Orchard Path.

Finding: Substantiated, individual responsibility Nature of Investigation: The Minnesota Department of Health investigated an allegation of maltreatment, in accordance with the Minnesota Reporting of Maltreatment of Vulnerable Adults Act, Minn. Stat. 626.557, and to evaluate compliance with applicable licensing standards for the provider type. Initial Investigation Allegation(s): A facility staff member/alleged perpetrator (AP) neglected a resident when they failed to provide care, services, and supervision as indicated in the resident’s care plan. The resident fell, sustained a brain bleed and died. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was substantiated. The AP was responsible for the maltreatment. The AP failed to follow the resident’s plan of care, did not complete scheduled rounds and left the resident unsupervised in the bathroom. The resident fell, sustained head injury requiring hospitalization in the intensive care unit (ICU) and died several weeks later. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The AP was interviewed. The investigator contacted the resident’s family members. The investigation included review of the resident’s facility record, death record, hospital record, facility internal investigation, facility incident reports, personnel files, staff schedules, law enforcement report, photos of the resident’s injuries, and related facility policy and procedures. Also, the investigator observed staff and resident interactions during her onsite visit. The resident resided in an assisted living memory care unit. The resident’s diagnosis included dementia. The resident’s care plan indicated the resident received assistance with personal cares, medication management, and safety checks. In addition, the resident required staff supervision while using the bathroom due to her high risk for falls. The resident’s assessment indicated the resident had severe cognitive impairment and was unable to use her call pendant. The resident used a walker and a wheelchair for mobility. The resident’s medical record indicated day shift staff found the resident on the bathroom floor during their morning rounds around 7:15 a.m. Due to the resident’s injuries, the resident was transported to the emergency department and admitted to the hospital. A police report from the time of the incident indicated the resident had a significant amount of dried blood on her head and face as well as her hands, eyes, and neck. In addition, there was a large hematoma and swelling near the resident’s right eye and cheek and a cut that was actively bleeding. The resident appeared confused and disoriented and was unable to state what happened or how long she had been on the floor. An unlicensed staff member told police the staff member/alleged perpetrator (AP) assigned to care for the resident during the overnight shift left quickly after her shift ended and mentioned no concerns. Police told leadership due to the amount of dried blood the resident had on her body the resident most likely had been on the floor for hours. The facility’s internal investigation report indicated another unlicensed staff stated during the end of shift rounds around 5:30 a.m., the AP told her the resident was in the bathroom. She reminded the AP about checking on residents in the bathroom but did not see the AP go back in the resident’s room. Camera footage reviewed showed the AP did not complete scheduled rounds during the night but did show the AP going in and quickly coming out of the resident’s apartment around 5:40 a.m. When interviewed by facility management, the AP’s statements changed several times stating initially the resident was in her bed during her 5:30 a.m. check and when questioned again, indicated the resident was in the bathroom. The AP acknowledged she did not complete all scheduled rounds during the shift. The resident’s hospital record indicated the resident was diagnosed with acute epidural hematomas (a serious rapid collection of blood outside the brain tissue but inside the skull from head trauma) on the right side of the resident’s temple and forehead, and a subdural hematoma (slower bleeding between the skull and brain tissue). The resident was admitted to the ICU for four days then discharged back to the facility. However, two days later the resident was sent back to the hospital due to increased weakness and low blood pressure. The resident remained in the hospital and died three weeks later. The resident’s death record identified the cause of death as complications of intracranial hemorrhage, blunt head trauma and fall. Review of the AP’s personnel file indicated the AP had received training and passed competency skills evaluations. The AP did not respond to requests for interview. When interviewed, a staff member stated the AP told her all the residents were “fine” when she arrived to work the morning shift. The staff member stated she entered the resident’s apartment to perform a morning check and found the resident sitting on the floor next to the stating, “it was a terrible sight,” and there was blood everywhere. The staff member said the resident’s eyes were bloody and swollen and the resident had blood on her face and hands. When interviewed, the nurse indicated the resident was at high risk for falls and the resident’s care plan was recently updated due to increased care needs. The nurse stated she was told by staff the resident was found in her apartment and was “bleeding all over the place.” The nurse stated due to the amount of dried blood the resident had on her face and body, emergency medical technician (EMT)s believed the resident was not checked on for several hours. When interviewed leadership stated they reviewed camera footage immediately after the incident and noticed the AP did not complete scheduled rounds on the resident. The camera footage did show the AP enter the resident’s apartment at the end of her shift and were surprised at how quick the AP entered and left the resident’s apartment, stating the AP spent maybe “five seconds” inside the resident’s apartment. Leadership questioned the amount of time the resident was on the floor due to the AP not completing rounds during the night and emergency responder’s concern of the amount of dried blood on the resident. Following completion of the internal investigation, the AP’s employment was terminated. In conclusion, the Minnesota Department of Health determined neglect was substantiated. Neglect: Minnesota Statutes, section 626.5572, subdivision 17 “Neglect” means neglect by a caregiver or self-neglect. (a) "Caregiver neglect" means the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to, food, clothing, shelter, health care, or supervision which is: (1) reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult; and (2) which is not the result of an accident or therapeutic conduct. Vulnerable Adult interviewed: No. The resident is deceased. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: No. AP did not respond to request for interview and did not respond to subpoena requests. Action taken by facility: The AP is no longer employed at the facility. The facility completed staff training following the incident. Action taken by the Minnesota Department of Health: The facility was issued a correction order regarding the vulnerable adult’s right to be free from maltreatment. To view a copy of the Statement of Deficiencies and/or correction orders, please visit: https://www.health.state.mn.us/facilities/regulation/directory/provcompselect.html You may also call 651-201-4200 to receive a copy via mail or email. The responsible party will be notified of their right to appeal the maltreatment finding. If the maltreatment is substantiated against an identified employee, this report will be submitted to the nurse aide registry for possible inclusion of the finding on the abuse registry and/or to the Minnesota Department of Human Services for possible disqualification in accordance with the provisions of the background study requirements under Minnesota 245C. cc: The Office of Ombudsman for Long Term Care The Office of Ombudsman for Mental Health and Developmental Disabilities Dakota County Attorney Apple Valley City Attorney Apple Valley Police Department PRINTED: 05/ 07/ 2026 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/ SUPPLIER/ CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ C B.

Finding: Not Substantiated Nature of Investigation: The Minnesota Department of Health investigated an allegation of maltreatment, in accordance with the Minnesota Reporting of Maltreatment of Vulnerable Adults Act, Minn. Stat. 626.557, and to evaluate compliance with applicable licensing standards for the provider type. Initial Investigation Allegation(s): The facility neglected resident-1 when the facility failed to supervise resident-1 and resident-2. Resident-2 physically assaulted resident-1 causing resident-1 to fall and injure her hip. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. Although resident-1 was found on the floor in the sunroom while resident-2 was also in the sunroom, the incident was unwitnessed. After the incident, resident-2 found staff and reported resident-1 was on the floor and needed help. Neither resident-1 nor resident-2 were able to report what happened as they both had memory impairment. Resdeint-2 had a history of aggressive behaviors, but the facility implemented numerous interventions to help manage these behaviors and keep other residents safe. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted resident-1’s family member. The investigation included review of resident-1 and resident-2’s records, resident-1’s death record, facility internal investigation, facility incident reports, surveillance footage of the hallway outside of the sunroom, staff schedules, and related facility policy and procedures. Also, the investigator toured the facility and observed resident supervision in the memory care area. Resident-1 resided in an assisted living memory care unit. The resident’s diagnoses included dementia, left sided weakness due to past stroke, and aphasia (difficulty speaking). The resident’s service plan included assistance with bathing, grooming, meals, medication management, reminders, and housekeeping. Resident-1 was on hospice and was at risk for falls. She had a recent fall less than a week before the incident. A progress note indicated resident-2 recently moved to the memory care area after increased confusion and memory concerns. Since moving to the memory care area, she began exhibiting some aggressive behaviors. The behaviors escalated from verbal threatening to physically pushing two different residents on two separate occasions. Residnet-2’s primary care provider adjusted her medications to help manage resident-2’s behaviors but then resident-2 began refusing her medications. After the second time resident-2 pushed a resident causing that resident to fall, the facility recommended resident-2 transfer to a psychiatric memory care unit where her behaviors could be managed more effectively. A referral was written to transfer resident-2 due to aggressive behaviors. In the meantime, the facility increased the frequency of resident-2’s safety checks, redirect other residents away from resident-2, and redirect resident-2 as needed. A progress note written a couple days later indicated the psychiatric facility denied resident-2’s admission based on insurance coverage. Resident-2 was transported to the hospital for inpatient psychiatric needs. The hospital sent the resident back to the facility a couple days later due to resident-2 not exhibiting any aggressive behaviors while at the hospital. A progress note written a week after resident-2 returned from the hospital indicated resident-2 was “suspected” of pushing resident-1 in the sunroom causing resident-1 to fall and injure her hip. Camera footage of the hallway leading into the sunroom showed resident-1 walking into the sunroom with her walker. A couple minutes later resident-2 walked into the sunroom with her walker. Twenty-five seconds later, resident-1’s walker was observed slowly rolling out of the sunroom into the hallway. A few seconds later, resident-2 was observed exiting the sunroom and knocking on resident apartment doors in the hallways near the sunroom. When nobody answered the door, resident-2 was observed walking back down the hallway quickly. A progress note indicated resident-2 reported resident-1 fell and needed help. Resident-1 and resident-2 were unable to voice further details of the incident due to cognition. After the suspected aggression against resident-1, the facility assigned a one-to-one staff member with resident-2. Resident-2’s family was notified and agreed to take resident-2 home during the day and return her in the evening. Resident-2’s family agreed to relocate her to a setting with increased behavioral support. Resident-2’s primary care provider reviewed medications and made more adjustments. A progress note written a week later indicated resident-2’s family hired a personal care attendant to provide one-to-one assistance during the day at the facility. The facility provided safety checks every two hours and would call 911 if resident-2 was physically aggressive and unable to redirect. Resident-2’s primary care provider sent a referral for psychiatry to evaluate and treat. During an interview, resident-1’s family member said resident-2 was physically aggressive towards resident-1 before the alleged incident. She said resident-1 had a black eye once and they suspected she received the black eye from resident-2 as they were in the sunroom together around the time they noticed the injury. There were no witnesses to the alleged incident. Another time resident-2 pushed resident-1 in the dining room and caused resident-1 to fall resulting in some bruising. She said resident-2 should have been evicted, medicated, or restrained to ensure other residents were safe. During an interview, a member of management, who was also a nurse, said resident-2 recently admitted to memory care due to increased confusion. Her behaviors began a few months after moving into memory care. The facility implemented several interventions to support resident-2 and keep other residents safe including medication adjustments, increased safety checks, redirection, and one-to-one staffing. The resident’s primary care provider referred her to a psychiatric facility, but resident-2 was denied due to insurance issues. Resident-2 was sent to the hospital and admitted to their psychiatric unit but returned two days later as she never exhibited any behaviors. The hospital also adjusted her medications. During an interview, a nurse said resident-2 recently became verbally threatening towards staff and others. Her behaviors escalated and she began running her walker into staff. She had a couple incidents of physical aggression towards other residents, usually when others were in her space or attempted to enter her apartment. Several interventions were implemented to keep resident-2 and others safe. The nurse trained facility staff on resident-2’s care plan. Resident-2’s care plan included specific instructions on how to manage her behaviors. The nurse updated the provider and family any time resident-2 exhibited an aggressive behavior. Resident-2’s primary care provider adjusted her medications several times. At one point, resident-2’s family was taking her home during the day and returning her in the evening. The family also hired an outside care attendant to monitor resident-2 until she was discharged to a geriatric psychiatric facility. Resident-2’s medical record included multiple interventions implemented at various times to support resident-2, alleviate behaviors, and ensure safety of others. The documented interventions included several medication adjustments reviewed and made by different providers, increased safety checks, a 911 protocol, redirection, one-to-one staff assigned, outside service support from various entities, referrals to outside agencies, and once approved and accepted an extended leave of absence for behavior support. In conclusion, the Minnesota Department of Health determined neglect was not substantiated. “Not Substantiated” means: An investigatory conclusion indicating the preponderance of evidence shows that an act meeting the definition of maltreatment did not occur. Neglect: Minnesota Statutes, section 626.5572, subdivision 17 “Neglect” means neglect by a caregiver or self-neglect. (a) "Caregiver neglect" means the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to, food, clothing, shelter, health care, or supervision which is: (1) reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult; and (2) which is not the result of an accident or therapeutic conduct. Vulnerable Adult interviewed: No, deceased. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Not Applicable the Action taken by facility: The facility implemented numerous interventions to support resident-2 and keep other residents safe. The facility completed incident reports, internal investigations, and educated staff on the resident’s care plan. Action taken by the Minnesota Department of Health: No further action taken at this time. cc: The Office of Ombudsman for Long Term Care The Office of Ombudsman for Mental Health and Developmental Disabilities PRINTED: 12/ 18/ 2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/ SUPPLIER/ CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ C B.

Finding: Substantiated, individual responsibility Nature of Investigation: The Minnesota Department of Health investigated an allegation of maltreatment, in accordance with the Minnesota Reporting of Maltreatment of Vulnerable Adults Act, Minn. Stat. 626.557, and to evaluate compliance with applicable licensing standards for the provider type. Initial Investigation Allegation(s): It is alleged the alleged perpetrators (AP)1 and AP2 financially exploited the resident when the AP1 received a total of $1250 for services and helping AP1 financially. AP2 cashed a $1600 check from the resident without authorization. Investigative Findings and Conclusion: The Minnesota Department of Health determined financial exploitation was substantiated. AP1 was responsible for the maltreatment. AP2 was not responsible for maltreatment. AP1 violated the facility policy and provided services outside of her work hours to the resident for cash. The resident stated $150 was paid to AP1 for services such as moving boxes/furniture and cleaning up items. The resident stated two checks, one for $500 and one for $600 was given as an “advance” because AP1 had financial troubles. Additionally, AP1 stole a blank check, filled out the amount for $1600 made payable to AP2 so AP2 could cash the check for her because she did not have her identification. AP2 gave AP1 the full $1600 and did not receive any money. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted law enforcement. The investigation included review of the resident record, bank records, facility internal investigation, personnel files, staff schedules, law enforcement report, related facility policy and procedures. The resident resided in an assisted living facility. The resident’s diagnoses included Parkinson’s disease. The resident’s service plan included assistance with weekly showers and homemaking. The resident’s assessment indicated she was cognitively intact and easily understood. The assessment indicated she had dystonia (muscle contraction) in her right hand. The resident’s service delivery records indicated AP1 provided services to the resident. AP2 did not provide services. Review of bank records indicated five checks were written and cashed within a week. Four of the checks were written in sequential check number order in the amounts of $50, $100, $600 and $1600. A fifth check in the amount of $500 was two check numbers after the $1600 check. The checks were all written to AP1 and were either cashed or deposited by AP1, aside from the $1600 check made out to AP2. AP2 cashed the $1600 check. The staff schedule on the date the $1600 check was cashed indicated both AP1 and AP2 worked that day, ending their shifts at 3:15 p.m. Four days later, the resident’s progress notes indicated she had professional organizers hired to her clean and organize her apartment. Later that same month, the resident reported to the facility leadership of a theft of her check. The facility internal investigation indicated the resident had a check cashed for $1600 and did not recognize the name or authorize a check for that amount. The facility suspended AP1 and AP2 and conducted an investigation. The facility also reported to law enforcement. AP2 stated she knew AP1 completed side jobs for the resident and the payment was for side work. AP2 stated AP1 did not have her identification to cash the check, so after their shift they went to the bank and she cashed it for AP1. AP1 failed to answer calls from the facility. Law enforcement provided an audio recording of AP1’s interview. AP1 stated she did side work for clients and the resident became one of her clients. AP1 stated she had been helping her for a couple of months with moving furniture, clean her residential house out and helped with a bath. AP1 stated she was paid by accumulation of work when the resident was ready to pay her. AP1 state she received $150. AP1 told law enforcement she thought the last check she received was roughly $1500. AP1 stated her phone battery was low and the call ended. AP1 failed to respond to further attempts of contact. During an interview, the resident stated due to Parkinson’s she had mobility issues, and her hands were shaky causing an inability to write well. The resident stated her spouse had health issues and before he went to the hospital/transitional care unit he signed a few blank checks, so the resident was able to pay for things while he was gone. The resident stated AP1 was an unlicensed staff who worked with her frequently at the facility; she was competent and helpful. The resident stated her and AP1 had a connection because AP1’s children were similar ages as her grandchildren. The resident stated she began having AP1 help her outside of her facility working hours to assist with opening boxes, helping with furniture and other things. The resident stated she paid AP1 what she thought was reasonable for her time to help, which were the $50 and $100 checks. The resident stated that was how the relationship developed, but then AP1 began to have financial troubles within a couple of weeks, such as car issues and health issues. AP1 had a $300 past due phone bill resulting in her cellphone being turned off. The resident stated she felt bad and did not want AP1’s children not able to contact her. The resident stated she made an agreement with AP1 that she would give her an advance and AP1 could work off payment or AP1 could pay her back. The resident stated AP1 filled in the check amount while with the resident present and at her directive due to her inability to write well. The resident stated the checks for the amounts of $500 and $600 were the advance to AP1 with the expectation she would pay her back (via services or payment). The resident stated when she was checking her bank account, she saw a check was cashed for $1600. The copy of the check on the bank record had a name she was unfamiliar with. The resident stated did not want to believe it at first that AP1 would do this, but then reported to the facility leadership the stolen check and to inquire if they knew the name on the check. The resident learned the check was written to AP2, another unlicensed staff member of the facility. The resident stated she had heard of AP2 and believed she worked in the memory care unit. The resident stated AP2 had never provided cares for her at the facility, nor had she had interactions with her. The resident stated she did not notice AP1 do it at the time, but believed AP1 took the blank check when she filled out the check for $600 because the check number of the check for $1600 was the next check number. Additionally, there was no duplicate for the $1600 check like the other checks. The resident stated she never authorized a $1600 check to AP1 or AP2. During an interview, AP2 stated she was friends with AP1 and would periodically give her rides. AP2 stated she knew AP1 had been doing work for the resident outside of work hours. AP2 stated she typically works an evening shift, however the day of the incident she worked a morning shift ending at 3:00 p.m. Shortly before the shift ended, AP1 approached her to ask if she could cash a check for her after work because she forgot her identification. She stated AP1 called the resident to ask her if it was ok to put AP2’s name on the check because AP1 did not have her identification. AP2 stated she assumed AP1 was talking to the resident, although she did not hear the conversation. AP2 stated AP1 left to get the check from the resident and AP1 met her in the car. AP2 stated when she saw the check it was already filled out and had her name on it. AP2 stated she went to the bank with AP1, cashed the check and gave AP1 the full amount of $1600. AP2 stated she did not know the resident did not authorize a check to AP1 in that amount. In hindsight, AP2 stated she should have reported it to a supervisor because staff are not allowed to accept gifts from residents. AP1 failed to participate in an interview. During the scheduled interview, AP1 asked to have the interview changed to a later date.

correction orders and document the actions taken to comply in the facility's records. The Department reserves the right to return to the facility at any time should the Department receive a complaint or deem it necessary to ensure the health, safety, and welfare of residents in your care. STATE CORRECTION ORDERS The enclosed State Form documents the state correction orders. The MDH documents state licensing correction orders using federal software. Tag numbers are assigned to Minnesota state statutes for Assisted Living Facilities. The assigned tag number appears in the far left column entitled "ID Prefix Tag." The state statute number and the corresponding text of the state statute out of compliance are listed in the "Summary Statement of Deficiencies" column. This column also includes the findings that are in violation of the state statute after the statement, "This MN Requirement is not met as evidenced by . . ." In accordance with Minn. Stat. § 144G.31 Subd. 4, MDH may assess fines based on the level and scope of the violations; h owever, no immediate fines are assessed for this survey of your facility. DOCUMENTATION OF ACTION TO COMPLY In accordance with Minn. Stat. § 144G.30, Subd. 5(c), the licensee must document actions taken to comply with the correction orders within the time period outlined on the state form; however, plans of correction are not required to be submitted for approval. The correction order documentation should include the following: Identify how the area(s) of noncompliance was corrected related to the resident(s)/employee(s) identified in the correction order. Identify how the area(s) of noncompliance was corrected for all of the provider’s resident(s)/employees that may be affected by the noncompliance. Identify what changes to your systems and practices were made to ensure compliance with the specific statute(s). An equal opportunity employer. Letter ID: IS7N REVISED 09/13/2021 Orchard Path October 17, 2023 Page 2 CORRECTION ORDER RECONSIDERATION PROCESS In accordance with Minn. Stat. § 144G.32, Subd. 2, you may challenge the correction order(s) issued, including the level and scope, and any fine assessed through the correction order reconsideration process. The request for reconsideration must be in writing and received by the MDH within 15 calendar days of the correction order receipt date. A state correction order under Minn. Stat. § 144G.91, Subd. 8, Free from Maltreatment is associated with a maltreatment determination by the Office of Health Facility Complaints. If maltreatment is substantiated, you will receive a separate letter with the reconsideration process under Minn. Stat. § 626.557. Please email reconsideration requests to: Health.HRD.Appeals@state.mn.us. Please attach this letter as part of your reconsideration request. Please clearly indicate which tag(s) you are contesting and submit information supporting your position(s). Please address your cover letter for reconsideration requests to: Reconsideration Unit 85 East Seventh Place St. Paul, MN 55164-0970 You are encouraged to retain this document for your records. It is your responsibility to share the information contained in the letter and state form with your organization’s Governing Body. If you have any questions, please contact me. Sincerely, Jodi Johnson, Supervisor State Evaluation Team Email: jodi.johnson@state.mn.us Telephone: 507-344-2730 Fax: 1 -866-890-9290 JMD PRINTED: 10/17/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 33804 09/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5400 157TH STREET WEST ORCHARD PATH APPLE VALLEY, MN 55124 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 000 Initial Comments 0 000 ******ATTENTION****** Minnesota Department of Health is documenting the State Correction Orders ASSISTED LIVING PROVIDER LICENSING using federal software. Tag numbers have CORRECTION ORDER(S) been assigned to Minnesota State Statutes for Assisted Living License In accordance with Minnesota Statutes, section Providers. The assigned tag number 144G.08 to 144G.95, these correction orders are appears in the far left column entitled "ID issued pursuant to a survey. Prefix Tag." The state Statute number and the corresponding text of the state Statute Determination of whether violations are corrected out of compliance is listed in the requires compliance with all requirements "Summary Statement of Deficiencies" provided at the Statute number indicated below. column. This column also includes the When Minnesota Statute contains several items, findings which are in violation of the state failure to comply with any of the items will be requirement after the statement, "This considered lack of compliance. Minnesota requirement is not met as evidenced by." Following the surveyors' INITIAL COMMENTS: findings is the Time Period for Correction. SL33804015 PLEASE DISREGARD THE HEADING OF On September 11, 2023, through September 14, THE FOURTH COLUMN WHICH 2023, the Minnesota Department of Health STATES,"PROVIDER'S PLAN OF conducted a survey at the above provider, and CORRECTION." THIS APPLIES TO the following correction orders are issued. At the FEDERAL DEFICIENCIES ONLY. THIS time of the survey, there were 300 active WILL APPEAR ON EACH PAGE. residents; 75 receiving services under the Assisted Living with Dementia Care license. THERE IS NO REQUIREMENT TO SUBMIT A PLAN OF CORRECTION FOR VIOLATIONS OF MINNESOTA STATE STATUTES. The letter in the left column is used for tracking purposes and reflects the scope and level issued pursuant to 144G.31 subd. 1, 2, and 3. 0 130 144G.12, Subd. 1 Application for Licensure 0 130 SS=C Each application for an assisted living facility license, including provisional and renewal LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 4FUE11 If continuation sheet 1 of 41 PRINTED: 10/17/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 33804 09/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5400 157TH STREET WEST ORCHARD PATH APPLE VALLEY, MN 55124 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 130 Continued From page 1 0 130 applications, must include information sufficient to show that the applicant meets the requirements of licensure, including: (1) the business name and legal entity name of the licensee, and the street address and mailing address of the facility; (2) the names, e-mail addresses, telephone numbers, and mailing addresses of all owners, controlling individuals, managerial officials, and the assisted living director; (3) the name and e-mail address of the managing agent and manager, if applicable; (4) the licensed resident capacity and the license category; (5) the license fee in the amount specified in section 144.122; (6) documentation of compliance with the background study requirements in section 144G.13 for the owner, controlling individuals, and managerial officials. Each application for a new license must include documentation for the applicant and for each individual with five percent or more direct or indirect ownership in the applicant; (7) evidence of workers' compensation coverage as required by sections 176.181 and 176.182; (8) documentation that the facility has liability coverage; (9) a copy of the executed lease agreement between the landlord and the licensee, if applicable; (10) a copy of the management agreement, if applicable; (11) a copy of the operations transfer agreement or similar agreement, if applicable; (12) an organizational chart that identifies all organizations and individuals with an ownership interest in the licensee of five percent or greater and that specifies their relationship with the STATE FORM 6899 4FUE11 If continuation sheet 2 of 41 PRINTED: 10/17/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B.