Minnesota Office of Health Facility Complaints Website Data - Resolved Complaint Findings As of 8/8/2018

Minnesota Office of Health Facility Complaints Website Data - Resolved Complaint Findings as of 8/8/2018
Benton, Sherburne, Stearns, Kanabec, Mille Lacs, Morrison & Wright County Reports Prepared By Elder Voice Family Advocates
Confidential – Not to be copied, distributed or reproduced without prior written approval from Elder Voice Family Advocates.
This document was compiled by Elder Voice Family Advocates. 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 vulnerable adults. The report was compiled by sifting through every public maltreatment finding available(*) on the Minnesota Department of Health Office of Health Facility Complaints website:
http://www.health.state.mn.us/divs/fpc/directory/surveyapp/provcompselect.cfm
Facil. Investigation finding
City Provider Name NH HCAL Complaint Description Date of visit Concluded on Allegation Subst Unsubst Inconcl
Albany Mother of Mercy Campus of Care It is alleged that residents' were financially exploited when a staff, alleged perpetrator (AP) took the x
x EXPLOITATION - DRUG DIVERSION 6/8,9/2015 7/17/2015
residents' pain medication for his/her own personal use.
Albany Mother of Mercy Senior Living It is alleged that client #1, client #2 and client #3 were financially exploited when the alleged perpetrator x
x EXPLOITATION BY DRUG DIVERSION 9/25/2017 2/15/2018
(AP) took the client's narcotic medications for their own personal use.
Albany Mother of Mercy Senior Living It is alleged that a client was neglected when the facility staff failed to provide medications as directed by the x
x NEGLECT-HEALTH CARE, MEDICATIONS 6/27/2017 12/28/2017
hospice care plan.
Albany Mother of Mercy Senior Living It is alleged that the facility failed to provide adequate supervision to two clients when one client was found x
x NEGLECT-SUPERVISION NURSING CARE 8/8/2016 4/24/2017
touching another client inappropriately on several occasions.
Annandale Annandale Care Center Feb 19-20 Based on a preponderance of evidence, facility failed to follow physician's orders for Coumadin, blood x
x NEGLECT - MEDICATION ERRORS 5/1/2017
2016 thinner, for 15 days, patient died as a result from complications.
Annandale CENTENNIAL VILLA ASSISTED LIVI x NEGLECT-HEALTH CARE ABUSE-EMOTIONAL- 11/28/2017 4/18/2018 It is alleged that neglect occurred when an employee, alleged perpetrator (AP) didn't provide services x
STAFF required and the client's bedding and mattress was saturated with urine. It also alleged that abuse occurred
when the AP yells at the client when she is incontinent.
Annandale Centennial Villa Assisted Living x
It is alleged that a client was neglected when staff failed to provide personal cares and toileting assistance
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.
Annandale Centennial Villa Assisted Living It is alleged that a client was neglected when staff failed to ensure the client's oxygen tank was filled x
x NEGLECT OF HEALTH CARE 12/12/2016 12/4/2017
properly. The client had an unresponsive episode due to empty oxygen tank.
Belgrade Belgrade Nursing Home It is alleged that a resident was abused when s/he was found with multiple bruising ranging from large hand x
NEGLECT-HEALTH CARE ABUSE-PHYSICAL- prints to tennis ball size bruising covering the resident's body. Also, the resident has multiple sores on
x 8/11/2015 12/10/2015
STAFF his/her feet that are black in color. In addition, the resident was neglected when staff failed to properly
monitor and assist with the resident's oxygen tank and s/he was found unresponsive.
Buffalo 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
Buffalo Gentle Touch Health Initiative It is alleged that a client was neglected when staff did not adequately assess the client's supervision needs. x
NEGLECT-HEALTH CARE, SUPERVISION 6/9/2015 9/11/2015 The client walked to town, fell in the street, and was found by a member of the community. In addition, the
client was cold and not dressed appropriately for the weather.
Buffalo Gentle Touch Health Initiative It is alleged that Client #1, Client #2, and Client #3 were financially exploited when their narcotic medications x
x ABUSE-EXPLOITATION-DRUG DIVERSION 10/23/2017 2/14/2018
went missing from a locked cabinet.
Buffalo Lake Ridge Care Center of Buffalo NEGLECT OF SUPERVISION-RESIDENT TO It is alleged that a resident, resident #1, was neglected when facility staff failed to provide adequate x
x 11/27/2017 3/22/2018
RESIDENT supervision that resulted in resident #2 touching resident #1 inappropriately.
Buffalo Lake Ridge Care Center of Buffalo It is alleged that a resident was neglected when staff did not administer two doses of seizure medication to x
x MEDICATION ERRORS 3/2/2017 9/20/2017 the resident. The resident suffered two seizures on the second day. The facility transferred the resident to
the hospital.
Buffalo Lake Ridge Care Center of Buffalo It is alleged that a resident was neglected when s/he did not receive his/her pain medications as scheduled x
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.
Buffalo Lake Ridge Care Center of Buffalo It is alleged that a resident was sexually abused by an unknown alleged perpetrator (AP). It is alleged that x
x ABUSE-SEXUAL 6/22/2017 11/14/2017
the AP touched the resident's perineal area.
Buffalo Park Terrace Assisted Living It is alleged that a client was financially exploited when an unknown staff, alleged perpetrator (AP), took five x
tablets of 5 milligram (mg) oxycodone from the client for personal use.
Buffalo Park Terrace Assisted Living It is alleged that a client was financially exploited when an unknown staff, alleged perpetrator (AP), took two x
tablets of Norco from the client for personal use.
* Office of Legislative Auditor 2018 Report: "the website may be missing up to 19% of reports that should be posted" Page 1 of 11
* Per MDH: Investigations occurred in 1% of nursing home complaints and 3% of assisted living facility complaints.
Buffalo PRAIRIE RIVER HOME CARE INC x EXPLOITATION BY STAFF 3/1/2018 5/17/2018 It is alleged that a client was financially exploited when a staff member, the alleged perpetrator (AP), stayed x x Fin.
with the client overnight and took the client's wallet and apartment key. It is alleged the wallet was located negle Expl.
in the AP sister's care and returned to the client missing two credit cards and having accrued $1,000.00 in ct
credit card debt. It is further alleged that the client was neglected when the AP failed to provide cares
resulting in an alteration in skin integrity.
Buffalo PRAIRIE RIVER HOME CARE INC PATIENT RIGHTS EXPLOITATION BY STAFF 3/1/2018 5/17/2018 It is alleged that a client was financially exploited when a staff member, the alleged perpetrator (AP), stayed x x Fin.
NEGLECT OF HEALTH CARE NEGLECT:DECUBITI with the client overnight and took the client's wallet and apartment key. It is alleged the wallet was located negle Expl.
in the AP sister's care and returned to the client missing two credit cards and having accrued $1,000.00 in ct
credit card debt. It is further alleged that the client was neglected when the AP failed to provide cares
resulting in an alteration in skin integrity.
Buffalo Prairie River Home Care Inc. It was alleged that a client was financially exploited when the perpetrator took the client's oxycodone for x
EXPLOITATION BY DRUG DIVERSION March 27 2017 6/27/2017
his/her own use.
Buffalo Prairie River Home Care Inc. June 17-18, It was alleged that a client #1 was financially exploited when the perpetrator took the client's Rolex watch x
ABUSE-EXPLOITATION-STAFF 12/4/2015
2015 and $600.00 for his/her own use.
Buffalo Prairie River Home Care Inc. It was alleged that a patient was financially exploited when a perpetrator took the client's money for his/her x
ABUSE-EXPLOITATION-STAFF 11/17/2015 11/27/2015
own use.
Buffalo Prairie River Home Care Inc. 01/24/2017 x
It is alleged that a resident was neglected when a wound on the buttocks was not covered with a dressing
NEGLECT-DECUBITI and 4/24/2017
and the wound became infected.
01/25/2017
Buffalo Prairie River Home Care Inc. 07/20/2015 Abuse occurred when a staff, alleged perpetrator (AP) took photos of a patient while the patient was naked. x
NEGLECT-HEALTH CARE and 9/8/2015 The AP touched the patient inappropriately during personal cares and the patient has expressed fear of the
07/21/2015 AP.
Buffalo Prairie River Home Care Inc. It is alleged that a client was neglected when a staff, AP, inserted a catheter incorrectly and the client x
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.
Buffalo Prairie River Home Care Inc. It is alleged that a patient was neglected when scheduled staff did not show up to provide necessary x
NURSING CARE 2/28/2017 5/16/2017
healthcare for two days when the client requires care seven days a week.
Buffalo Prairie River Home Care Inc. It is alleged that a client was neglected when staff did not respond appropriately when the client had a x
NEGLECT-HEALTH CARE 11/2/2016 3/9/2017
medical emergency. The client died three days later.
Buffalo Prairie River Home Care Inc. 01/26/2016 It is alleged that a client was neglected when facility nurses failed to ensure his/her medications were set-up x
NEGLECT-HEALTH CARE, MEDICATIONS and 11/7/2016 as prescribed. The client subsequently did not receive medications and was hospitalized with heart
01/27/2016 problems.
Buffalo REM South Central Services Buffalo 09/06/2017 It is alleged that a client was neglected when facility staff failed to provide adequate medical care and x
NEGLECT-HEALTH CARE and 11/6/2017 assessment of the client's catheter and urinary symptoms. It is alleged that the client has had multiple
09/07/2017 emergency department visits due to bladder infections and clogged urinary catheter.
Cokato Brookridge x
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
hospitalized with blood sugars over 300 and the staff had not checked his/her blood sugar levels.
Cokato BROOKRIDGE x NEGLECT-HEALTH CARE 7/23/2015 8/13/2015 It is alleged that a client was neglected when s/he was closing a window and it fell on him/her, resulting in x
the client's arm being broken in three places and required hospitalization. The facility was aware that the
window was not working properly since March 2015.
Cold Spring Assumption Home It is alleged that a resident was neglected when s/he had a change in condition and the facility failed to x
x NEGLECT-HEALTH CARE 6/22/2016 7/11/2016 adequately assess the resident. The resident was found to be unresponsive by family and was hospitalized.
The resident died ten days later.
Delano The Estates at Delano LLC It is alleged that staff failed to supervise a resident when the resident eloped from the facility. The resident x
x SELF ABUSE 2/8/2017 3/22/2018
signed out for a short leave of absence, but never returned to the facility.
Delano The Estates at Delano LLC It is alleged that residents were neglected when facility has been understaffed, resulting in lack of adequate x
NEGLECT OF HEALTH CARE-FALLS STAFFING
x 11/8/2017 3/16/2018 care. It is alleged that residents have developed pressure ulcers due to not being repositioned according to
SHORTAGE
the care plan.
Delano The Estates at Delano LLC It is alleged that a client was neglected when the alleged perpetrator (AP) failed to provide adequate nursing x
care. AP was rude to resident and did not help resident to put on stockings which s/he needed for cellulitis.
NEGLECT-HEALTH CARE ABUSE-EMOTIONAL-
x 3/9/2017 9/25/2017 Resident is wheel-chair bound, has dementia and is unable to put the stockings on his/herself. In addition,
STAFF
the AP failed to supervise resident's medication intake, resulting in a pill found on the table by the resident's
bed.
Delano The Estates at Delano LLC It is alleged that Resident #1 and Resident #2 were neglected when staff failed to provide adequate x
x NEGLECT-SUPERVISION 9/20/2016 6/12/2017 supervision to both residents. Resident #1 pulled Resident #2 out of his/her bed, and s/he had scalp
contusion.
Delano The Estates at Delano LLC It is alleged that a resident was neglected when facility staff failed to provide adequate personal care. It is x
NEGLECT OF HEALTH CARE STAFFING
x 11/8/2017 3/16/2018 alleged that the resident had to wait for extended periods of time for assistance with peri care resulting in
SHORTAGE
skin breakdown and wounds. It is alleged that the facility is understaffed.
Delano The Legacy of Delano LLC 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 x
x ABUSE BY STAFF PHYSICAL ABUSES BY STAFF 4/17/2017 11/7/2017 member made inappropriate sexual comments to client #1. It is also alleged the facility failed to provide hot
PHYSICAL PLANT MAINTENANCE water for bathing. It is alleged client #2 had a bruise on the forearm.
Elk River Accurate Home Care LLC It is alleged that a patient was financially exploited when the alleged perpetrator (AP) took the patient's x
ABUSE-EXPLOITATION-DRUG DIVERSION 4/20/2015 6/6/2015
medication for the AP's own use.
Elk River Guardian Angels By The Lake NEGLECT OF SUPERVISION-RESIDENT TO It is alleged that client #1 was neglected when the facility staff failed to provide adequate supervision that x
x 9/13/2017 12/29/2017
RESIDENT resulted in client #2 pushing client #1 down resulting in hip fracture.
Elk River Guardian Angels By The Lake NEGLECT-SUPERVISION-RESIDENT TO It is alleged that the facility did not adequately supervise two residents resulting in an accident where one x
x 1/27/2016 6/28/2017
RESIDENT PATIENT RIGHTS resident pushed the other and the resident who was pushed fell and fractured his/her arm.
Elk River MacGregor Place It is alleged that residents were financially exploited when a staff alleged perpetrator (AP) took the resident's x
medications for his/her own use.
Foley Cherrywood Advanced Living It is alleged that a resident was neglected when Alleged Perpetrator (AP) failed to properly assess resident x
x NEGLECT-HEALTH CARE 4/6, 4/7/2015 6/24/2015 after a fall and resident was in pain for multiple hours before being sent to the emergency room. Resident
was found have broken ribs and acute fractures of the spine.
Foley Cherrywood Advanced Living It is alleged that a client was neglected when a staff, alleged perpetrator, did not follow the care plan when x
x NEGLECT-HEALTH CARE 4/6, 4/7/2015 6/16/2015
turning the client and s/he fell out of bed.
Foley Foley Nursing Center It is alleged that a client was neglected when staff did not adequately assess and treat his/her ski breakdown x
x ABUSE-PHYSICAL-STAFF 2/21/2017 8/29/2017 and the client has now developed open wounds. This was brought to the attention of the facility RN and no
action was taken.
Foley Foley Nursing Center It is alleged that a client was neglected when staff failed to assess him/her and update his/her care plan x
x ABUSE-PHYSICAL-STAFF 2/6/2015 7/31/2015 when the client stopped eaten, subsequently the resident lost 15 pounds in 2 wks. It was brought to the
attention of the facility R.N. and no action
Foley FOLEY NURSING CENTER x ABUSE-PHYSICAL-STAFF 2/21/2017 8/29/207 It is alleged that abuse occurred when a staff, alleged perpetrator slapped a resident. x
Foley Foley Nursing Center x

It is alleged that a resident was neglected 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 was
x NEGLECT-HEALTH CARE , FALLS 6/21, 6/22/201 8/14/2017
found to have broken ribs and acute fractures of spine. During the investigation, the alleged perpetrator
(AP) resigned from the facility. The AP did not respond to a request for an interview or a subpoena.
Foley HERITAGE HOME HEALTH AND HOSPIC It is alleged that a resident was neglected when the staff failed to adequately assess the resident for falls risk x
12/1, after s/he had multiple falls in the last two months. In addition, the staff left the resident unsupervised in
NEGLECT OF HEALTH CARE-DECUBITI 4/14/2016
12/2/2015 his/her wheelchair and the resident has fallen as a result. In addition, it is alleged staff are not adequately
trained in
Foley HERITAGE HOME HEALTH AND HOSPIC It is alleged that a client was financially exploited when the alleged perpetrator (AP) took the client's x
medication for his/her own personal use.
Foreston Scandia Senior Care LLC It is alleged that financial exploitation occurred when an employee, alleged perpetrator (AP), took narcotic x
x ABUSE-EXPLOITATION-DRUG-DIV 12/11/2017 3/9/2018
medications from a client.
Foreston Scandia Senior Care LLC It is alleged that a client was neglected when staff failed to adequately supervise him/her when s/he left the x
x NEGLECT-SUPERVISION 10/12/2015 12/24/2015
facility and was found walking in a lane of traffic for at least 30 minutes.
Holdingford Hyatt House It is alleged that a client was sexually assaulted when the client was outside smoking and was attacked by an x
x ABUSE-SEXUAL PATIENT RIGHTS 1/13/2017 8/15/2017
alleged perpetrator. The facility did not assess the client.
Howard Lake GOOD SAMARITAN SOC HOWARD LAKE x NEGLECT-FALLS 4/2/2018 6/13/2018 It is alleged that multiple residents, resident #1, #2, and #3, were abused by the alleged perpetrator while x
receiving assistance during cares.
Little Falls Highland Senior Living Community It is alleged that a client was neglected when staff failed to provide adequate personal cares, assessments x
NEGLECT-HEALTH CARE NURSING CARE LACK
x 10/1/2015 4/6/2016 and overall cares according to the client's care plans. Also, it is alleged that staff are not properly trained
OF TRAINING
and supervised to provide adequate nursing cares for clients.
Little Falls Highland Senior Living Community It is alleged that clients #1 and #2 were financially exploited when staff, alleged perpetrator, (AP), took their x
narcotic medication for his/her own personal use.
Little Falls Minnesota Heritage House It is alleged that a client was neglected when the alleged perpetrator failed to provide an adequate medical x
assessment when the client had a change in condition resulting in the client's death.
Little Falls Minnesota Heritage House It is alleged that a client was neglected when the care plan was not being followed when a client had a fall x
x NEGLECT OF HEALTH CARE - FALLS 8/31,9/1/2017 9/22/2017
that resulted in death.
Little Falls Minnesota Heritage House It is alleged that neglect occurred when a fire was intentionally set. The fire at the facility led to the x
x NEGLECT-SUPERVISION 6/15,16/2017 9/14/2017
evacuation of more than 30 assisted living residents.
Little Falls Minnesota Heritage House It is alleged that a client was neglected when the client had an unexplained injury to his/her forearm. The x
x NEGLECT-HEALTH CARE UNEXPLAINED INJURY 2/6,7/2017 8/3/2017 client was made to wait a significant period of time to have his/her catheter flushed when it was needed and
the client's environment was not kept clean.
Little Falls MINNESOTA HERITAGE HOUSE x NEGLECT-HEALTH CARE, SUPERVISION 12/11-12/2017 5/10/2018 It is alleged that a client was neglected when staff inadequately assessed and supervised a client. The client x
voiced suicidal ideation.
Little Falls MINNESOTA HERITAGE HOUSE x NEGLECT-HEALTH CARE INADEQUATE 12/11-12/2017 5/10/2018 It is alleged that a client was neglected when the facility did not provide adequate care assistance. Staff did x
HOUSEKEEPING not provide shower assistance or housekeeping services. The client was incontinent of urine after staff
informed the client not to request assistance between 11:00 p.m. and 2:00 a.m.
Little Falls MINNESOTA HERITAGE HOUSE x NEGLECT-SUPERVISION 12/11-12/2017 5/10/2018 It is alleged that a client was neglected when staff did not supervise the client during lunch. The client x
choked. A visitor performed the Heimlich maneuver.
Little Falls Minnesota Heritage House It is alleged that client had been neglected when the client did not get insulin injection for one to four hours X
x NEGLECT-HEALTH CARE 9/24/2015 12/27/2017 after requested. The client subsequently had mood swings and dizziness. This occurred about four times a
week.
Little Falls Minnesota Heritage House 10/31, It is alleged that a client was neglected when the facility staff administered a narcotic medication to the X
x NEGLECT OF HEALTH CARE-MEDICATIONS 12/27/2017
9/1/2017 client, which caused the client's death. The medication was missing.
Little Falls Minnesota Heritage House NEGLECT-SUPERVISION-RESIDENT TO It is alleged that clients were neglected when an altercation occurred between the clients. Client #1 tried to x
x 6/15,16/2017 9/26/2017
RESIDENT strike Client #2 with a chair.
Little Falls Minnesota Heritage House It is alleged that neglect occurred when the facility inadequately supervised a client when the client started a x
x NEGLECT OF SUPERVISION SAFETY HAZARDS 8/31, 9/1/2017 9/24/2017
fire at the facility and eloped.
Little Falls Minnesota Heritage House NEGLECT-SUPERVISION-RESIDENT TO It is alleged that a client was neglected when the facility failed to supervise clients and the client received a x
x 8/31, 9/1/2017 9/24/2017
RESIDENT bite on the arm.
Little Falls Minnesota Heritage House It is alleged that a client was neglected when a staff member intentionally administered the client the wrong x
x NEGLECT-MEDICATIONS 8/31, 9/1/2017 9/22/2017
medication, because the client's supply of the correct medication had run out.
Little Falls Minnesota Heritage House x
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.
Little Falls Minnesota Heritage House It is alleged that five clients were neglected when the facility failed to maintain adequate staffing, administer x
NEGLECT OF HEALTH CARE NEGLECT OF
medications in a timely manner, process new orders in a timely manner, complete personal cares, assess
x HEALTH CARE-FALLS NURSING CARE 2/6,7/2017 7/5/2017
changes in condition and provide adequate training to direct care staff. In addition, it is alleged there was an
MEDICATION ADMINISTRATION
increase in the number of falls in the facility.
Little Falls Minnesota Heritage House It is alleged that client had been neglected when the client did not get insulin injection for one to four hours X
x NEGLECT-HEALTH CARE 9/24/2015 4/11/2016 after requested. The client subsequently had mood swings and dizziness. This occurred about four times a
week.
LITTLE FALLS NOUIS HOME CARE INC x NEGLECT OF SUPERVISION-RESIDENT TO 12/13/2017 6/1/2018 It is alleged that Client #1 was neglected when facility staff failed to provide adequate supervision when x
RESIDENT Client #2 sexually assaulted Client #1.
Little Falls St Ottos Care Center Inc x
It is alleged that a resident was neglected when the facility staff failed to follow proper skin checks ordered
by the physician. As a result, the resident sustained a pressure ulcer which needed surgical debridement.
Little Falls St Ottos Care Center Inc x NEGLECT-HEALTH CARE, SUPERVISION 2/8/2017 11/15/2017 See Report #: H5257008. Investigation report contained multiple allegations. x
Milaca Elim Home Milaca It is alleged that a resident was neglected when the facility staff did not adequately supervise the resident. x
The resident sustained a fall, which resulted in a right wrist fracture and right hip fracture. It is also alleged
x NEGLECT-HEALTH CARE, FALLS 2/12/2018 3/29/2018
that resident was neglected when the plan of care was not updated to reflect new toileting needs after
removal of an indwelling urinary Foley catheter.
Milaca Heritage House of Milaca It is alleged that a client was neglected when the client developed bed sores because the facility staff failed x
NEGLECT OF HEALTH CARE-DECUBITI NEGLECT
x 07/11,12/2017 12/27/2017 to reposition the client. In addition, the client had significant water retention and a decline in mental status.
OF HEALTH CARE
The facility did not address these issues.
Milaca Heritage House of Milaca It is alleged that a client was neglected when, after a fall, staff did not assess the client before moving the x
x NEGLECT-FALLS 07/11,12/2017 11/7/2017 client. Staff did not offer further assessment or care when the client reported pain, was unable to eat, and
had reduced range of motion due to the fall.
Milaca Heritage House of Milaca It is alleged that a resident was not supervised when the resident had oxygen and an oxygen mask on, lit up x
a cigarette and sustained burns to the side of the face and lungs. Staff extinguished the fire and called for
x NEGLECT-SUPERVISION NURSING CARE 11/01,02/2016 2/3/2017
emergency medical services. The resident was transferred to a hospital and then transferred to a burn unit
at a second hospital.
Milaca Heritage House of Milaca It is alleged that a client was neglected when the facility failed to ensure the client's oxygen tanks were filled, x
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.
Milaca Heritage House of Milaca x
It is alleged that a client was neglected when facility staff failed to assess and monitor the client. Facility
x NEGLECT-HEALTH CARE 10/5/2017 12/15/2017 staff found the client unresponsive and transferred the client to the hospital. It is alleged the client had a
subdural hematoma and large decubitus ulcer. The client was taken off life support and passed away.
Milaca Heritage House of Milaca It is alleged that a client was financially exploited when the alleged perpetrator (AP) signed out a tablet of x
the client's as needed oxycodone, but did not administer it to the client.
Monticello CENTRACARE HEALTH MONTICELLO x NEGLECT-FALLS 3/20/2018 6/1/2018 It is alleged that a resident was neglected when the alleged perpetrator did not follow the care plan resulting x
in a fall. The client sustained an ankle fracture.
Monticello CENTRACARE HEALTH MONTICELLO x NEGLECT OF HEALTH CARE MEDICATION 10/3/2017 4/10/2018 It is alleged that a resident was neglected when facility staff increased resident's oxygen flow without a x
ERRORS physician order.
Monticello Centracare Health Monticello It is alleged that a resident was neglected when the facility did not adequately supervise the resident. The x
x NEGLECT-FALLS 1/29/2018 3/30/2018
resident sustained a fall resulting in a right hip fracture.
Monticello Centracare Health Monticello It is alleged that a resident was neglected when the resident had a change in condition, including symptoms x
x NEGLECT-HEALTH CARE 3/30/2016 9/26/2016 of drowsiness, inability to speak, and unresponsiveness for several days. The resident was hospitalized in
critical condition, with severe dehydration, and possible kidney failure.
Mora St. Clare Living Community of Mora It is alleged that clients are neglected when the clients in the memory care unit are left unsupervised. As a x
x NEGLECT-SUPERVISION, HEALTH CARE 10/28/2015 1/20/2016 result, there have been several falls, not enough staff to provide adequate personal cares and assistance
with transfers.
Ogilvie Signe and Olivias It is alleged that clients (#1, #2, #3) were financially exploited when a staff, alleged perpetrator took the x
client's medication for his/her own personal use.
Onamia Lake Song Assisted Living x
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
x NEGLECT-HEALTH CARE, SUPERVISION 03/28,29/2017 12/22/2017
client's arm and left it on overnight. Next morning, the client developed swollen fingers and a bright red,
noticeable groove in the arm from the tourniquet. The client passed away due to sepsis.
Onamia Lake Song Assisted Living It is alleged that a client was financially exploited when a staff member/alleged perpetrator took $100 from x
x ABUSE-EXPLOITATION-STAFF 03/28,29/2017 12/22/2017
the client.
Onamia Mille Lacs Health System NEGLECT OF SUPERVISION-RESIDENT TO It is alleged that two residents (resident #1 and resident #2) were neglected when facility staff failed to x
x 12/20/2017 3/21/2018
RESIDENT provide adequate supervision leading to resident #2 grabbing at resident #1 genitals.
Onamia Mille Lacs Health System It is alleged that a resident was abused when the alleged perpetrator swore at the resident resulting in the x
x ABUSE-EMOTIONAL-STAFF 12/20/2017 3/12/2018
resident becoming tearful.
Otsego Accurate Home Care LLC It is alleged that a patient was neglected when a staff, alleged perpetrator unsafely transferred, dumping x
NURSING CARE NEGLECT-HEALTH CARE Feb 2 - 3 2016 2/2/2017 water on his / her face. Emergency response called, CPR administered. Admitted to hospital with
pneumonia.
Otsego Accurate Home Care LLC 08/31/2017 It is alleged that a client was neglected when staff/alleged perpetrator (AP) inappropriately transferred the x
PATIENT RIGHTS and 1/11/2018 client with the use of a mechanical lift. The client sustained a fall that resulted in loss of a tooth, loosened
09/05/2017 teeth, a swollen cheek and wrists and continued pain.
Otsego Accurate Home Care LLC 01/18/2017 x
It is alleged that a client was neglected when a nurse did not show to the client's home to provide scheduled
NEGLECT-HEALTH CARE NURSING CARE and 2/2/2017
care and the client had to go to the emergency room. There is no adequate plan of care in place.
01/19/2017
It is alleged that a client was neglected when an alleged perpetrator provided and served client with multiple
NURSING CARE NEGLECT-HEALTH CARE and 5/10/2016
glasses of wine without a physician order.
12/29/2015
Otsego Accurate Home Care LLC It is alleged that a client was neglected when staff/alleged perpetrator (AP) did not adequately provide x
NURSING CARE NEGLECT-HEALTH CARE 11/1/2016 12/22/2016
emergency care when the client was unresponsive. The client died three days later.
It is alleged that a patient was neglected when s/he was found with an improperly connected ventilator.
NURSING CARE NEGLECT-HEALTH CARE and 10/24/2016
Patient's oxygen levels were extremely low and needed to be hospitalized.
02/03/2016
Paynesville Centracare Health Paynesville It is alleged that a resident was neglected when staff failed to adequately transfer the resident resulting in x
x NEGLECT-HEALTH CARE NEGLECT-FALLS 12/1/2014 3/23/2015 the resident falling and requiring stitches and multiple cuts on the resident's legs. The facility failed properly
assess the resident's position of his/her bed.
Paynesville ENTRACARE HEALTH PAYNESVILLE x ABUSE-PHYSICAL, EMOTIONAL 3/22/2018 5/14/2018 It is alleged that a resident was emotionally and physically abused when the alleged perpetrator became x
demanding toward the resident and grabbed the resident's hand(s) during toileting cares which resulted in
bruising.
Pierz Harmony House x
It is alleged that a client was neglected when staff failed to provide adequate personal cares to the client.
NEGLECT-HEALTH CARE 2/27/2015 3/26/2015 The client was admitted to another facility with blood, dirt, feces and food on his/her clothing, hair and skin.
In addition, the client was physically weak and was observed to have severe chest congestion.
Pierz Pierz Villa Inc x
It is alleged that a resident was neglected when s/he was administered the incorrect dosage of Warfarin and
x NEGLECT-MEDICATIONS 6/2/2016 10/18/2016
the resident was sent to the emergency room with significant bruising and persistent bleeding.
Princeton ELIM HOME x NEGLECT OF SUPERVISION 12/20/2017 6/18/2018 It is alleged that a resident was neglected when the facility failed to provide adequate supervision resulting x
in the resident sustaining a burn.
Princeton Elim Home ABUSE-SEXUAL NEGLECT-SUPERVISION- x
x 12/01,02/2016 5/1/2017 It is alleged Resident #1 was not adequately supervised when Resident #1 sexually assaulted Resident #2.
RESIDENT TO RESIDENT PATIENT RIGHTS
Princeton ELIM HOME x NEGLECT OF SUPERVISION-RESIDENT TO RESIDENT 12/20/2017 6/18/2018 It is alleged that two residents were neglected when the facility failed to provide adequate supervision x
resulting in a resident-to-resident altercation.
Princeton Elim Home It is alleged that a resident was neglected when facility staff failed to provide adequate supervision resulting x
in 14 falls during the month of May. It is alleged that the facility failed to provide adequate fall interventions
NEGLECT-FALLS, SUPERVISION NEGLECT- to ensure the resident safety. Facility did not self-report any falls to the State Agency. In addition, the staff
x 09/12,13/2017 10/23/2017
HEALTH CARE NEGLECT-FAILURE TO REPORT failed to provide adequate incontinence care leaving the resident in his/her incontinence product for
extended periods resulting in a yeast infection. In addition, it is alleged that staff retaliated against resident
for behaviors.
Princeton Elim Home It is alleged that a resident was neglected when staff failed to adequately monitor the resident's oxygen x
level. The resident was turning blue and needed to be transported to the emergency room.
Princeton Sterling Pointe Senior Living It is alleged that a client was neglected when the staff/alleged perpetrator failed to follow the client's care x
NEGLECT-HEALTH CARE, FALLS DUE TO EQUIP
x 6/23/2017 3/9/2018 plan that required a mechanical lift w assist of 2 people for transfers. The AP transferred the client with only
FAILURE/INAPPROP USE OF EQUIPMENT
a gait belt, which resulted in a fall and femur fracture.
Princeton Sterling Pointe Senior Living 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 x
x 11/27/2017 12/7/2017
EXPLOITATION BY DRUG DIVERSION also alleged that financial exploitation occurred when the client's medication went missing.
Sartell Country Manor HLTH & REHA It is alleged that a client was neglected when staff failed to assess him/her and update his/her care plan x
x NEGLECT-FALLS, HEALTH CARE 6/21/2017 8/16/2017 when the client stopped eaten, subsequently the resident lost 15 pounds in 2 wks. It was brought to the
attention of the facility R.N. and no action was taken.
Sartell Country Manor HLTH & REHA It is alleged that a resident was neglected when s/he rolled out of bed and hit his/her bead. The resident was x
x NEGLECT-HEALTH CAREBE 4/5/2016 4/6/2017 taken to the hospital and admitted with a brain bleed and facial lacerations and passed away less than 24
hours later.
Sartell Country Manor HLTH & REHA x
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.
Sartell Welcome Home Health Care Inc It is alleged that a client was neglected when the facility stopped the client's medication for one week and x
x NEGLECT-HEALTH CARE 3/10/2015 1/21/2016 then restarted the client on it without the physician's order and the client subsequently became unconscious
and was hospitalized.
Sartell Welcome Home Health Care Inc It is alleged when client #1 was abused by a staff, alleged perpetrator (AP), was touching the client x
x SEXUAL ABUSE 3/30/2015 6/27/2015 inappropriately. In addition, the AP touched clients #2 and #3 inappropriately. This has been reported to the
facility on two occasions and no action has been taken.
Sartell Welcome Home Health Care Inc NEGLECT OF HEALTH CARE NEGLECT OF x
It is alleged that a resident was neglected when s/he had a fall in his/her room and the alleged perpetrator
x HEALTH CARE FALLS EMOTIONAL ABUSE BY 9/28/2015 12/28/2015
(AP) left the resident on the floor while in the room.
STAFF
Sauk Centre Centracare Health System It is alleged that a resident was neglected when s/he had blood sugars over 300 and facility failed to update x
x NEGLECT OF HEALTH CARE 12/1,2/2015 6/29/2016 on-call physician per facility protocol. Resident was transported to the hospital and admitted to the Intensive
Care Unit for increased blood sugars and decreased blood pressure.
Sauk Centre Centracare Health System It is alleged that a client was neglected when the facility failed to provide adequate assistance and
NEGLECT OF HEALTH CARE-FALLS NEGLECT OF
x 11/29,30/2016 8/22/2017 supervision resulting in multiple falls and skin abrasion/bruise. Resident had total four falls in the last three
HEALTH CARE NURSING CARE
months.
Sauk Centre Getty Street Assisted Living It is alleged that a client was financially exploited when the alleged perpetrator (AP) used the client's debit x
x EXPLOITATION BY STAFF 1/10/2018 4/6/2018 card to make withdrawals of cash for personal use.
Sauk Centre Getty Street Assisted Living x ABUSE-EXPLOITATION-OTHER 12/28/2016 1/23/2017 It is alleged that two clients personal items and money were stolen. x
Sauk Rapids Cherrywood Advanced Living It is alleged that a client was neglected when staff failed to provide adequate cares and s/he had two stage 2 x
x NEGLECT-HEALTH CARE 8/6/15 8/6/2015 pressure ulcers on the coccyx, abraded areas on the inner thighs, fecal matter in the perineal area and an
odor.
Sauk Rapids Cherrywood Advanced Living It s alleged that a client was neglected when a staff failed to follow the care plan and the client fell out of x
x NEGLECT-SUPERVISION 1/8/15 3/16/2015 his/her wheelchair. The client was not assessed and sent to the hospital until the next day and subsequently
died.
Sauk Rapids Cherrywood Advanced Living It is alleged that a client was neglected when staff failed to provide adequate supervision. The client x
x NEGLECT-HEALTH CARE 4/6, 4/7/2015 6/16/2015 wandered outside, was in subzero temperature for 25 minutes and was found with blisters on his/her fingers
and was admitted to the hospital with hypothermia.
Sauk Rapids GOOD SHEPHERD LUTHERAN It is alleged that a resident was abused when staff alleged perpetrator #1 (AP1) and alleged Perpetrator #2 x
x NEGLECT-FALLS LACK OF TRAINING 6/3/2015 2/3/2016 (AP2) held down the resident and sprayed lavender oil in the residents face. Also, the resident had bruising
on his/her arm.
Sauk Rapids GOOD SHEPHERD LUTHERAN It is alleged that a resident was physically abused when a staff, alleged perpetrator (AP) punched the x
x ABUSE-PHYSICAL-STAFF PATIENT RIGHTS 5/12/2016 4/18/2017
resident in the stomach. In addition, it is alleged staff have been withholding meals from the resident.
Sauk Rapids GOOD SHEPHERD LUTHERAN HOME x ABUSE-EXPLOITATION-DRUG DIVERSION 3/30/2018 5/14/2018 It is alleged that residents were financially exploited when the alleged perpetrator (AP) took the residents' x
pain medication for his/her own use.
Sauk Rapids RIDGEVIEW PLACE it is alleged that a client was abused when a staff member swore at the client and slapped the client's hand x
ABUSE-PHYSICAL-STAFF 3/8/17 3/31/2017
leaving a bruise.
St. Cloud Centracare Health Home Care It is alleged that a patient was abused when a staff member, alleged perpetrator (AP) sexually assaulted the x
SEXUAL ABUSE 3/4,5/2015 5/27/2015
patient.
St. Cloud Nature's Point Assisted Living It is alleged that a client was neglected when the client did not get scheduled warfarin for 10 days. The x
x MEDICATION ERRORS 7/25/2017 9/25/2017
client's condition declined and the client was transported to the hospital.
St. Cloud Nature's Point Assisted Living It is alleged that a client was financially exploited when a staff/alleged perpetrator (AP) took ten tablets of x
x ABUSE-EXPLOITATION-DRUG DIVERSION 6/21/2017 8/28/2017 Vicodin/acetaminophen 10/325 milligrams (mg) for personal use. The AP admitted to taking the medication
and resigned.
St. Cloud Recover Health It is alleged that a patient was neglected when a staff/alleged perpetrator worked with the patient while x
impaired. The patient's ileostomy and urostomy bags were overflowing. The patient was fearful and had
NEGLECT-HEALTH CARE ABUSE-SEXUAL ABUSE- difficulty sleeping since the night of the incident. It is alleged that a patient was financially exploited when AP
6/7,8/2017 12/27/2017
PHYSICAL-STAFF PATIENT RIGHTS took a variety of the patient's medications. It is alleged that a patient was abused when blood was found on
syringes in the nurses' room, counter, floor and sofa. The patient had bleeding noted in the patient's
underwear later that night.
St. Cloud Recover Health It is alleged that a patient was neglected when a staff/alleged perpetrator worked with patient while x
NEGLECT-HEALTH CARE PATIENT RIGHTS 6/7,8/2017 12/27/2017
impaired.
St. Cloud REM Central Lakes Inc Fernwood It is alleged that a resident was abused when the alleged perpetrators AP #1 and AP #2, used excessive force x
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.
St. Cloud St Benedict's Senior Community It is alleged that a resident was abused when the resident was found to be restrained to his/her wheelchair x
x ABUSE-RESTRAINTS 7/6/2017 12/29/2017
with a gait belt.
St. Cloud St Benedict's Senior Community It is alleged that five clients were financially exploited when the alleged perpetrator (AP) took the client's x
x ABUSE-EXPLOITATION-STAFF 10/5/2016 1/5/2017
money.
St. Cloud St Benedict's Senior Community x
x See Report: HL20711004. Investigation report contained more than one allegation.
ABUSE-EXPLOITATION-OTHER 10/5/2016 1/5/2017
St. Cloud St Benedict's Senior Community It is alleged that Client #1 was not adequately supervised by the facility when Client #2 pushed Client #1 x
NEGLECT-SUPERVISION-RESIDENT TO
x 1/13/2017 3/1/2017 during a verbal and physical altercation. Client #1 fell and was taken to the hospital for a fractured hip that
RESIDENT
required surgical intervention.
St. Cloud St Benedict's Senior Community NEGLECT-SUPERVISION-RESIDENT TO x
x 1/13/2017 3/1/2017 See Report: HL20711006. Investigation report contained more than one allegation.
RESIDENT PATIENT RIGHTS
St. Cloud St Benedict's Senior Community It is alleged that a client was neglected when the client had a change in condition, including being x
x NEGLECT-HEALTH CARE, MEDICATIONS 12/7/2015 6/6/2016 increasingly sleepy and lethargic, and the client was being overmedicated. The client was not assessed for a
change in condition by the staff and later suffered a fall, broke his/her back and was hospitalized.
St. Cloud St Benedict's Senior Community It is alleged that resident was sexually abused staff/alleged perpetrator (AP) inappropriately touched the x
x ABUSE-SEXUAL 3/8,9/2017 12/14/2017
resident.
St. Cloud St Benedict's Senior Community It is alleged that a resident was neglected when Alleged Perpetrator (AP) did not transfer the resident per x
his/her care plan. The resident sustained a left femur fracture.
St. Cloud St Benedict's Senior Community It is alleged that neglect occurred when a resident's foot was fractured; it is unclear as to how the fracture x
x UNEXPLAINED INJURY/FRACTURE 9/11/2015 6/10/2016
occurred. Care was delayed for a week resulting in increased pain and suffering.
St. Cloud Talahi Nursing & Rehab Center x
NEGLECT OF SUPERVISION-RESIDENT TO It is alleged that Resident #1was neglected when facility staff failed to provide adequate supervision that
x 7/28/2017 1/3/2018
RESIDENT resulted in a resident to resident altercation, Resident #2 pushed Resident #1 resulting in a fractured arm.
St. Cloud Talahi Nursing & Rehab Center NEGLECT OF SUPERVISION-RESIDENT TO x
x 7/28/2017 1/3/2018 See Report #: H5438048. Investigation report contained more than one allegation.
RESIDENT
St. Cloud Talahi Nursing & Rehab Center It is alleged that a resident was neglected when s/he had a change in condition with stroke like symptoms X
x NEGLECT OF HEALTH CARE 3/22/2016 5/18/2017 and the facility did not provide adequate nursing care and assessment. The client was not sent to the
emergency room until eight hours after staff noticed the change in condition.
St. Cloud TALAHI NURSING & REHAB CENTER x NEGLECT-FALLS, FAILURE TO REPORT 11/20, 5/31/2018 It is alleged that a resident was neglected when the resident had a fall resulting in a fractured leg and facility x
21/2017 staff did not provide adequate emergency medical services. It is also alleged that the facility did not report
this incident.
St. Cloud TALAHI NURSING & REHAB CENTER x NEGLECT-HEALTH CARE INFECTION 11/20, 5/31/2018 It is alleged that a resident was neglected when staff reinserted a used catheter that was dislodged during x
CONTROL 21/2017 cares. Staff also handled this catheter without gloves.
St. Cloud Talahi Nursing & Rehab Center x
It is alleged that a resident was neglected when the staff failed to provide personal cares in a timely manner.
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.
St. Michael The Legacy of St. Michael It was alleged that client was neglected when staff failed to provide the client's scheduled medications, x
NEGLECT-MEDICATION ERRORS NEGLECT-
x 7/6/2015 9/15/2017 which was prescribed for client's multiple myeloma, resulting in worsening pain and increased clinic visits.
HEALTH CARE
The client's missing medications has been an ongoing issue.
Waite Park Sterling Park Commons ABUSE-EXPLOITATION-EXPLOITATION-DRUG It is alleged that a client was exploited when staff/alleged perpetrator (AP) took client's narcotics for x
x 6/20/2017 9/6/2017
DIVERSION personal use.
Waite Park Sterling Park HCC It is alleged that a resident was neglected when the Alleged Perpetrator (AP) failed to provide the resident x
x NEGLECT-PAIN MANAGEMENT NURSING CARE 8/31/2016 2/28/2017 pain medications when the resident exhibited signs of pain, and failed to respond when the resident had
seizures. The patient died the next day.
Waite Park Sterling Park HCC It is alleged that a resident choked in the dining room and it took facility staff seven minutes to get the crash x
cart, as it was covered in boxes. Also, another resident with eating difficulties is being left unsupervised in
x NEGLECT-SUPERVISION OTHER 8/24/2015 8/28/2015
the dining area. In addition, it is alleged that some licensed nursing staff come to work under the influence of
alcohol.
TOTALS Abuse: 13% Neglect: 69% Financial Exploitation: 18% 46 68 39

Minnesota Office of Health Facility Complaints Website Data - Resolved Complaint Findings As of 8/8/2018

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Minnesota Office of Health Facility Complaints Website Data - Resolved Complaint Findings As of 8/8/2018

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