DULUTH, Minn.-The room Jerry Pollard recently moved to in the Wesley Residence is cluttered with boxes, bodybuilding equipment and miscellaneous stuff. There's just enough room for the 70-year-old to perform his daily exercises.

Asked if he's happy with the move to the assisted living facility in West Duluth, Pollard quickly answers: "So far - I'm not happy with some of the things that happened during the move."

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Pollard, a Vietnam War veteran and self-described community activist, has done some moving this year. He started the year in Bayshore Residence on Park Point, later moving to Superior View in Hermantown. His move to Wesley Residence was forced when Rob Gannucci, Superior View's owner, chose to close the facility after the Minnesota Department of Health slapped him with a license suspension.

That means, based on state documents, that Pollard lived within the past year in two of the region's more-troubled facilities:

-According to a search of health department records from fiscal year 2015 (July 1, 2014 through June 20, 2015), state investigators visited to probe six maltreatment complaints filed against Bayshore. That was tied for more than any other facility in the state except for Providence Place in Minneapolis, which had seven. Moreover, Bayshore was tagged for 32 "deficiencies" in the most recent visits by state investigators, according to documents from the Centers for Medicare & Medicaid Services, a U.S. government agency. That was more than four times both the state and national averages and more than any other Minnesota facility.

-The license suspension notice sent to Gannucci on July 27 came at the front of a more-than-600-page document alleging violations by Superior View of state standards. It's replete with phrases such as "she received no formal training," "there had not been a RN available," "failed to ensure that a background study was completed," "no individual abuse prevention plan could be located" and "did not have staff in sufficient numbers." It alleged that Superior View staff failed to notify the doctors of two residents when their conditions worsened. One of the two, it said, was found by a family member with "his mouth ... open and ... dry and caked with substance. His respirations sounded like he was choking. His shirt appeared to have vomit on it and he was crying 'Ow, Ow' repeatedly." Both eventually were sent to the hospital and died, according to the report.



Although those two facilities may stand out, nursing homes and assisted-living facilities statewide have experienced a dramatic increase during this decade in the number of maltreatment complaints filed against them.

The total number of maltreatment allegations received by the health department's Office of Health Facility Complaints rose from 3,608 in fiscal year 2010 to 16,954 in fiscal year 2015, according to information provided by the state health department. That was actually down from more than 20,000 in both 2013 and 2014 - but still represents a more than fourfold increase over five years.

The increase in maltreatment complaints in the category of home care and assisted living was from 407 to 4,143 - a more than tenfold increase.

The allegations in themselves don't mean maltreatment actually occurred. State investigation of each allegation results in one of three findings: substantiated, inconclusive and unsubstantiated. Gilbert Acevedo, assistant commissioner of the state health department, said a minority of allegations are substantiated - meaning a "preponderance of evidence" suggests the facility or an individual was at fault. Over five years, 21 percent of maltreatment allegations were substantiated.

Only a small subset of the allegations rise to the level that they result in onsite visits by state investigators, said Scott Smith, a health department spokesman. Some are resolved quickly, such as when an allegation of theft is reported, but then the client discovers a "stolen" item was merely misplaced or taken home for safekeeping by a family member. Others are investigated during the facility's next regular visit from inspectors. Multiple allegations might be involved in a single inspection, Smith added.

During fiscal year 2015, 475 allegations resulted in onsite inspections in cases that were able to be closed. During that time, only one facility - Angels Care Center in Cannon Falls - had as many as three allegations against it that were substantiated during the period from July 1, 2014 through Dec. 31, 2015. Only one of the allegations against Bayshore was listed as substantiated.

Moreover, state health officials say not all of the increase in allegations necessarily means such facilities have gotten that much worse. Among the more benign explanations, according to the health department:

-An increasing population of older Minnesotans.

-Home care legislation passed in 2013 that added to oversight of home care and assisted-living providers.

-A streamlined process for reporting allegations known as the Minnesota Adult Abuse Reporting Center. The latter, however, was implemented in July 2015, after the overall increase in allegations had peaked.



Acevedo also pointed out that facilities are required to immediately self-report allegations against them, and some of those may prove to be unfounded. For example, a resident might report $200 stolen from her room, prompting the facility to immediately self-report the complaint.

Still, the health department finds the numbers concerning.

"Absolutely, MDH is concerned about the increase in allegations," Acevedo wrote in a follow-up email. "The health and safety of residents and patients is our chief concern. To compensate for the increasing number of complaints, MDH is taking steps to improve our processes and better communicate with families. However, we are concerned that as the trend continues demand will exceed our ability to effectively investigate complaints in a timely manner."

Cheryl Hennen, statewide ombudsman for the Minnesota Board of Aging, also cites mitigating factors such as the improved statewide reporting system and increased self-reporting by facilities. But, she added: "It may be a much greater problem (than the numbers show). ... What we learn in our business as ombudsmen is there could be things happening and going unreported because people are afraid. Our clients, for example, can be afraid of reporting for fear of retaliation."

Both Hennen and Acevedo point to understaffing as a possible explanation for some of the increase in allegations.

"More people are entering the system, and there's also a worker shortage," Acevedo said. "If you go more into outstate Minnesota, you may have fewer workers who can work in those areas."



In spite of the challenges, some facilities manage to come through unscathed, at least in the eyes of state regulators. John Hansen, administrator of McCarthy Manor - a small assisted-living facility in the Duluth Heights neighborhood - received a letter from the Department of Health in January congratulating him because their survey team had found no violations in their most recent inspection. It was the only facility in Minnesota to achieve that distinction last year.

Where problems crop up, staffing might not be the only problem. Amanda Johnson, vice president for clinical operations at Bloomington, Minn.-based Tealwood Senior Living, agreed the number of workers in such facilities is stretched just as the baby boom generation enters its senior years. But she didn't necessarily agree that this explained the increasing complaints.

"Most of the complaints have nothing to do directly with the staffing," she said.

Indeed, Heritage Manor in Chisholm and Bayshore Residence are ranked below average and much below average, respectively, in the Medicare "Nursing Home Compare" website, which is designed to allow consumers to consider which facilities close to home might be best for their loved ones. But when it comes to staffing, Bayshore ranks "above average" and Heritage Manor "much above average."

One of the most recent substantiated allegations against a regional facility involved Heritage Manor. In a report issued on July 12, state investigators said they determined from a preponderance of evidence that "neglect occurred when the facility positioned the resident's bed alongside a heat register and the resident's foot was burned."

Although the resident's doctor was contacted initially, the doctor wasn't informed over the next several days as the wound grew worse, the investigators reported. Eventually, the resident was hospitalized with "severe sepsis with septic shock." The resident died four days later, according to the report.

Chester Fishel, the nursing home's administrator, said it was the policy of Heritage Manor's parent company, St. Francis Health Service, not to comment on such reports.



As for Bayshore, a search of Office of Health Facility Complaints reports revealed four substantiated allegations over the past three years:

-From an investigator's visit on Dec. 12 and 13, 2013, a finding that neglect occurred because Bayshore lacked a system to follow up on doctors' orders. The result was delayed treatment for four patients and hospitalization for a fifth.

-A finding from a visit on Feb. 3 and 4, 2015, that a resident was not properly assessed for fall risk and the resident's care plan not updated. The resident, who had fallen several times previously, fell from a wheelchair, suffered a head injury and later died.

-A finding from a visit on Oct. 12, 2015, that a resident was hospitalized after not being given prescribed anti-seizure medication.

-A finding from the same visit that a resident didn't receive prescribed blood thinner medication for four days because of a transcription error by nursing staff.

Perhaps the low point for Bayshore came last November, when state investigators turned in a 53-page report detailing deficiencies at the facility. Although the majority were labeled as "minimal harm or potential for actual harm" affecting "few" residents, they detailed a wide variety of unmet requirements, such as "Provide proof that all residents' personal money which is deposited with the nursing home is secure," "Keep each resident's personal and medical records private and confidential" and "Try to resolve each resident's complaints quickly."

The present leadership team at Bayshore doesn't deny the problems.

Stephanie Friberg, director of admissions at Bayshore, wasn't on the staff there at the time of that survey; she was a student at the University of Minnesota Duluth. She graduated in May after majoring in health care management and started work at Bayshore six days later.

Bayshore figuratively has an "under new management" sign on the door. Not only is Friberg new, but so are the administrator and the director of nursing, she said. It also has new ownership, having been purchased by Superior Health Care Management, based in Plymouth, Minn., from New York-based Paragon Healthcare Group in April.

Friberg's message: Give the new people a chance.

"The whole picture of the facility has really kind of flipped over, and now we've got some good leadership," Friberg said.

New programs have been implemented, including a new nursing compliance program - completed just this month - designed to address the flaws that turned up in the past, she said. Bonuses have been put in place for "floor staff" such as nurses and nursing assistants, and of 23 new hires in the past quarter, "they're all still here," Friberg said.

Facility management know the window of time in which state inspectors will come, but never the exact date. For Bayshore, the latest visit came on the week of Oct. 24. In official report won't be available for a couple of weeks, but at the end of their visit - on Oct. 28 - the inspectors filled Bayshore staff in on their preliminary findings, Friberg said.

"It went really well," she said. "Based on preliminary results, we did astronomically better than last year."

But it takes time to rebuild a reputation, Friberg acknowledged. Savvy families considering Bayshore as a place for their loved ones come with questions about the bad marks in places such as the U.S. News & World Report's "Best Nursing Homes" report, Friberg said. So far those families, after discussing their concerns with the new leadership, have all chosen Bayshore, she said.



Jerry Pollard said he had lived at Bayshore since 2012 before relocating to Superior View in early June of this year. By then, he said, he was considered a "whistleblower" at Bayshore because he had spoken up for residents who said items they owned had been stolen. He also had contacted Maisie Blaine, an ombudsman for the Minnesota Board of Aging whose region includes St. Louis County.

Theft is a recurring theme with Pollard, who looks something like a wiry Santa Claus with a fringe of gray-white hair and a long gray-white beard. He moves with surprising speed on his prosthetic legs. He lost his legs, Pollard said, as a result of infections that developed in the early 2000s after a skateboarder sliced across his feet in an incident at Second Street and Second Avenue East.

Pollard claims that there were problems with residents' belongings being taken from rooms at past facilities where he lived.

Likewise, on the move from Superior View to Wesley Residence, he said, his computer disappeared, and when he opened a duffle bag he fills with fishing tackle he found partial rolls of toilet paper instead. That was the reason for his displeasure when he was interviewed last month in his new home.

Two tragedies involving Wesley Residence clients have occurred in recent years. In July 2013, 74-year-old Dale Gerard, stricken with dementia, wandered away from the facility. She was found dead in a grassy area near Piedmont Avenue nine months later. Although the health department did not issue any sanctions against the facility, Gerard's family in February filed a wrongful death lawsuit against Wesley and its parent company, At Home Living Facilities. The case is scheduled to be heard in court next February.

In January of this year, Melvin Stelten, who had lived at Wesley Residence for nine years, died when he was struck by two vehicles in the dark on Grand Avenue just outside of the facility. Duluth police found no wrongdoing by either of the drivers.



When he was interviewed while still at Superior View, Pollard was the last resident remaining there. After Gannucci made the decision to close the facility - which at the time housed 15 residents - in August, the state had asked Twin Cities-based Avinity Senior Living to manage the residents' relocation, said Laura Lokken, the nonprofit company's director of nursing. A number of them moved to Golden Oaks of Hermantown, which Lokken founded in 2006 and sold to Avinity on Jan. 1 of this year.

At the time of that interview, Pollard had met with a representative from Wesley but was unenthused.

"All I want to do is have my own apartment and be completely, 100 percent independent," he said. "I don't want any more assisted living. I've had so many problems with assisted living that it's unreal."

Jamie Tuura was the director of nursing at Superior View from July 2015 until Oct. 20, 2015, four days after a fire that made one of the facility's home-like buildings uninhabitable.

Tuura, now the nurse manager at Golden Oaks in Proctor, said he inherited problems at Superior View.

"There was some bad staffing," Tuura said.

To respond to the problems, Tuura said, he made staffing changes - even though he knew it would be difficult to find replacements.

"I put the other staff at maximum capacity as far as hours go and we had no choice," he said. "Luckily, I had some pretty dedicated people that came on board while I was there and stepped up to the plate."

Tuura said that he had been correcting the problems and getting beds filled at Superior View until he was terminated.

In one instance in January of this year, according to state documents, only one client in "house A" had a call light, and it was broken.

The report said that two staff members "forced the client to take medications orally by restraining the client in a chair, tilting the chair back, holding the client's arms at her side and forcing the client to take oral medication."

The action violated the client's right to refuse service, the state report said.

Gannucci disputed that allegation, saying the incident was distorted by staff from a home health agency who witnessed it. "They did try to give her meds when she didn't want them, but she had to have them," he said of his staff, but he denied that the forcible actions took place.

The violations regarding the two clients whose physicians weren't notified as their conditions worsened also were overstated, Gannucci said.

"Both individuals were sent to the hospital," he said. "They were both cared for. Everything that needed to be done was done."

Superior View accepted clients who were unwanted by other facilities, Gannucci said.

"Some of them came in very, very sick," he said. "When they say they died in the hospital, it's because they were sick to begin with."

He could have fought the allegations and won back his license, Gannucci said, but chose not to make the attempt. It had become hard to fill positions, especially after the fire, he said.

"We were struggling to keep staff," he said. "It's hard to hire anybody. Nobody wants to work much anymore. You're constantly trying to find people. They just go from one place to the other."

Avinity's Lokken agreed that staffing residential care facilities can be a challenge.

"The work ethic has changed so drastically with Kwik Trips, Fleet Farm," she said. "Why would anyone want to come here and scrub bottoms for $12, $13, $14 an hour when you can get $11 an hour there with benefits?"

She sold to Avinity, Lokken said, because they had the "deep pockets" to provide benefits to her staff and clients that she couldn't afford anymore, and its management has the caring attitude that's important to her.

Her facilities have had their share of deficiencies reported by state investigators, she said, but she always has moved quickly to make the needed corrections. She consults what she calls "the good book" - a softbound book with a light blue cover titled "Home Care Laws" - religiously. She doesn't resent those requirements, Lokken said, because she knows they were written for a reason.

"Someone was probably harmed," Lokken said. "So the state comes out with new home care laws, and I agree with them. Policies weren't written because things were perfect. Policies were written because there's a problem."

She's in a business that's not right for everyone, Lokken said.

"Having an assisted-living facility is a choice," she said. "And you really have to have a heart for this. Because it's not just scanning a barcode. You're taking care of people. And I always tell people it's an honor to be taking care of your loved ones."