Neglect complaint upheld against Iron Range assisted-living facility

The staff at an assisted-living facility in Biwabik waited four hours to call 911 after a client with senile dementia was found wedged between a bed and a nightstand with a seriously bruised leg, the Minnesota Department of Health said in a repor...

The staff at an assisted-living facility in Biwabik waited four hours to call 911 after a client with senile dementia was found wedged between a bed and a nightstand with a seriously bruised leg, the Minnesota Department of Health said in a report released this week.

Salmi Homes Inc. owns the facility -- Clayridge assisted living. The Health Department's Office of Health Facility Complaints substantiated a neglect complaint against the facility for the incident.

The report found Clayridge failed to provide reliable nurse backup for unlicensed personnel in case of an emergency, failed to provide adequate supervision for unlicensed personnel, failed to ensure the staff knew and carried out the policy for emergency situations and failed to provide necessary care and services for a client who "experienced a change in condition."

The date of the trapped patient incident wasn't listed in the report, which was filed on Dec. 20. The report also didn't list the client's gender. Stella French, director of the Office of Health Facility Complaints, explained that those details are no longer released

because they make it possible for people to learn the identity of the vulnerable adult.


Salmi Homes owners Clyde and Shirley Salmi did not immediately return requests for comment via phone and email on Thursday. They also operate WillowWood memory care in Eveleth. Both Clayridge and WillowWood have been providing care for more than 35 years, according to the Salmi Homes website.

Clayridge was given a clean bill of health after an investigator's unannounced follow-up visit on Oct. 14 of this year, the report said. It said the facility had complied with eight orders the department had issued on June 6.

Those orders stemmed from an earlier follow-up visit in April, in which the facility didn't fare well.

Among other findings in that report by special investigator DeeAnn Hogenson:

  • On April 15, an unlicensed employee found a client bleeding from the ear and complaining of pain. The client's bed was soaked with blood. The staff member told Hogenson she had wanted to call a nurse, but the supervisor said they had been directed not to call a nurse "for every little thing."
  • On April 17, Hogenson knocked on a client's door and heard the client say "just a minute," but the accompanying staff person immediately unlocked the door with a master key. The client told Hogenson that staff didn't respect privacy.
  • Between March 10, 11 and 12, unexplained bruises were found around a client's left eye, on the right upper arm and middle toe of the right foot, and on the left side of a the face. The client, who was diagnosed with memory loss and congestive heart failure, couldn't recall what had happened. The facility failed to investigate the cause or report the injuries, Hogenson's report said.
  • In March, a staff member with a positive tuberculin skin test had direct contact with clients before being cleared by a physician, the report said. Regarding the client trapped against a nightstand, Hogenson's report said the client, who was independent and largely mobile but very forgetful, was checked by a male employee about 2:30 a.m. and found in bed. But sometime between 4 a.m. and 5:30 a.m., the employee returned to find the client "in an awkward position with the upper part of the client's body on the night stand and part of the client's body on the bed."

    The client was wedged in and unable to move, the staffer said. The employee was unable to move the client alone, and when he called for help from another employee he was told she couldn't come "because she was busy with other clients."

    A third employee arrived at the facility about 6 a.m. and was able to help free the client. Three workers were then able to get the client back into bed.

    The client complained of pain in the left leg, which had a large scrape and was swollen. The client became lethargic and the left leg began to swell, but vital signs weren't taken until a fourth employee arrived at 7:30 a.m. That employee called 911 at 7:45 a.m., according to the 911 dispatch record.

    The emergency room doctor found extensive bruising on the client's left leg, the report said. He told Hogenson the type of injury the client had was caused by pressure to one area of the body for a long period of time, and he estimated the client had been in the same position "a minimum of all night due to the impressive amount of bruising and degree of impaired kidney function."

    The client remained hospitalized for four days and then was discharged to a nursing home, the report said.

    The emergency policy directed employees to immediately call 911 in the event of an accident, and then to notify the nurse on call, the report said.

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