Information About Facilities in the News

Providence Place

May 4, 2010

In a story in the Star Tribune on Tuesday it was noted that Minnesota Department of Health Investigators concluded that Providence Place failed to change a resident’s care plan after she had twice previously tried to open a door to a stairway. The woman eventually opened the door and rolled down a stairwell in her wheelchair and died last May. The State’s report stated that according to the care plan the resident “needed assistance of staff to avoid potentially dangerous situations.” The resident had a suffered from anxiety, depression and other behavior problems, and had a history of wandering around the facility, include the stairwell in the past.

Here is the link for the rest of the story: Nursing home blamed for fatal wheelchair fall

Texas Terrace Care Center
Star Tribune
April 29, 2010
There was a story in the Star Tribune last week concerning a finding of neglect when a nursing home nurse fail to properly intervene on behalf of a resident who was having difficulty breathing at the Texas Terrace Center in St. Louis Park, Minnesota.
For the rest of the story: State: Nurse’s neglect led to nursing home death.

Federal Law mandates that resident in a nursing home:

42 CFR Section 483.25 – Quality of care.

Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.
(l) Unnecessary drugs(1) General. Each resident’s drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used: (i) In excessive dose (including duplicate drug therapy); or (ii) For excessive duration; or (iii) Without adequate monitoring; or (iv) Without adequate indications for its use; or (v) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or (vi) Any combinations of the reasons above.

Report Suspected Abuse and Neglect

If you suspect abuse or neglect to any vulnerable adult, please contact the Minnesota Department of Health/ Department of Human Services, where you can file a confidential report protecting those unable to do so for themselves. Positive change and accountability starts with reporting all suspected neglect and abuse.

By filing a complaint about suspected neglect or abuse a trained investigator is assigned to review the issue and the facility to protect the safety of the residents by identifying areas of care not in compliance with the minimum state and federal standards.

For assistance with filing a complaint with the state concerning abuse or neglect on the behalf of your family member or yourself, WITHOUT CHARGE, please call or email attorney Kenneth L. LaBore to schedule an appointment.

According to Minnesota Statute § Subd. 21(a) “Vulnerable adult” means any person 18 years of age or older who:
(1) is a resident or inpatient of a facility;
(2) receives services at or from a facility required to be licensed to serve adults under sections 245A.01 to 245A.15, except that a person receiving outpatient services for treatment of chemical dependency or mental illness, or one who is served in the Minnesota sex offender program on a court-hold order for commitment, or is committed as a sexual psychopathic personality or as a sexually dangerous person under chapter 253B, is not considered a vulnerable adult unless the person meets the requirements of clause (4);
(3) receives services from a home care provider required to be licensed under section 144A.46; or from a person or organization that exclusively offers, provides, or arranges for personal care assistant services under the medical assistance program as authorized under sections 256B.04, subdivision 16, 256B.0625, subdivision 19a, 256B.0651, 256B.0653 to 256B.0656, and 256B.0659; or
(4) regardless of residence or whether any type of service is received, possesses a physical or mental infirmity or other physical, mental, or emotional dysfunction:
(i) that impairs the individual’s ability to provide adequately for the individual’s own care without assistance, including the provision of food, shelter, clothing, health care, or supervision; and
(ii) because of the dysfunction or infirmity and the need for care or services, the individual has an impaired ability to protect the individual’s self from maltreatment.
(b) For purposes of this subdivision, “care or services” means care or services for the health, safety, welfare, or maintenance of an individual.

Woodbury Health Care Center
April 14, 2010

In a story dated April 13, 2010, by Paul Walsh from the Minneapolis Star & Tribune newspaper detailed a RN from a Woodbury Nursing Home who was faulted by the State of Minnesota for Improper Conduct. The complaint deals with a wrongly ordered halt to CPR on a dying resident in the nursing home.

For more information concerning Woodbury Health Care Center and this incident go the the attached: Minnesota Department of Health and type in facility name and under Provider Type either put “nursing home” or “all”.

As an attorney who handles nursing home abuse and neglect cases confusion in the Do-Not-Recusitate (DNR) or Do-Not-Intubate (DNI) leading to many situations where care is either withheld or provided when not wanted. Confusion on the DNR/DNI status of a resident can be dealt with through a clear and consistent policy at the nursing home to ensure that the resident or their legal representative’s wishes with respect to emergency care issues is addressed and that there is those wishes are easily found and identified by the staff when there is such a need.

Good Samaritan, Brainerd

March 31, 2010

Star Tribune

According to a story by Warren Wolfe from the Star Tribune titled: Brainerd nursing home is cited for abuse At least 20 aides were involved in belittling and abusive behavior, state investigators say. State investigators found: A “pattern of resident abuse” by at least 20 nursing assistants that included belittling elderly patients, telling a man to urinate in his incontinence briefs and removing a call-light from a confused female resident. The mistreatment had been underway for more than three months and was known to as many as 40 other employees, including some supervisors, investigators were told. “This was a systemwide failure,” said Stella French, who oversees state Health Department investigators. “It’s a situation that the administration should have known about and should have stopped.”

Nursing Home Elder Abuse and Neglect Nursing home abuse and nursing home neglect of the elderly and vulnerable in nursing homes and other facilities occurs in many forms. A nursing home lawyer is here to assist your loved ones with holding the wrongdoers accountable. Some types of abuse are obvious such as elder sexual or elder physical assault or financial exploitation. Others forms of abuse and neglect are less noticeable and are often the result of having fewer nursing staff and aides than are needed and required. Staffing and training issues lead to many forms of avoidable neglect such as: falls, pressure ulcers (bed-sores), medication errors, dehydration and malnourishment, urinary tract infections, unsupervised residents wandering or suffering burn injuries and a multitude of other problems. Ken LaBore represents a professional Minnesota Nursing Home Law Firm, which is dedicated to holding nursing homes accountable for providing quality care to residents pursuant to the contracts they sign with the government, Medicare and Medicaid. The nursing home has an obligation to provide the: “highest quality of care practicable”. If you suspect abuse or neglect to any vulnerable adult, please contact the Minnesota Department of Health where you can file a confidential report protecting those unable to do so for themselves.

WHAT SHOULD I DO IF I SUSPECT NEGLECT OR ABUSE If you have reason to suspect that a loved one sustained an injury in a hospital, nursing home or assisted living facility the State of Minnesota Department of Health will investigate the issue upon reasonable suspicion. The first step to resolve the issue is a complaint form which must be filed with the MDH to start an investigation. The MDH Complaint Form is a three page document filed through the Office of Health Facility Complaints (OHFC) through a specified complaint form, which requests a reporting parties name, address and other contact information, the name of whom the complaint is on behalf of, the name and address of the facility, the date of the incident and a narrative statement on what occurred. The form contains a notice called a Tennessen Warning stating that the information you provide on the form may be used in an investigation report, however, your identity is confidential and is not revealed to the general public, except as required by law. The form goes on to give some situations where it may be necessary to reveal your identity to persons in a hearing. Giving your name is optional, but failing to do so may hinder efforts to resolve the problem. For more information and a copy of an OHFC Complaint Form go to: http://www.health.state.mn.us/divs/fpc/ohfcinfo/hfccomplaintform.pdf

Elder Physical and Sexual Abuse:

Way to avoid Physical and Sexual abuse of the elderly is outlined in a brochure from Eldercare Rights Alliance called: Elder Abuse is a Crime.
National Citizens’ Coalition for Nursing Home Reform (NCCNHR) provides a free brochure and article on the called: Faces of Neglect.
The Power and Control Wheel for Elders and People with Disabilities.
The Types of Elder Abuse and Warning Signs is a brochure and checklist of warning signs to look for to avoid elder abuse produced by Eldercare Rights Alliance.

Elder Financial Exploitation and Abuse:

Eldercare Rights Alliance materials on Financial Exploitation of the elderly and vulnerable: Theft In Nursing Homes Awareness and Prevention.
Minnesota Eldercare Rights Alliance, Personal Property Inventory Form, to use upon admission.

Resources for Resident’s and Family of Nursing Homes – Long Term Care Facilities

Minnesota Nursing Home Residents’ Bill of Rights brochure from Eldercare Rights Alliance
The Eldercare Rights Alliance has a brochure called Tips for Choosing a Nursing Home
Center for Medicare and Medicaid Services, CMS, Nursing Home Compare provides the user with assistance in finding a nursing home based upon particular criteria such as the types of care and rehabilitation provided, location and past history of the facility.
Minnesota Department of Health, Nursing Home Report Card provides a way to compare nursing homes in Minnesota based upon the quality of care provided in the facility as determined by the facility’s survey and complaint history.
Family Councils are an important way that family and other community members can promote quality care of the resident of nursing homes, complaints made by the family council must be addressed by the facility under penalty with the state surveyors. The Minnesota Eldercare Alliance produced the following brochure on Family Councils.
The ElderCare Rights Alliance information on the Elder Justice Program which provides training to members of family and resident councils.
Resident Councils are a direct way for residents to get involved in issues related to the quality of care given to the residents.

Redeemer Health and Rehab
March 3, 2010

Star Tribune

There was a story this week in the Star Tribune titled: Minneapolis nursing home blamed in resident’s death.

Redeemer Health and Rehab on Lake Street in Minneapolis was found to be negligent for allowing a resident with dementia to sustain burns on his legs and feet from a radiator next to his bed. The resident apparently suffered second to third degree burns and was taken to the emergency room.

For the entire story see: Minneapolis nursing home blamed in resident’s death.

This was an obviously avoidable form of negligent that would have been prevented with minimum care and supervision for the resident.

Nursing homes across Minnesota have an obligation to comply with minimum care standards established by state and federal regulations. Many times the explanation for burn injuries occurring to residents of Minnesota nursing homes, assisted living and other types of elder care facilities is related to a corporate organization which is focused on maximizing profits at the expense of safety. Many of the burn incidents resulting in serious injury or deaths could have been prevented with increased numbers of attentive and well qualified staff providing additional supervision.

Minnesota law requires that a nursing home must have on duty at all times a sufficient number of qualified nursing personnel, including registered nurses, licensed practical nurses, and nursing assistants to meet the needs of the residents at all nurses’ stations, on all floors, and in all buildings if more than one building is involved. This includes relief duty, weekends, and vacation replacements.

Minnesota Rule 4658.0015 states that a nursing home must operate and provide services in compliance with all applicable federal, state, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in a nursing home.

Minnesota Rule 4658.0105 mandates that a nursing home must ensure that direct care staff are able to demonstrate competency in skills and techniques necessary to care for residents’ needs, as identified through the comprehensive resident assessments and described in the comprehensive plan of care, and are able to perform their assigned duties.

Federal regulation 42 CFR §483.25 (h) establishes a duty for the nursing home to that the resident receives adequate supervision and assistive devices to prevent accidents:

42 CFR §483.25 (h) Accidents. The facility must ensure that—
(1) The resident environment remains as free of accident hazards as is possible; and
(2) Each resident receives adequate supervision and assistance devices to prevent accidents.
Minnesota Statute 626.5572, Subd. 3.Accident.
“Accident” means a sudden, unforeseen, and unexpected occurrence or event which:
(1) is not likely to occur and which could not have been prevented by exercise of due care; and
(2) if occurring while a vulnerable adult is receiving services from a facility, happens when the facility and the employee or person providing services in the facility are in compliance with the laws and rules relevant to the occurrence or event.

Despite the state and federal regulations designed to protect vulnerable adult, there are still an unacceptably high number of preventable burn incidents in nursing homes but the most common involve hot water in bathtubs or showers, or thermal burns due to the misuse of hot packs, or injuries due unsupervised smoking of resident. Or in the case of

This website is not intended to provide legal advice as each situation is different and specific factual information must be obtained before an attorney is able to assess the legal questions relevant to your situation.

If you or a loved one has suffered an injury from neglect or abuse in a nursing home or other care facility that serves the elderly in Minnesota please contact our firm for a free consultation and information regarding the obligations of the facility and your rights as a resident or concerned family member. To contact Attorney Kenneth L. LaBore, directly please send an email to KlaBore@mnnursinghomeneglect.com or call Ken at 612-743-9048.

Sunny Care Center – Lake Park

March 2010

Star Tribune

According to a story from the Star Tribune titled:
Nursing home aide stuffed sock in dementia patient’s mouth

The story states:
“An aide at a northwestern Minnesota nursing home crammed a sock in the mouth of a screaming resident because the woman, elderly and in the late stages of dementia, wouldn’t be quiet, according to a state Health Department report released Tuesday.

The report quotes a co-worker as saying, “What the hell are you doing?” as the incident unfolded on Jan. 4 in the resident’s room at the Sunnyside Care Center in Lake Park.

The co-worker told an investigator that the nursing assistant “chuckled” and responded that the resident “wouldn’t quit hollering,” the report added. The co-worker then removed the sock from the resident’s mouth.”
This is an example of completely avoidable and in-execusable neglect, demonstrating a lack of concern for human dignity.

Nursing Homes must learn to treat the vulnerable resident under their charge with the respect they deserve. As an attorney who handles nursing home abuse and neglect cases, I wish I could say this type of incident, reckless and abusive care, is isolated.

Elder Physical and Sexual Abuse:

Way to avoid Physical and Sexual abuse of the elderly is outlined in a brochure from Eldercare Rights Alliance called: Elder Abuse is a Crime.
National Citizens’ Coalition for Nursing Home Reform (NCCNHR) provides a free brochure and article on the called: Faces of Neglect.
The Power and Control Wheel for Elders and People with Disabilities.
The Types of Elder Abuse and Warning Signs is a brochure and checklist of warning signs to look for to avoid elder abuse produced by Eldercare Rights Alliance.

Elder Financial Exploitation and Abuse:

Eldercare Rights Alliance materials on Financial Exploitation of the elderly and vulnerable: Theft In Nursing Homes Awareness and Prevention.
Minnesota Eldercare Rights Alliance, Personal Property Inventory Form, to use upon admission.

Fair Oaks Lodge in Wadena
March 5, 2010
Star Tribune

There was a story today in this week in the Star Tribune titled: Drug errors led to patient’s death in Wadena nursing home.

A central Minnesota nursing home committed serious medication mistakes three times within 16 days last year causing the death of one of them according to state investigators. Apparently the “significant medication errors”at Fair Oaks Lodge in Wadena indicated a systems failure at the facility, prompting state Health Department investigators to place blame with the home. State investigators observed a medication rate of 18 percent during one evening’s staff rounds.

The story states that deaths from medication errors are rare in nursing homes. In 2008 records show that there were 253 allegations of medication errors up from 199 the year before.

According to the story an 82-year-old resident of the nursing home who was suffering from Alzheimers died after he was negligently given three medications on one day. The medication caused the resident’s blood pressure to drop and eventually she became unresponsive and was taken by ambulance to an emergency room and then passed away form pneumonia. There were other improperly medicated residents also taken the emergency room.

For the rest of the story see: Drug errors led to patient’s death in Wadena nursing home.

Nursing Homes MUST Ensure that Residents are Free of any Significant Medication Errors. (42 CFR § 483.25 (m)) and Minnesota Rule 4658.1320.
42 CFR § 483.1320 (m) Medication Errors. The facility must ensure that—
(1) It is free of medication error rates of five percent or greater; and
(2) Residents are free of any significant medication errors.

4658.1320 MEDICATION ERRORS.
A nursing home must ensure that:
A. Its medication error rate is less than five percent as described in the Interpretive Guidelines for Code of Federal Regulations, title 42, section 483.25(m), found in Appendix P of the State Operations Manual, Guidance to Surveyors for Long-Term Care Facilities, which is incorporated by reference in part 4658.1315. For purposes of this part, a medication error means:
(1) a discrepancy between what was prescribed and what medications are actually administered to residents in the nursing home; or
(2) the administration of expired medications.
B. It is free of any significant medication error. A significant medication error is:
(1) an error which causes the resident discomfort or jeopardizes the resident’s health or safety; or
(2) medication from a category that usually requires the medication in the resident’s blood to be titrated to a specific blood level and a single medication error could alter that level and precipitate a reoccurrence of symptoms or toxicity.
C. All medications are administered as prescribed. An incident report or medication error report must be filed for any medication error that occurs. Any significant medication errors or resident reactions must be reported to the physician or the physician’s designee and the resident or the resident’s legal guardian or designated representative and an explanation must be made in the resident’s clinical record.

Knowing that there should not have a medication rate above 5%, the 18% referenced by this story is shown to be grossly negligent. Medication errors usually occur when there is a shortage of well qualified and trained nursing home staff.

Augustana Chapel View Apartments
February 10, 2010

Hopkins Health Care Aide was Terminated for Stealing from Resident

A home health aide at the Augustana Chapel View Apartments had stolen from a resident by paying about $1000.00 of bills with the resident’s checks. According to a story in the Star Tribune the aide was terminated was fired less than two months after being accused of theft. The newsstory went on to explain how in another facility owned by Augustana Care Corp., of Minneapolis, a home-care aide took OxyContin narcotic pain medicine from a resident and replaced it with Ibuprofen, according to a state investigator.

As an attorney that handles abuse and neglect cases in Minnesota I have seen many forms of criminal activity. Unfortunately, there are situations where a resident in a nursing home or other type of senior care facility is taken advantage of and financially exploited.

For the rest of the Star and Tribune article title: Health aide stole from Hopkins care patient.

To reduce the risk of financial exploitation you may want to:

• Conducting background checks on any individual who is handling the senior’s finances, or comes into senior’s home.
• Keep valuables in safety deposit box at bank or other safe place if possible.
• Keep copies of bills and receipts for expenses.
• Request regular accounting concerning any expenditures with copies of paid bills.
• Report suspected abuse to police, friend and family.

If you or a family member has been the victim of financial exploitation or any other type of abuse or neglect in a nursing home or other health care residence, please contact attorney Kenneth LaBore for a free consultation.

St. Anthony Health Center, February 11, 2010

According to a Star Tribune article dated February 11, 2010 a St. Anthony nursing home resident was injured when she fell from her bed moments after a nursing assistant left the woman’s side with various safety precautions not in place, and the woman’s condition worsened until her death four days later.
Apparently, state health investigators cited the unnamed aide for neglect. The fall occurred Oct. 7 at St. Anthony Health Center, causing a hematoma on the woman’s forehead, the Department of Health investigative report said. Soon after she fell, the woman was “very drowsy” with weakness in her limbs, followed by unresponsiveness and difficulty breathing.

With “significant physical status changes,” according to the report, the woman was admitted to hospice care and died Oct. 11th. The nursing assistant was suspended one day after the woman fell and fired the day after the resident died, having admitted the neglect, according to the news report.

Apparently, the aide was caring for the woman when another resident’s sensor alarm beeped. The employee left the woman unattended and “without her safety precautions in place” to care for the other resident. A nurse found the woman on the floor in her room. At the time the woman fell, according to the report, the resident’s sensor alarm was not set, the bed was not in the lowered position and a floor mat was not next to the bed. All were required precautions outlined in the woman’s care plan.

For the rest of the story, An aide left the resident without the ordered safety precautions just before she fell.

If you or a loved one has suffered an injury from neglect or abuse in a nursing home or other care facility that serves the elderly in Minnesota please contact our firm for a free consultation and information regarding the obligations of the facility and your rights as a resident or concerned family member. To contact Attorney Kenneth L. LaBore, directly please send an email to Klabore@mnnursinghomeneglect.com, or call Ken at 612-767-7503.”>An aide left the resident without the ordered safety precautions just before she fell.

Crestview Lutheran Home in Columbia Heights, Minnesota
December 4, 2009

There was another article this weekend on nursing home abuse and neglect in the Star Tribune newspaper. The article focused on a nursing home resident from Crest View Lutheran Home in Columbia Heights who was in the facility for short term rehabilitation therapy. The gentleman who was unnamed in the story, had stopped breathing while in the 24/7 care facility yet no attempts were made to resuscitate him. According to the Minnesota Department of Health investigative report the LPN and the nurse supervisor was not aware that the resident needed be revived and did not have a DNR order. The story goes on to explain that the nurses did not have the necessary training in CPR and did not know where to find the resuscitation equipment even if there was not the confusion on the patient’s orders. After an investigation of the matter the facility was determined to neglected the resident by not acting promptly to try to revive him. For the rest of the Star and Tribune story, State Cites Nursing Home, click here. This is a prime example of the need for qualified and properly trained staff. Unfortunately, the LPN was not properly trained and familiarity with how to find and use the necessary equipment to save the resident’s life. The answer to the “why” there was a lack of adequate staffing and equipment appears to be consistent with many such incidents, financial. Unfortunately, unlike many accidents, this case seems to be avoidable if there was additional training for the staff. This website is not intended to provide legal advice as each situation is different and specific factual information must be obtained before an attorney is able to assess the legal questions relevant to your situation. If you or a loved one has suffered an injury from neglect or abuse in a nursing home or other care facility that serves the elderly in Minnesota please contact our firm for a free consultation and information regarding the obligations of the facility and your rights as a resident or concerned family member. To contact Attorney Kenneth L. LaBore, directly please send an email to KLaBore@mnnursinghomeneglect.com, or call Ken at 612-767-7503.

Kenneth LaBore is a member or supports the following organizations:

Minnesota Nursing Home Neglect Lawyer

Information About Facilities in the News

Resources for Resident’s and Family of Nursing Homes – Long Term Care Facilities