Rochester Minnesota Nursing Home Abuse Lawyer - Part 2

400 15th Avenue Southwest
Austin, Minnesota 55912
(507) 437-4594

A “Not for Profit” 61-certified bed Medicaid/Medicare-participating facility

Overall Rating – 2 out of 5 possible stars

2 stars rating

Primary Concerns –

Failure to Provide Proper Treatment and Care to Prevent the Development of a New Bedsore or Allow an Existing Bedsore to Heal That Results in Actual Harm

In a summary statement of deficiencies dated 10/02/2015, a state surveyor made a notation during an annual licensure and certification survey concerning the facility’s failure to “implement interventions, including repositioning and toileting, based on the comprehensive assessment for [a resident at the facility] who had a current pressure ulcer.” The deficient practice by the nursing staff at St. Mark’s Lutheran Home “resulted in harm for [the resident] who had a Stage III (Stage III – full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) pressure ulcer.”

The state investigator reviewed a resident’s Quarterly MDS (Minimum Data Set) indicating that the resident “had severe cognitive impairment, required extensive two-person physical assist with bed mobility and transfer, and had a Stage III pressure ulcer. In addition, [the resident’s] Quarterly MDS (Minimum Data Set) indicated [that the resident] was not able to fully reposition self in bed or in a wheelchair.”

The deficient practice was noted by state surveyor in regards to action by Registered Nurse on 10/02/2015 who “removed an old Duoderm dressing (an opaque dressing for wounds) which covered the Stage II pressure ulcer located on the coccyx and it was reddened around edges, open ulcer and approximately 3.5 centimeters by 2.0 centimeters in size.”

While providing care to the resident, the Registered Nurse “treated the wound with topical medication and a Duoderm dressing to [the resident’s] coccyx.” The investigator reviewed the Facility’s Weekly Ulcer/Complex One Observation Tool form that showed that beginning on 08/15/2015, the resident’s Coccyx Stage III pressure ulcer measured 0.5 centimeters by 0.5 centimeters and was “blanchable with no pain noted on the skin assessment form.” By 09/02/2015 [17 days later] the pressure ulcer had increased in size to 2.0 centimeters by 1.0 centimeters.” Eight days later on 09/09/2015, the resident’s Stage III coccyx pressure ulcer had again grown in size and now measured 3.0 centimeters by 0.7 centimeters. By the end of the month on 09/30/2015, the coccyx pressure sore measured 1.0 centimeters by 0.3 centimeters, but was still considered a Stage III wound.

The investigator reviewed the resident’s 09/09/2015 Care Plan that identified “skincare/pressure ulcer risk and included the intervention of pressure reducing mattress and wheelchair cushion, gentle perineal cares and strict every two-hour repositioning sitting and laying.”

However, at 1:32 PM on 10/02/2015, the nursing assistant providing the resident care was interviewed and asked if the resident “had been repositioned, which included offloading (removing pressure to the buttocks area for at least two minutes), since her transfer to the wheelchair at 8:04 AM and prior to her transfer back to bed just before 1:00 PM.” The nursing assistant replied, “No, she hasn’t. Sometimes we just put her in her recliner and sometimes we just leave her in her wheelchair all morning to watch TV (television). Today was a typical day.”

A few minutes later, at 1:45 PM another nursing assistant who assist the resident with cares during the day shift stated, “Normally, you work on your own group (each nursing assistant has an assigned group of residents to provide care and services for during their shift), and after lunch we lay everyone down. No, I did not reposition her [the resident] since we got her into her wheelchair this morning.”

During these interviews, both nursing assistants “were asked about [the resident’s] care plan for repositioning.” The second nursing assistant stated, “I think she is every two hours. I don’t know with her wound if she is currently one or two. On our Point Click Care Tab Computer Program, it is every two hours to reposition.” The first nursing assistant added, “sometimes it just gets crazy and we don’t get to it.”

That following afternoon at 2:41 PM, the state investigator conducted an interview with the facility’s Director of Nursing who stated “The expectation is that the Care Plan is followed. If staff are unsure of what it is they need to ask the Charge Nurse, Nurse Manager or myself.” The Director of Nursing also added that “if a resident is to be repositioned every two hours they should be repositioned within that time frame.”

Our Austin nursing home neglect attorneys recognize it failing to provide care according to the resident’s Care Plan when treating a resident with pressure ulcers could place their life in Immediate Jeopardy. The deficient practice by the nursing staff at St. Mark’s Lutheran Home could be considered negligence or mistreatment because their actions fail to follow the facility’s September 2013 policy title: Pressure Ulcer Treatment that defines the seriousness of a Stage III pressure ulcer. The policy reads in part:

“Stage III pressure ulcer is defined [as] full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.”

906 College Avenue
Red Wing, Minnesota 55066
(651) 385-3434

A “Not for Profit” 84-certified bed Medicaid/Medicare-participating facility

Overall Rating – 2 out of 5 possible stars

2 stars rating

Primary Concerns –

Failure to Provide Adequate Services and Care to Ensure That the Resident Maintains Their Highest Well-Being

In a summary statement of deficiencies dated 04/23/2015, a notation was made during an annual licensure and certification survey by a state investigator concerning the facility’s failure to “incorporate fluid restrictions and resident’s noncompliance related to fluid restriction.”

The state investigator reviewed the resident’s Care Plan the review of the resident “was cognitively intact” but had an ordered fluid restriction due to their medical condition.

The deficient practice was noted by state investigator after reviewing a resident’s medical records noting that the resident was admitted with end-stage renal disease and receiving treatment three times every week. After he returned from the hospital on 05/22/2014, the resident began receiving that medical treatment for times a week.

The state investigator conducted an interview and observation of the resident at 1:49 PM on 04/22/2015 revealing of the resident “was in their room resting in bed.” And observation of the room noted, “at the bedside was an empty bottle of water; a large (approximately 20 ounce) empty Styrofoam water container, to other Styrofoam pictures, the same size, and a blue insulated water container (holding approximately 12 ounces) which was full.”

The investigator noted that the resident said: “I know exactly how much fluid I can have, but sometimes I do like more.” The resident also stated, “on my food tray I usually get water, coffee and juice […and] explained that the empty bottle was used to water the plants in the empty Styrofoam containers were from several days ago.”

However, a review of the resident’s physician’s orders indicated that “no water pitcher at the bedside.”

The investigator also reviewed the resident’s 03/30/2015 Plan of Care that indicates “1700 cc fluid restriction and ice water at the bedside. Staff to monitor and record food/fluid intake. The Plan of Care did not indicate how much fluid could be consumed at meals and in between meals to maintain the 1700 cc amount.”

A review of the resident’s Nutritional Risk Assessment identified the resident “as being noncompliant with fluid restrictions and that risks/benefits had been explained, however, the Plan of Care did not address the behaviors of non-compliance with fluid restrictions and the risks/benefits explained to the resident.”

The state investigator noted the resident’s Fluid Intake Record documenting fluid intake between 04/08/2015 and 04/22/2015 indicated that the resident “was taking anywhere from 220 ccs to 1140 cc of liquid at the meals. Each shift documented the amount of fluid consumed in between meals however, no calculated amount was identified to keep [the resident] within the 1700 cc restriction.” An interview was conducted at 1:59 AM on 04/22/2015 with the facility’s Culinary Service Assistant Director who indicated that staff “passed out the water pitchers and [the resident] does have a small insulated water container at the bedside. For meals, [the resident] is to receive 10 ounces of liquid per meal, however, if [the resident] asks for more the staff will give it. She was unaware of the physician’s orders.”

An interview was conducted at 2:28 PM the same day what the facility’s Nurse Manager who “indicated the water pitcher at [the resident’s] bedside is a smaller one and it is part of what [the resident] consumes.” That Registered Nurse also “was not aware of the physician’s orders […and] agree the documentation of fluid intake was not being done correctly so the staff was unaware of how much the resident was actually consuming.” The Registered Nurse also “agreed the Plan of Care was not up to date, regarding [the resident’s] behaviors and refusals to abide by the restriction.”

The state investigator conducted a 7:24 AM 04/22/2015 interview with the facility’s Director of Nursing who “indicated monitoring of food and fluids may be a problem because ‘I don’t think it’s getting done correctly’.”

Our Red Wing nursing home neglect attorneys recognize it failing to follow physician’s orders involving a restriction of the intake of fluids could place the health and well-being of the resident in immediate jeopardy. The deficient practice by the nursing staff at seminary home might be considered negligence or mistreatment because it fails to follow specific protocols and procedures when providing care to residents suffering chronic kidney disease (CKD). This is because:

“Normal amounts of fluid can build up in the body and be dangerous […and] cause swelling and increase blood pressure [… making the] heart work harder. Too much fluid can build up in the lungs, making it difficult to breathe.” – Davita[i]

1412 West Fourth Street
Red Wing, Minnesota 55066
(651) 385-4800

A “For-Profit” 145-certified bed Medicaid/Medicare-participating facility

Overall Rating – 1 out of 5 possible stars

1 star rating

Primary Concerns –

Failure to Follow Procedures and Protocols and Reporting and Investigating Any Act or Alleged Act of Abuse, Neglect or Mistreatment of Residents

In a summary statement of deficiencies dated 05/21/2015, a state surveyor made a notation during an annual licensure and certification survey concerning the facility’s failure to “investigate allegations of potential mistreatment for [a resident at the facility] who had reported to the facility staff possible neglect of care.”

The deficient practice was noted by state investigator after a review of a resident’s electronic health record That revealing the resident’s 04/21/2015 Brief Interview for Mental Status (BIMS) revealing the resident “scored 14 out of 15 indicating the resident “was cognitively intact.”

In addition, the resident’s 08/12/2013 Care Plan revealed that the resident “was able to reliably recognize a dangerous situation, but cannot remove myself to safety in a dangerous situation, I would need staff to assist me to safety.”

The state investigator also reviewed the resident’s Quarterly MDS (Minimum Data Set) revealing that the resident “was always incontinent of urine and required an extensive assistance of one staff for grooming and toileting.”

The resident was interviewed by the state investigator 11:37 AM on May’s 18 2015 who revealed that “there were times when the nursing assistant ignored [the resident] by not answering the call light, not assisting the resident and not changing [the resident’s] incontinent product.” The resident stated that the problem had been reported to the Registered Nurse but that the Registered Nurse no longer works at the facility.

Two days later at 11:00 AM on 05/20/2015, the resident again was interviewed about the Registered Nurse mentioned two days previously and how the resident “felt when cared for by [that Registered Nurse.” The resident responded, “not feeling very good and explained that [the Registered Nurse] had not treated him well and [that the Registered Nurse] had an attitude [but] was better than others.” Earlier in the morning at 9:50 AM, the investigator conducted an interview with the facility’s Director of Nurses regarding the resident’s “report of alleged neglect. The [Director of Nurses] reported never hearing of the incident.” A different Registered Nurse was also interviewed a few minutes later at 9:58 AM and reported not recalling speaking with the resident in regards to a failure of providing care to the resident by the Registered Nurse no longer employed there.

Later that morning at 10:30 AM, a nursing assistant stated that about 1.5 months ago, the resident reported to them and another nursing assistant that there was a nursing assistant who ignored the resident and did not do anything for the resident, “ was not caring for the resident properly.” It was noted that the two nursing assistants “immediately wrote everything down that [the resident] had told them and presented the information to [two different Registered Nurses] at the facility.” Since that time, the nursing assistant stated that the resident “seemed happier now is not mentioning any more bad information.”

At 11:04 AM on 05/20/2015, a discussion was conducted with the Registered Nurse who had allegedly received notice of the resident’s alleged neglect issue. that “Registered Nurse stated, ‘I guess I don’t recall that’, and denied having received any written information of the alleged negligent incident.”

A few minutes later 11:20 AM, a different nursing assistant said they had “verbally told [another Registered Nurse] what the resident had verbalized and provided [the Registered Nurse noted above] with the written information.” That nursing assistant “stated the information was brought to the Registered Nurse after [the resident] made a report […and stated that the resident] verbalized wanting to die […and that the resident’s] behavior and attitude changed whenever [the nurse no longer under employment] cared for the resident and explained that [the resident] would report not having a good evening because of having to do things without help, such as self-transferring to bed.”

The investigator interviewed the facility’s Social Worker at 11:25 AM on the same day who stated “not being aware of any possible neglect of care for [that resident, and stated that the resident] had recently seen a psychologist as [they] had been complaining about a new resident in the next room being noisy at night.” The Social Worker stated that the staff felt the resident “did not do well with changes and that seeing the psychologist would be good for the resident, and [the resident] was doing better since having seen the psychologist.”

An interview was conducted with the facility’s Director of Nursing at 11:33 AM on the same day who stated “she had spoken to [both Registered Nurses who] did not recall receiving information from either [nursing assistants in regards to the resident’s] alleged negligent incident.” At 2:00 PM the same day, the Director of Nurses was again interviewed in regards to the [nurse no longer employed]. The Director of Nurses stated that that nurse “had been terminated because of a vulnerable adult incident with a resident. A review of [that nurse’s] personal file revealed that the vulnerable adult incident the Director of Nursing referred to did not involve [this resident] but another resident residing in the facility.”

Our Redwing nursing home abuse attorneys recognize the failing to follow procedures and protocols to report and investigate any act or alleged act of abuse could place the health and well-being of the resident in Immediate Jeopardy. The deficient practice by the nursing staff and Administrator might be considered abuse or mistreatment because their actions failed to follow established procedures and protocols enforced by federal and state nursing regulators.

1635 West Service Drive
Winona, Minnesota 55987
(507) 454-5540

A “Not for Profit” 71-certified bed Medicaid/Medicare-participating facility

Overall Rating – 2 out of 5 possible stars

2 stars rating

Primary Concerns –

Failure to Hire Only Individuals That Have No History of Abuse, Neglect or Mistreatment of Residents and Report and Investigate Any Act or Reported Act of Abuse, Neglect or Mistreatment of Residents

In a summary statement of deficiencies dated 10/15/2015, a notation was made by a state investigator during an annual licensure and certification survey concerning the facility’s failure to “ensure allegations of abuse were reported to the State Agency immediately.” The failure by the nursing staff at Sauer Health Care affected one resident at the facility. This failure also involved not securing “licensure status and previous work history to determine if any concerns with abuse/neglect had occurred for five out of five employees [hired at the facility].” These failures involved the hiring of a Registered Nurse, Licensed Practical Nurse and three nurse’s aides “who worked at the facility and had direct contact with residents.”

The deficient practice was noted by the state surveyor noted a “lack of reporting allegations of abuse immediately to the designated state agency.” One incident at the facility involved a resident reporting “to staff concerning allegations of abuse by the night staff. However, this allegation had not been reported to the designated state agency until two days later.”

As a part of the investigation, the state surveyor reviewed the resident’s Significant Change MDS (Minimum Data Set) that identify the resident “is cognitively intact and requires extensive assistance with all ADL (activities of daily living) … had no behavior.

The investigator noted that “the facility submitted an incident report to the state agency (Office of Health Facility Complaints – OHFC)” after a resident “voiced a concern of night aides CNA (Certified Nursing Aides) staff members” listed by name. The resident also stated that both Certified Nursing Aides “do not provide the care that she requests and are ‘verbally nasty’ to her. When staff asked the resident for more details, the resident stated, ‘I don’t want any trouble. I’m scared it’s going to make it worse for me’.”

Both the Human Resources Director and Director of Nursing “immediately initiated an investigation and [both Certified Nursing Aides] were placed on administrative leave until the investigation is concluded.” Then both Directors “interviewed other residents who confirmed and voiced their own concerns for the care [that both Certified Nursing Aides] provide to them. Other residents stated both aides do not assist with taking them to the bathroom and report feeling intimidated by [both nurses]. The facility policy indicates reports must be made to the State Agency immediately.”

State investigator conducted an interview with the facility’s Administrator and Licensed Social Worker in regards to the resident’s report of alleged abuse. “The Administrator stated she became aware of the incident at the [resident’s] Care Conference […and] said she was filling in for the Licensed Social Worker that week.” The Administrator also indicated that “it was reported that staff had been rough and verbally assaulted the resident.” The Administrator also said “she immediately began to investigate the allegation and didn’t think about reporting the incident to the State Agency. When the Licensed Social Worker returned on Monday, she said she noticed the report to the State Agency had not been completed so she filed a report.”

The investigator reviewed the facility’s Nurse’s Progress Notes that did not reveal any documentation regarding the resident’s allegation of abuse.

The state investigator also noted that the facility had a “lack of thorough pre-hire work history, current licensure and listed on the Nursing Assistant Registry before working directly with residents.” The investigator reviewed hiring the employee records and noted a variety of areas including:

  • A lack of documentation of reference checks being completed before the hire date of a Licensed Practical Nurse at the facility.
  • A lack of documentation of a nursing assistant certification being verified and no reference check being completed before three nursing assistants were

In an interview with the Director of Human Resources, it was revealed that “her normal process is to check for licenses and call references before employee’s hire date and before the license expires.” The Human Resources Director also indicated that “they call all potential hires’ previous employers for references. The facility does not document the conversation.”

Our Winona nursing home abuse attorneys recognize the failing to follow procedures and protocols when hiring employees who come in direct contact with residents could place their health and well-being in Immediate Jeopardy. In addition, failing to notify proper authorities of an allegation of abuse could place the life of a resident in danger. The deficient practice by the nursing staff and Administrator at Sauer Health Care might be considered mistreatment or abuse because their actions failed to follow numerous policies including the facility’s policy title: Vulnerable Adult Policy and Abuse Prohibition Policy that both read in part:

“Sauer Health Care will report all cases of known or suspected maltreatment of [residents]. All vulnerable adult reports need to be reported immediately to the Office of Health Facility Complaints and Common Entry Point at the county. All Vulnerable Adult Reports must be reported to the Administrator immediately.”

“Screening of Potential Hires: Including obtaining information from previous employers, and checking with appropriate licensing board and registries.”

  When Abuse Involves More Than Just Physical Injury

Abuse and negligence occurring in nursing facilities encompass various forms of passive and aggressive mistreatment of the resident. Many of these kinds of negligence and abuse often go unnoticed. However, our Minnesota nursing home attorneys handle a variety of cases that involve:

  • Verbal and Emotional Abuse – The resident can suffer serious abuse when subjected to any form of a non-verbal or verbal act of aggression. This can include intimidation, insults, threatening actions, harassment or humiliation. These types of injuries often leave the victim suffering serious psychological anxiety and distress.
  • Sexual Assault – One of the most heinous, horrific and violent kinds of nursing abuse involve sexual assault. While sexual abuse can include nonconsensual sexual action and rape, many of the cases handled by our Minnesota sexual abuse attorneys have involved forced nudity, forced witnessing of others performing sexual acts or actions where the resident is unwillingly forced to view pornography.
  • Physical Abuse – Not every type of physical assault is detected by an unexplained injury left behind such as internal bleeding, sprains, fractures, bruises or wounds. Physical assault can also include kicking, slapping, hitting, overdosing for chemical restraint or any other type of physical contact that leaves the resident physically harmed.
  • Financial Exploitation – The indicators of financial exploitation often go unnoticed when the nursing facility fraudulently exploits the assets, property or finances of the resident without their knowledge or the knowledge of family members.
When Negligence Is Not Always Obvious

Many times, residents of nursing facilities become the victim of negligence when the nursing staff fails to provide an acceptable standard of care. The most common forms of negligence handled by personal injury attorneys on behalf of their clients involve:

  • Medication Errors – Residents can be seriously injured or killed as a result of a medication error including receiving another resident’s medication or not administering their drug at all. Many residents have suffered life-threatening harm by not receiving insulin medication or the nursing staff failing to follow physician’s orders.
  • Unsanitary Conditions – Making the resident live in filth, soiled garments or unsanitary conditions can cause their health and well-being to the great quickly.
  • The Spread of Infection – Without taking proper precautions, the nursing staff can quickly spread contagious infection from one resident to the other. State investigators and surveyors are constantly reviewing medical records and performing on-site observations to see if the staff is following protocols to minimize the spread of infection they could be contagious or fatal to other residents.

If you believe your loved one has suffered serious injury through neglect or abuse at a nursing facility, it’s imperative to take immediate legal action. Family members will often hire a personal injury attorney who specializes in nursing home abuse cases. A skilled attorney who handles abuse and neglect cases can take immediate action to stop the unacceptable behavior and ensure the loved one receives the highest quality medical care.

How an Attorney Can Help

The Rochester nursing home abuse attorneys at Nursing Home Law Center LLC have extensive experience and knowledge in assisting residents of abuse and neglect. Working on your behalf, we can take immediate legal action to report the abuse/neglect and serve as your loved one’s liaison between law enforcement officer and state agencies investigating the case.

We urge you to contact us today at (800) 926-7565 to ensure your loved one’s interest and rights are protected. We have immediate access to all necessary resources to build a case for full compensation for any mental, physical, sexual, emotional or financial harm your loved one has endured. We accept all of these nursing home abuse/neglect cases through contingency fee arrangements. This means we are only paid for legal services once we have obtained an acceptable out of court financial settlement or win your case at trial.


For additional information on Minnesota laws and information on nursing homes look here.

Nursing Home Abuse & Neglect Resources

If you are looking for information on a specific facility or an attorney, please see links below to respective locality pages.

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