipes, hand soap, toilet paper, napkins, and any “essential cleaning supplies.” It was “impossible” to get P2 to purchase cleaning products and when s/he did, s/he purchased “cheap stuff.” It would take up to two weeks to get the supplies, when ordered. In order to maintain the cleanliness of the facility, fecal matter had to be cleaned daily, and gloves were “constantly worn” at the facility. Staff persons were not always supplied with gloves and had to purchase gloves and supplies with their own money. It was “impossible to clean” when staff persons did not have the supplies to clean. · P2 told P3 that the facility would need to try to get the clients’ insurance companies to purchase cleaning supplies. In May 2024, P2 told P3 that the facility was “over [their] cleaning supply budget astronomically” and would not be able to purchase more cleaning supplies until October 2024. · Prior to P3 working at the facility, staff persons were locking the client bathrooms, and s/he did not know who told them to do that. P3 told staff persons not to lock the client bathrooms doors because it caused clients to “have [incontinence] accidents” when clients could not get in the bathroom. Prior to the bathroom doors being kept locked, the VA could use the bathroom independently, but sometimes needed assistance with wiping when s/he had a bowel movement. The VA was not able to ask for help, due to his/her disability, and if the door was locked, the VA would stand there not knowing what to do and would have “an [incontinence] accident.” The VA did not always wear disposable undergarments when P3 worked at the facility. · One client played with water in the bathrooms and P3 asked P2 to install alarms or chimes to alert staff persons when doors were open. P2 purchased the alarms, but they were never installed. P3 asked P2 three times to install the alarms. When P3 stopped working at the facility, the alarms were still not installed. · P2 had most of the furniture removed from the facility and replaced it with “institutionalized” furniture. · Staff persons did a “really good job” of meal planning and cooking. There was an issue with a previous staff person who packed “cookies and pudding” for the VA when s/he left for day program and P3 was “very upset” that there was not adequate food for the VA. P3 called P2 to see if someone near the VA’s day program could deliver food to the VA. P2 did not return P3’s phone call. Staff persons ended up bringing food to the VA. The facility also sometimes ran out of food because other facility locations would come and take it from them. One time when food inventory was low at the facility, P3 ordered food and did not “care” if s/he “got in trouble” for it. P1 provided the following information: · P1 was not very familiar with the VA or the facility location as s/he did not generally oversee it. The VA was “more quiet” than the other clients. The facility did not have a supervisor for this location for approximately the last two weeks and P2 was handling some of the things that a supervisor would usually do. There were usually two staff persons working alongside the supervisor but with the supervisor position open, there were two staff persons working during the day. · P1 was unsure about “bathroom use” by clients at the facility but was aware that the VA recently had a rash. The pharmacy was “out” of the medication and so a suggestion was to use corn starch on the rash. According to P1, it “was suspect” that staff persons could not get bathroom doors unlocked earlier in the day when this investigator asked staff persons to unlock the two client bathroom doors. · P2 ordered groceries and cleaning supplies for the facility which were then delivered. P1 was unsure if there was meal planning at the facility. · P2 usually visited all the facility locations s/he oversaw “every day.” · Staff persons were to be cleaning daily and doing laundry “as needed.” Each client was supposed to have bedding and pillows provided. Several clients were incontinent in bed overnight and when this happened, staff persons were supposed to assist the client up, change the bedding, and begin washing the bedding. Over the prior weekend, some clients were “smearing feces all over the place” and staff person took the clients on a van ride so that they could clean the facility. · One client at the facility tended to “slip away” and “run off [without supervision]” if staff persons were not watching. Two of the clients each had one to one staffing. · Staff persons were trained to document over the counter medications on the backside of the Medication Administration Record (MAR) and to document prescribed medications on the front. · The bent screens on the facility windows were broken when P1 arrived at the facility that day and s/he did not know why. P1 stated that other facility locations were not like this. P4 provided the following information: · The VA had a rash on his/her groin for about two weeks. Staff persons were to “disinfect it” when s/he went to the bathroom. Staff persons could not “rub” the skin with medication because it was sensitive. P4 was “pretty sure [the VA] had ointments” to apply. P2 gave staff persons the instructions to apply the ointments. P4 did not notice any other injuries or any bruising to the VA’s groin area. P4 felt like clients were seen by medical doctors when needed. · The VA was the “most challenging” when it came to showers because s/he was “afraid of slipping.” It took more time to assist the VA to shower than with other clients. The VA was the “nicest one” at the facility, often kept to him/herself, and would sit and watch TV quietly. When the VA was tired, s/he would get up and go to his/her bedroom. · There was a lot of “stress” when working at the facility and they were sometimes working “short-staffed.” Two of the clients required one to one supervision and the other two clients were not at the facility during the day, so normally there were only two staff persons working together during the day. One of the clients who stayed at the facility during the day would be “doing something” as soon as a staff person took their eyes off the client. P4 stated that that clients did not urinate on other clients’ belongings. · Morning duties involved doing laundry, cleaning the facility, and making lunch for the two clients that did not go to day program. The VA and the other client who went to day program were gone by the time P4 arrived. The overnight staff person was to assist all four clients to shower, but sometimes, morning staff persons would assist if things were “too hectic.” The overnight staff person also packed lunches for the VA and the other client who went to day program. · Staff persons left both client bathroom doors locked because staff persons “had a routine” where all four clients were taken to the bathroom every two hours and also changed their disposable undergarments if needed. All four clients were “capable” of using the bathroom independently but needed assistance with “wiping” after bowel movements. Staff persons were to unlock the doors when clients needed to use the bathroom. All four clients wore disposable undergarments to sleep, but sometimes a client would not be wearing one and that would “get hectic” for staff persons. One client typically threw his/her disposable undergarment out the windows about three times per week. · P4 described the cleanliness of the facility as a four out of ten with zero being the cleanest and ten being the dirtiest. The facility could get “a lot, lot worse” than where its cleanliness level was. When it was a “ten,” it usually meant that one of the clients had put his/her feces all over the living room, upstairs, into the air conditioner vents, and would typically “hide” his/her feces. Another client tended to “bite” him/herself and then there would be “blood everywhere” around the facility. · Laundry was done by staff persons during the day and evening. Bedding was washed “almost daily.” P4 did not know why there was no soap in the client bathroom. · “Proper management” of the facility and “actual training” would help the facility to operate more smoothly. P3 recently “quit,” and s/he had also been supervising another facility location in addition to this one. Supervisory staff persons were trying to have supervisors only supervise one facility location so that they could be more focused. The supervisor handled more of the paperwork rather than showing staff persons a “routine” and how to do “actual cleaning.” Staff persons had to “learn it over time” as to how to clean properly. · Staff persons had been trying to get supervisory staff persons, including P2 and others to get more staff persons working at the facility and to add another overnight staff person. When clients woke up early, there would be only one staff person and not enough staff persons for one to one supervision. The overnight staff person would have to get the VA and another client ready for their day before leaving for day program. · There was no meal plan at the facility and staff persons tried to make sure that there was enough protein and carbohydrates for meals. When clients overate, the facility ran out of groceries. One client was “more aggressive than most” when it came to eating. The bowl of macaroni on the kitchen counter should have been “put in the fridge” by staff persons. · P4 did not know why the window screens were bent. P5 provided information similar to P4 and added the following: · When P5 arrived to work in the morning, s/he would check in on the client s/he was assigned to, give medications if they had not yet been given, help with showers, and make breakfast for the clients. P5 was typically assigned to supervise the client that would smear feces. When that client would be walking around the facility, P5 would clean that client’s bedroom. On the day of this investigator’s site visit, that client’s bedroom had fecal matter and an adult undergarment torn apart. P5 closed that client’s bedroom door and was unable to clean it because there were no disposable gloves. The client did this approximately every other day. · Usually, one client bathroom was locked, and one was unlocked. Staff persons assisted clients with showers in the larger bathroom and the clients used the smaller bathroom for toileting. Staff persons were supposed to assist the clients to use the bathroom every two hours. The VA generally had dry disposable undergarments when P5 checked, but P5 did not usually see much of the VA when P5 was assigned to supervise the other client. P5 had not seen the VA in approximately two weeks so P5 was not sure about what was going on with the VA’s groin area, but P5 had read a “post” about applying “something” to it. · The VA “always” had pillows and laundry was done by afternoon staff persons every one to two days. · The facility typically ran out of gloves once per month, but it was “not very common.” · Afternoon staff persons or overnight staff persons packed lunches for the next day for the clients who went to day program. · P3 was “nice and organized.” When P3 worked at the facility and the facility needed groceries delivered that same day, they would tell P3. · P5 felt like there was enough food in the house. P5 thought that the facility did meal planning and thought the meal plan was kept in the kitchen but could not show where that information was kept. P5 would check the freezer and cabinets to decide what to make for meals. The VA’s medical records showed that on July 24, 2024, P2 talked to a physician and discussed the VA having a rash in the groin area from wearing absorbent undergarments. P2 told the physician that the VA did not want anyone touching the sores area, but that the skin was not yet “raw.” P2 said that s/he would be picking up non-scented wipes to be used and that the VA had been in the bathtub to “soak” before washing and “patting” the area dry. P2 asked about getting nystatin powder for the VA without the VA being seen by the provider as to not disrupt the VA’s day. The physician sent in an order to the pharmacy on July 24, 2024, which stated nystatin powder was to be applied topically to the VA’s groin area every eight hours if needed. The pharmacy confirmed receipt of the prescription at 1:03 p.m. on July 24, 2024. Facility documentation showed the following information: · The VA’s July MAR showed that nystatin powder was applied at 8 a.m. and at 8 p.m. from July 25 to July 31, 2024. · The VA’s cares form for July 2024 showed a column where “yes” or “no” was to be circled once for each date. If “yes” was circled, that meant personal cares were completed. If “no” was circled, staff persons were to list the reason why they were not completed. Of those dates, there were fifteen dates when “yes” was circled, four dates when “no” was circled, and twelve dates when nothing was circled (one of these had initials on the side). There were only twelve dates with initials. The LE report provided the following information: · On July 24, 2024, a law enforcement officer (LEO) received a call to follow up on regarding the VA’s groin irritation. The information provided in the LE report was consistent with the DP’s information. · The LEO observed the VA with clothing on and could see that the VA “appeared to be just fine.” The LEO was unable to interview the VA due to the VA’s disability. · The LEO spoke with P2 who stated that s/he called the VA’s physician and that they got a prescription to apply to the area. On August 2, 2024, this investigator spoke with a facility administrator and advised him/her of some of the issues at the facility to include, but not limited to feces, torn disposable undergarments, locked bathrooms, no cleaning supplies, and no gloves. The facility administrator was told to address the fecal matter as soon as possible. Facility documentation showed the following additional information: · The facility administrator contacted this investigator on August 5, 2024, and stated that on August 1, 2024, P2 directed staff persons to complete all cleaning tasks and laundry. Staff persons sent images to P2 during their shift. On August 2, 2024, P2 went to the facility with cleaning supplies and “they were not needed” because P5 had previously picked up a box of gloves on August 1, 2024. P2 reported to the facility administrator that the feces and the disposable undergarment had been removed and cleaned. (Investigator’s note: According to the county licensor, the torn undergarment and feces on the second level of the facility had not been cleaned as of August 8, 2024, when s/he conducted an unannounced visit). · Staff persons were working with one of the clients who smeared feces and threw things out of windows. It was noted by facility administrators that “supervising [the client] at times takes precedence over cleaning.” · The facility’s process for cleaning bedding was that beds were to be “stripped, sprayed, and washed” and this process “may have been interrupted by staff [persons] needing gloves.” On August 8, 2024, this investigator received information that the upstairs landing with feces and a torn disposable undergarment was not cleaned up and that the picture of that area was similar to the pictures taken by this investigator during the site visit on August 1, 2024. On August 9, 2024, this investigator communicated with a facility administrator that the feces and torn disposable undergarment needed to be cleaned up and asked why it had not been cleaned when they had stated that it had been cleaned. The facility administrator advised that s/he would have another facility administrator look into the issue and get back to this investigator. Later in the afternoon of August 9, 2024, the facility provided digital images to this investigator of the cleaned upstairs area and that they had installed a gate at the bottom of the stairwell. All staff persons interviewed for this report were trained on the VA’s plans and the Reporting of Maltreatment of Vulnerable Adults Act. Relevant Rules and Statutes: Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (5), and paragraph (b), clause (3) stated that a person’s protection related rights included the right to receive services in a clean and safe environment, and to have free access to common areas in the residence. Minnesota Statues 245D.06, subdivision 2, clause (5), stated that the license holder must follow universal precautions and sanitary practices. Conclusion: Regarding the VA’s cares and rash: According to the DP, on July 23, 2024, the VA had three open sores on his/her right hip with “discharge” present with additional “rashes” and “skin irritations” on the VA’s groin area. According to the DP and the G, the sores varied in size from the size of a pencil eraser to a quarter. The DP contacted P2 and the next day, P2 arrived to look at the sores and a new rash that had developed. The DP did not hear more about how the VA’s rash was to be treated until s/he again contacted the DP, who stated that the facility was caring for the VA’s rash. According to P2, the DP informed P2 of the “breakdown of skin” on the VA’s groin area on July 23, 2024. P2 told the DP that they needed to “clean the area really good.” P2 called the VA’s physician and nystatin powder was ordered for the VA. P2 went to the facility to explain to staff persons how to apply the powder since s/he would not be at the facility when the pharmacy delivered the prescription. P2 later stated that the sores s/he saw on the VA’s hip were “scabbing” by the time s/he saw them on July 24, 2024. The VA was able to use the bathroom independently but would not do any additional care or wiping of him/herself after using the bathroom and needed assistance from staff persons. The VA had always worn absorbent undergarments while living at the facility. P2 was told by staff persons that personal cares were being done daily. P2 said that s/he was “working with staff persons” to tell them that the bathroom doors could not be locked. P2 stated that the smaller bathroom “needed to be unlocked” and when P2 went to the facility, it was “always unlocked.” There was a tool on top of the doorframe to the smaller bathroom for staff persons to use and it was “just a twist lock.” Information from the VA’s plans stated that the VA depended on staff persons for “full assistance” with cares and showering. The VA’s Support Plan Addendum stated, “[The VA] often self-initiates using the toilet but does not always do so appropriately . . . and relies on staff [persons] to help wipe after bowel movements. According to the G, staff persons kept the bathroom doors closed. P3 stated that prior to P3 working at the facility, staff persons locked both bathroom doors. P3 did not have information about the VA’s rash, because s/he no longer worked for the facility in July 2024, but locked bathroom doors resulted in the VA being unable to use the bathroom independently. As a result, according to the G, staff persons started putting disposable adult absorbent undergarments on the VA and leaving them on without changing. The VA had a “sore groin area,” and a rash with a red and irritated appearance located on his/her thighs, but not on his/her buttocks from wearing wet absorbent undergarments. The VA sometimes arrived at day program with dried feces in his/her disposable undergarment. The VA’s medical records showed that on July 24, 2024, P2 was aware of the VA’s rash and P2 called the VA’s physician and said that s/he would be picking up non-scented wipes to be used and asked about getting nystatin powder for the VA without the VA being seen by the provider. The physician sent in an order to the pharmacy that day. The nystatin powder was to be applied topically to the area every eight hours if needed. According to P1, since the pharmacy could not deliver on July 24, 2024, it was “suggested” that they use corn starch on the area until the prescription arrived. The VA’s July MAR showed that nystatin powder was applied at 8 a.m. and at 8 p.m. from July 25 to July 31, 2024. Of the VA’s cares form for July 2024, there were fifteen dates when “yes” was circled, four dates when “no” was circled, and twelve dates when nothing was circled. There were only twelve dates where the task was initialed. P4 said that staff persons left both client bathroom doors locked because staff persons “had a routine” where all four clients were taken to the bathroom every two hours and also changed their disposable undergarments if needed. Staff persons were to unlock the doors when clients needed to use the bathroom. The VA had a rash on his/her groin for about two weeks. Staff persons were to “disinfect it” when s/he went to the bathroom. Staff persons could not “rub” the skin with medication because it was sensitive. P4 was “pretty sure [the VA] had ointments” to apply. P2 gave staff persons the instructions to apply the ointments. P5 stated that usually, one client bathroom was locked and the other was unlocked. Staff persons were supposed to assist the clients with using the bathroom every two hours. The VA generally had dry disposable undergarments when P5 checked, but P5 did not usually see much of the VA when P5 was assigned to supervise another other client. P5 had read a “post” about the VA’s rash and that staff persons were to apply “something” to it. On August 1, 2024, during a facility tour, this investigator observed locked doors on the two client bathrooms which was a violation of Minnesota Statutes, section 245D.04, subdivision 3, part b. P4 was attempting to use his/her fingernail and thumbnail to unlock the door. The VA had a rash and sores likely caused by wearing absorbent adult undergarments which were reported to have been used so bathroom doors at the facility could be locked, and it was reported that the VA’s daily cares were not completed with incomplete documentation. However, given that P2 contacted the VA’s physician regarding the rash and sores and that nystatin powder was ordered, delivered, and applied per the physician’s orders, that staff persons stated they completed the VA’s cares daily but sometimes the VA was not cooperative, that the VA could use the bathroom independently but could not clean him/herself after adequately, that information was inconsistent how often bathroom doors were locked and if one or both were locked when the VA needed to use the bathroom, and that staff persons assisted the VA to the bathroom every two hours at the facility, there was not a preponderance of the evidence whether staff persons failed to supply the VA with care or services. It was not determined whether neglect occurred (the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct). Regarding cleaning supplies: When this investigator arrived for a site visit on August 1, 2024, there was a torn absorbent undergarment with feces throughout one of the bedrooms and at the top of the second-floor stairway landing. Additional fecal matter was observed throughout the facility and on client toilet seats which was a violation of Minnesota Statutes, section 245D.04, subdivision 3, part a. P4 and P5 stated that it had not yet been cleaned up because the facility was out of gloves, which was a violation of Minnesota Statutes, section 245D.06, subdivision 2. According to P5, the facility typically ran out of gloves once per month, but it was “not very common.” P4 did not know why there was no soap in the client bathrooms. According to P3, there was “constantly” a shortage of cleaning supplies at the facility such as disposable gloves, disinfectant wipes, laundry soap, dishwashing soap, wet wipes, hand soap, toilet paper, napkins, and any “essential cleaning supplies.” It was “impossible” to get P2 to purchase cleaning products and would often take up to two weeks for them to arrive, when ordered. Gloves were “constantly worn” at the facility to clean feces “daily” and when out of products, staff persons had to purchase gloves and supplies with their own money. It was “impossible to clean” when staff persons did not have the supplies to clean. In May 2024, P2 told P3 that the facility was “over [their] cleaning supply budget astronomically” and would not be able to purchase more cleaning supplies until October 2024. P2 stated that s/he only gave P5 one box of gloves because the order was due to arrive and that it “took a little longer” for a bigger box of gloves to arrive. After this investigator’s site visit, P2 showed staff persons where a five-gallon bucket of cleaning solution was located. P2 did not think that staff persons were “understanding” that “all they had to do was fill up the spray bottles.” As long as staff persons told P2 that they were low, P2 would order it. P2 denied saying in May 2024 that the facility could not reorder supplies until October 2024. Instead, P2 stated that the facility had “tried to utilize other resources to help get gloves and wipes and briefs” to reduce what the facility had to spend on those items. According to P2, staff persons were to only use disposable gloves when doing “personal cares with individuals” or cleaning. P2 stated that this facility location, specifically, went through three times more gloves than they should be. P2 did not know why staff persons felt that they needed to wear gloves more often during the shift. Although there was exposed feces that the residents were exposed to and an unknown shortage of cleaning supplies at the facility, given that there was a resident who smeared feces around the facility which information showed that staff persons made an effort to clean when they could, that cleaning supplies were ordered when P2 was notified they were low or out, that a staff person went to get gloves which delayed cleaning of the feces on the day of the site visit, and there was no information that the exposure to the feces caused the VA or other residents health issues, there was not a preponderance of the evidence whether there was a failure to provide reasonable and necessary care and services. It was not determined whether neglect occurred (the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct). Action Taken by Facility: The facility’s Internal Review stated that policies and procedures were adequate but not followed. There was a need for additional staff training and the VA’s Services and Support strategies were not adequate. The report was similar to previous reports and incidents. There was a need for corrective action by the facility. The facility requested additional staffing positions to “ensure cleanliness,” and put up a gate and lock for the bottom of the stairwell leading upstairs. New screens were ordered for the facility windows, “deep cleaning” occurred,” and staff training occurred in areas related to this report where refresher training was needed. Action Taken by Department of Human Services, Office of Inspector General: On August 28, 2025, the facility was issued a Correction Order for the violations outlined in this report. Concerns with the facility’s physical plant including cleanliness, linens, and mold were referred to the county licensor.
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