According to the Minnesota Department of Health, Health Regulation Division, under a cooperative agreement with the Centers for Medicare and Medicaid (CMS), is responsible for ensuring that facilities accepting Medicare and Medicaid payment for services provided to program beneficiaries meet federal regulations and certification rules.
The surveys evaluate the quality of care and services provided, as well as the appropriateness of the facility’s building, equipment, staffing, policies, procedures and finances. They are a snapshot of the facility’s performance at the point in time when the survey is conducted.
Call Attorney Kenneth LaBore to Discuss Nursing Home Survey Findings
If you have concerns about the results of state surveys or nursing home or assisted living elder abuse and neglect injuries and you are interested in a free consultation to discuss your case call Kenneth LaBore at 612-743-9048 or toll free at 1-888-452-6589 or by email at KLaBore@MNnursinghomeneglect.com. Mr. LaBore can also be reached at 1-888-452-6569. There is no fee charged unless there is a verdict or settlement offered by wrongdoer.
Disclaimer
Survey Findings was last modified: November 24th, 2019 by Kenneth LaBore
Nursing homes cannot seek pre-dispute arbitration agreement as condition for admission. Pursuant to federal regulations 42 CFR 483.70(n), binding arbitration agreements. (1) A facility must not enter into a pre-dispute agreement for binding arbitration with any resident or resident’s representative nor require that a resident sign an arbitration agreement as a condition of admission to the LTC facility.
Nursing homes attempt to get arbitration agreements many of which limit the rights of person who is injured or even killed due to the neglect of the facility. Anything that limits your rights is not a good idea and a really bad idea if it reduces the exposure to the owners of the facility for mistakes made during resident cares. The arbitration agreement acts as a disincentive to provide the highest quality of care, supervision and services practicable.
Arbitration agreements usually do not allow you to litigate your case to a jury and may limit the parties that can hear the dispute. There is an inherent conflict in a system where the same arbitration association hears all the disputes for the nursing home since they deal with the injured plaintiff only once but are selected by the nursing home in every case in the arbitration agreement. If the arbitration awards go against the facility they can simply decide to choose another company to hear the disputes, this could make the arbitration association or arbitrators they use dependent on facility awards, hence creating a bias to a party which is supposed to be neutral.
Here are the Conditions When There Are Signed Arbitration Agreements
Pursuant to 42 CFR 483.70(n)(2), if, after a dispute between the facility and a resident arises, and a facility chooses to ask a resident or his or her representative to enter into an agreement for binding arbitration, the facility must comply with all of the requirements in this section.
(i) The facility must ensure that:
(A) The agreement is explained to the resident and their representative in a form and manner that he or she understands, including in a language the resident and their representative understands, and
(B) The resident acknowledges that he or she understands the agreement.
(ii) The agreement must:
(A) Be entered into by the resident voluntarily.
(B) Provide for the selection of a neutral arbitrator agreed upon by both parties.
(C) Provide for selection of a venue convenient to both parties.
(iii) A resident’s continuing right to remain in the facility must not be contingent upon the resident or the resident’s representative signing a binding arbitration agreement.
(iv) The agreement must not contain any language that prohibits or discourages the resident or anyone else from communicating with federal, state, or local officials, including but not limited to, federal and state surveyors, other federal or state health department employees, and representatives of the Office of the State Long-Term Care Ombudsman, in accordance with §483.10(k).
(v) The agreement may be signed by another individual if:
(A) Allowed by state law;
(B) All of the requirements in this section are met; and
(C) That individual has no interest in the facility.
(vi) When the facility and a resident resolve a dispute with arbitration, a copy of the signed agreement for binding arbitration and the arbitrator’s final decision must be retained by the facility for 5 years and be available for inspection upon request by CMS or its designee.
Contact Attorney Kenneth LaBore Before of After Signed Arbitration Agreements
It is best to have a lawyer review any agreement, especially a nursing home arbitration agreement before the resident or their legal representative signs, however if there is an injury contact an elder abuse attorney to review the contract before agreeing to terms as well. There are requirements in the law that may effect the enforceability of all or part of the arbitration agreement and there are situations where you may be able to contest the agreement or some of its terms.
If you have questions about your rights and an arbitration agreement or to discuss a nursing home injury call Kenneth L. LaBore for a free consultation at 612-743-9048 or 1-888-452-6589 or by email at KLaBore@MNnursinghomeneglect.com.
Disclaimer
Nursing Home Arbitration Agreements was last modified: February 5th, 2017 by Kenneth LaBore
There are many ways that residents suffer nursing home injuries, many are falls, being dropped from lifts or injured in transfer, falls from the toilet or in the shower, fall from bed or out of a wheelchair. Since the way that many injuries happen is foreseeable the facility has an obligation to analysis and assess the risks to each resident and take reasonable measures and interventions to protect them from preventable accident situations.
According to 42 CFR 483.25, nursing homes must take efforts to prevent accidents which would include falls, medication errors, or any other way you could be injured such as through the use of oxygen, smoking, scalding burns, urinary tract infections, pressure wounds and others set out in the statute.
Common Types of Nursing Home Injuries
Here are some summaries on various topics related to nursing home falls and fractures, pressure sores and other nursing home injuries:
If you or someone you love is in a skilled nursing facility or nursing home and the victim of abuse or neglect injuries contact Attorney Kenneth LaBore for a free consultation to discuss the fall or injuries and he does not charge a fee unless there is a verdict or settlement offer with the wrongdoer. Call Kenneth LaBore at 612-743-9048 or toll free at 1-888-452-6589 or send an email to KLaBore@MNnursinghomeneglect.com.
Disclaimer
Nursing Home Injuries was last modified: February 5th, 2017 by Kenneth LaBore
Assisted living facilities deal with people with cognitive deficiencies with a wide range of abilities and risks for each resident. Some residents are very mobile and active and other need assistance with transfer and other activities of daily living.
Despite the fact that many assisted living care providers charge more for a room and care than a nursing home there is a trade off you are getting a nicer room and usually newer more luxurious dining room and other areas but there very little training required to be a staff member in the facility.
According to Minnesota Statute 144G.03, Subd. 2, assisted living shall be provided or made available only to individuals residing in a registered housing with services establishment. Except as expressly stated in this chapter, a person or entity offering assisted living may define the available services and may offer assisted living to all or some of the residents of a housing with services establishment. The services that comprise assisted living may be provided or made available directly by a housing with services establishment or by persons or entities with which the housing with services establishment has made arrangements.
(b) A person or entity entitled to use the phrase “assisted living,” according to section 144G.02, subdivision 1, shall do so only with respect to a housing with services establishment, or a service, service package, or program available within a housing with services establishment that, at a minimum:
(1) provides or makes available health-related services under a home care license. At a minimum, health-related services must include:
(i) assistance with self-administration of medication, medication management, or medication administration as defined in section 144A.43; and
(ii) assistance with at least three of the following seven activities of daily living: bathing, dressing, grooming, eating, transferring, continence care, and toileting.
All health-related services shall be provided in a manner that complies with applicable home care licensure requirements in chapter 144A and sections 148.171 to 148.285;
(2) provides necessary assessments of the physical and cognitive needs of assisted living clients by a registered nurse, as required by applicable home care licensure requirements in chapter 144A and sections 148.171 to 148.285;
(3) has and maintains a system for delegation of health care activities to unlicensed personnel by a registered nurse, including supervision and evaluation of the delegated activities as required by applicable home care licensure requirements in chapter 144A and sections 148.171 to 148.285;
(4) provides staff access to an on-call registered nurse 24 hours per day, seven days per week;
(5) has and maintains a system to check on each assisted living client at least daily;
(6) provides a means for assisted living clients to request assistance for health and safety needs 24 hours per day, seven days per week, from the establishment or a person or entity with which the establishment has made arrangements;
(7) has a person or persons available 24 hours per day, seven days per week, who is responsible for responding to the requests of assisted living clients for assistance with health or safety needs, who shall be:
(i) awake;
(ii) located in the same building, in an attached building, or on a contiguous campus with the housing with services establishment in order to respond within a reasonable amount of time;
(iii) capable of communicating with assisted living clients;
(iv) capable of recognizing the need for assistance;
(v) capable of providing either the assistance required or summoning the appropriate assistance; and
(vi) capable of following directions;
(8) offers to provide or make available at least the following supportive services to assisted living clients:
(i) two meals per day;
(ii) weekly housekeeping;
(iii) weekly laundry service;
(iv) upon the request of the client, reasonable assistance with arranging for transportation to medical and social services appointments, and the name of or other identifying information about the person or persons responsible for providing this assistance;
(v) upon the request of the client, reasonable assistance with accessing community resources and social services available in the community, and the name of or other identifying information about the person or persons responsible for providing this assistance; and
(vi) periodic opportunities for socialization; and
(9) makes available to all prospective and current assisted living clients information consistent with the uniform format and the required components adopted by the commissioner under section 144G.06. This information must be made available beginning no later than six months after the commissioner makes the uniform format and required components available to providers according to section 144G.06.
Assisted Living Assault by Other Residents
Due to medications and perception issues such as hearing and vision, perhaps a change in environment or other difficulties persons in elder care facilities especially those with Alzheimer’s and dementia may get anxious and irritable and strike out at staff and other residents. Or the assault may be in the form of inappropriate sexual contact or verbal abuse from residents who have lost some of their social filters. Assisted living facilities have an obligation to keep residents safe and to supervise the other residents with the goal of as little confrontation as possible. This may involve separating residents that are a risk to others and perhaps discharging them to a facility with more supervision if there is a risk to fellow residents.
Assisted Living Assault by Staff Members
There are also of course situations where staff members take advantage of the fact that resident’s may be confusion or have other cognitive issues that make them very vulnerable to sexual assault. Staff members should have background checks to limit the ability of persons with a known history to have contact with the residents. However, the backgrounds are not always performed in a timely manner, or there are new criminal issues that show up once the staff member is hired, or the report is missing key information from other states or countries. Then there are the staff that had never been caught abusing before but lacked the supervision of the staff and their actions which fostered an environment for those with a propensity to attempt abuse.
Residents need to be properly assessed, and then the staff needs to be well trained then supervised by protective management to assure the safety of all the residents. Minnesota is a one person consent video state which means that you can place a hidden camera in the room of a resident. The room in an assisted living facility is a private space just like an apartment in any other building and the resident can have a hidden camera if the resident and/or their legal representative consents to the recording.
(1) any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed health care provider;
(2) abduction of a patient of any age;
(3) sexual assault on a patient within or on the grounds of a facility; and
(4) death or serious injury of a patient or staff member resulting from a physical assault that occurs within or on the grounds of a facility.
In addition to the reporting requirements for the facility you should also report any sexual or physical abuse to the local police department and the Minnesota Department of Health Office of Health Facility Complaints, OHFC. See the attached for more information about reporting elder abuse and neglect.
Assisted Living Assault Attorney
If you have questions about physical abuse or assualt in a assisted living facility or other elder provider or nursing home or other elder abuse and neglect issues contact Kenneth LaBore for a free consultation. There is no fee unless there is a verdict or settlement offer from the wrongdoer. Mr. LaBore can be reached directly at 612-743-9048 or toll free at 1-888-452-6589 or by email at KLaBore@MNnursinghomeneglect.com.
Disclaimer
Assisted Living Assault was last modified: February 5th, 2017 by Kenneth LaBore
Due to the fact that many of the residents have Alzheimer’s or dementia memory care assault is a real risk that needs to be addressed. Well trained staff who know how to redirect residents who are upset and separate those who are a risk from others, is a key to reducing the environment which leads to aggravated interactions.
Even though a memory care facility may charge more per month than other types of elder care providers including nursing homes, the staff is not generally well trained and they are not there to provide medical care unless they are coming in to see a resident as contracted services.
According to Minnesota Statute 144D.065 (a)(2),direct-care employees must have completed at least eight hours of initial training on topics specified under paragraph (b) within 160 working hours of the employment start date. The specialized training under paragraph (b) includes:
(b) Areas of required training include:
(1) an explanation of Alzheimer’s disease and related disorders;
(2) assistance with activities of daily living;
(3) problem solving with challenging behaviors; and
(4) communication skills.
As you can see the training for specialized memory care staff is very limited and does not include any medical training what-so-ever. The lack of training with many resident which have limited mobility and other medical and physical issues leads to many forms of preventable situations including assault to vulnerable residents from other residents and unfortunately sometimes staff.
Memory Care Assault by Other Residents
Due to problems with confusion and cognitive issues related to Alzheimer’s or dementia or medications, loss of vision or hearing or some other reason, residents can become agitated and irritated with each other and if not properly supervised and controlled there can be assaults some leading to serious falls, and other injuries such as head injuries with subdural hematomas.
Memory Care Assault by Staff Members
There are unfortunately situations where staff members lose control of their temper and inappropriately let their frustration on staffing issue or personal problems out on the residents dependent on their assistance and supervision. There is no excuse for elder abuse ever. Management has to take all reasonable measures to protect the safety of residents from abuse by staff including background checks of the staff, training on Alzheimer’s and dementia and issues related to providing care to those with cognitive issues. There should be a climate in the organization to treat all the clients with respect and dignity and to report any concerns about abuse to residents from staff or other residents to management and the department of health.
Minnesota is a one person consent video state which means that you can place a hidden camera in the room of a resident. The room is a private space just like an apartment in any other building and the resident can have a hidden camera if the resident and/or their legal representative consents to the recording.
(1) any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed health care provider;
(2) abduction of a patient of any age;
(3) sexual assault on a patient within or on the grounds of a facility; and
(4) death or serious injury of a patient or staff member resulting from a physical assault that occurs within or on the grounds of a facility.
In addition to the reporting requirements for the facility you should also report any physical abuse to the local police department and the Minnesota Department of Health Office of Health Facility Complaint, OHFC. See the attached for more information about reporting elder abuse and neglect.
If you have questions about physical assault or abuse in a memory care facility or other elder provider or nursing home or other elder abuse and neglect issues contact Kenneth LaBore for a free consultation. There is no fee unless there is a verdict or settlement offer from the wrongdoer. Mr. LaBore can be reached directly at 612-743-9048 or toll free at 1-888-452-6589 or by email at KLaBore@MNnursinghomeneglect.com.
Disclaimer
Memory Care Assault was last modified: February 4th, 2017 by Kenneth LaBore
Memory Care Falls Result in Part Due to Lack of Training
Falls in memory care and other elder care facilities are common occurrences. The resident’s usually have Alzheimer’s or dementia and are prone to confusion and many are able to ambulate which leads to a higher risk of falls. Due to osteoporosis and other age related issues falls lead to very serious many leading to death. The irony is that despite the lack of regulation and training many memory care providers charge premium prices and often exceed the expense for rehabilitative care and skilled nursing in a traditional nursing home.
You may think that many memory care providers are providing cares similar to a nursing home. This assumption is reasonable when you seen literature talking about “nursing services in a home like environment”. What this means is that you are renting an apartment or room and that you are subcontracting for home care services to be provided at that location. The staff at the memory care provider needs no special credentials as they are not considered nursing aides. They need only limited training and the limited disclosures to tenant families. According to Minnesota Statute 325F.72. Written disclosure shall include, but is not limited to the following:
(1) a statement of the overall philosophy and how it reflects the special needs of residents with Alzheimer’s disease or other dementias;
(2) the criteria for determining who may reside in the special care unit;
(3) the process used for assessment and establishment of the service plan or agreement, including how the plan is responsive to changes in the resident’s condition;
(4) staffing credentials, job descriptions, and staff duties and availability, including any training specific to dementia;
(5) physical environment as well as design and security features that specifically address the needs of residents with Alzheimer’s disease or other dementias;
(6) frequency and type of programs and activities for residents of the special care unit;
(7) involvement of families in resident care and availability of family support programs;
(8) fee schedules for additional services to the residents of the special care unit; and
(9) a statement that residents will be given a written notice 30 days prior to changes in the fee schedule.
According to Minnesota Statute 144D.065 (a)(2),direct-care employees must have completed at least eight hours of initial training on topics specified under paragraph (b) within 160 working hours of the employment start date. The specialized training under paragraph (b) includes:
(b) Areas of required training include:
(1) an explanation of Alzheimer’s disease and related disorders;
(2) assistance with activities of daily living;
(3) problem solving with challenging behaviors; and
(4) communication skills.
As you can see the training for specialized memory care staff is very limited and does not include any medical training what-so-ever. The lack of training with many resident which have limited mobility and other medical and physical issues leads to many forms of preventable injuries including falls.
Memory Care Falls
There are many types of falls which occur in memory care facilities. The residents need to be supervised to assure they do not wander or elope from the facility, fall down stairwells, slip out of chairs or wheelchairs, fall from beds or in the bathroom off the toilet or in the shower.
Pursuant to Minnesota Statute 144.7065, Subd. 1., each facility shall report to the commissioner the occurrence of any of the adverse health care events described in subdivisions 2 to 7 as soon as is reasonably and practically possible, but no later than 15 working days after discovery of the event. The report shall be filed in a format specified by the commissioner and shall identify the facility but shall not include any identifying information for any of the health care professionals, facility employees, or patients involved. The commissioner may consult with experts and organizations familiar with patient safety when developing the format for reporting and in further defining events in order to be consistent with industry standards.
The statute goes on in Subd. 5, to state that it is required for the facility to report patient death or serious injury associated with a fall while being cared for in a facility.
Attorney for Memory Care Falls
If you have questions about fall injuries or other forms nursing home abuse and neglect contact Kenneth LaBore for a free consultation. There is no fee unless there is a verdict or settlement offer from the wrongdoer. Mr. LaBore can be reached directly at 612-743-9048 or toll free at 1-888-452-6589 or by email at KLaBore@MNnursinghomeneglect.com.
Disclaimer
Memory Care Falls was last modified: February 4th, 2017 by Kenneth LaBore
Selecting an elder care facility is a difficult and import decision. The resident or family member needs to consider many factors including the location, costs, payment sources such as Medicaid and Minnesota Elder Waiver, and probably most importantly the care needs of the resident and the services offered by the provider.
Another important issue is to consider the quality of care the potential nursing home, assisted living, memory care provider, home care provider, group home or other care or service provider focused on elder and vulnerable adult clients.
Additional Resources for Selecting and Elder Care Facility
Finally, The Center for Medicare Medicaid Services, CMS, Offers a Nursing Home Selection Checklist covering many important care and service related issues before choosing a facility.
For more information from the Minnesota Department of Health, Office of Health Facility Complaints concerning nursing homes, assisted living and other elder care providers view resolved complaints at the MDH website.
Summaries of Issues Related to Elder Abuse and Neglect
Nursing Home Elder Abuse and Neglect Topic Summaries
The following are issues related to finding a nursing home and prevention of elder abuse and neglect, related state and federal regulations as well as ways to research and get information about facilities and providers and types of injuries often suffered by residents who do not receive proper care.
For more information about elder abuse or questions on how to hold negligent care providers accountable call attorney Kenneth LaBore at 612-743-9048 for a free consultation or by email at KLaBore@MNnursinghomeneglect.com. There is no fee unless a verdict or settlement with the wrongdoer.
You can investigate on the State of Minnesota website, including the quality of care provided at nursing homes and assisted living facilities with information on recent surveys and complaints against facilities.
Elder abuse and neglect comes in many forms but all are preventable. Many of the most serious injuries or deaths are due to situations where there is a lack of supervision by the staff, a lack of training of staff, the improper use of medical equipment, or medication errors. Unfortunately physical assaults and sexual abuse are also serious issues for vulnerable adults in elder care facilities. Sufficient numbers of well trained caring staff is the best way to reduce the chance of injuries to seniors.
Disclaimer
Elder Abuse and Neglect Summaries was last modified: January 2nd, 2020 by Kenneth LaBore
Information About Reporting Elder Abuse and Neglect
Reporting Suspected Neglect of Nursing Home Residents
Minnesota law mandates safe environments and services for vulnerable adults and protective services for vulnerable adults who have been maltreated. The DHS Adult Protective Services Unit provides training and consultation to citizens, service providers, counties, law enforcement and state agencies regarding the Minnesota Vulnerable Adult Act [Minnesota Statute Section 626.557 (1995)]. The unit also develops policy and best practices and collects and evaluates data to prevent maltreatment and plan adult protection services.
According to Minnesota Statute 626.5772, Subd. 2,“abuse” can include many things, including: an act against a vulnerable adult that constitutes a violation of, an attempt to violate, or aiding and abetting a violation of an assault, the use of drugs to injure or facilitate crime, the solicitation, inducement, and promotion of prostitution, criminal sexual conduct as well as, the act of forcing, compelling, coercing, or enticing a vulnerable adult against the vulnerable adult’s will to perform services for the advantage of another.
According to NAPSA, if you witness a life-threatening situation involving a senior or adult with disabilities, dial 911. Contact your local Adult Protective Services agency anytime you observe or suspect the following:
Sudden inability to meet essential physical, psychological or social needs which threatens health, safety or well-being
Disappearing from contact with neighbors, friends or family
Appearing hungry, malnourished, or with a sudden weight loss
Appearing disoriented or confused
Suddenly appearing disheveled or wearing soiled clothing
Failing by caregiver(s) to arrive as scheduled — or disappearing without notice
Expressing feelings of hopelessness, worthlessness or insignificance
Failing to take prescribed medications or nutritional supplements
Blaming self for problems arising with family or caregivers
Living in squalor or hazardous situations such as hoarding or cluttering
Minnesota Elder Neglect and Abuse Reporting System
Minnesota has a new central system for reporting suspected maltreatment of vulnerable adults, through a common entry point available 24/7 at 1-844-880-1574 a toll free phone number for the general public.
This Adult Protection website offers information on how to report abuse and neglect in many different languages.
Reporting Abuse Requirements for Mandated Reporters
Mandated reporters include law enforcement, educators, doctors, nurses, social workers and other licensed professionals. Pursuant to Minnesota Statute 626.5772, Subd. 16.,”mandated reporter” means a professional or professional’s delegate while engaged in: (1) social services; (2) law enforcement; (3) education; (4) the care of vulnerable adults; (5) any of the occupations referred to in section 214.01, subdivision 2; (6) an employee of a rehabilitation facility certified by the commissioner of jobs and training for vocational rehabilitation; (7) an employee or person providing services in a facility as defined in subdivision 6; or (8) a person that performs the duties of the medical examiner or coroner.
Mandated reporters reporting an allegation of suspected maltreatment of a vulnerable adult that did not occur in Minnesota must make the report to the state in which the allegation occurred. The National Adult Protective Services Association has information for reporting in all states.
Click Here For Link To Report Abuse To Adult Protection
Chris Jensen Health and Rehabilitation Center is Placed on Medicare Special Focus Facility Initiative List
Information About Chris Jensen Health and Rehabilitation Center
Name: CHRIS JENSEN HLTH & REHAB CTR
Address: 2501 RICE LAKE ROAD
DULUTH, MN 55811
Phone: 218-625-6400 Fax: 218-625-6452
Administrator: MS. AMY PORTER
Minnesota Licensed Bed Capacity: (Nursing Home Beds = 170)
Federally Certified Beds: (Dual Medicare/Medicaid Skilled Nursing and Nursing Facility Beds = 170)
Chris Jensen Health and Rehab Center Survey Results
Results from a survey dated May 12, 2016, indicated that Chris Jensen Health and Rehabilitation Center in Duluth Minnesota had deficiencies which were severe enough to place them on dubious list of special focus facility list of nursing homes with high numbers of serious deficiencies.
On April 7, 2016, the Minnesota Department of Health completed a Post Certification Revisit (PCR) and on April 5, 2016, the Minnesota Department of Public Safety completed a PCR to verify that the facility had achieved and maintained compliance with federal certification deficiencies issued pursuant to an extended survey, completed on February 10, 2016. The MDH presumed, based on their plan of correction, that the facility had corrected these deficiencies as of March 29, 2016. Based the visit, it was determined that your Chris Jensen Health and Rehabilitation Center has not obtained substantial compliance with the deficiencies issued pursuant to our extended survey, completed on February 10, 2016. The deficiencies not corrected are as follows:
The most serious deficiencies in the facility were found to be isolated deficiencies that constituted actual harm that was not immediate jeopardy (Level G), as evidenced by the attached CMS-2567, whereby corrections were required.
As a result of the revisit findings, the Category 1 remedy of state monitoring remained in effect.
In addition, this Department recommended to the CMS Region V Office the following actions related to the imposed remedies in their letter of March 7, 2016:
Discretionary denial of payment for all Medicare and Medicaid admissions effective April 10, 2016, remain in effect.
For more information from the Minnesota Department of Health, inspection surveys and reports, website, which usually has the most recent survey and the one taken before that.
Chris Jensen Health and Rehab Center on CMS Special Focus Facility List Due to High Number of Deficiencies in Quality of Care was last modified: February 21st, 2019 by Kenneth LaBore
