Golden Hearts Inc.

correction orders issued pursuant to the August 28, 2025 survey. The Department of Health concludes the licensee is in substantial compliance. State law requires the facility must take action to correct the state 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. In accordance with Minn. Stat. § 144G.31 Subd. 4 (a), state correction orders issued pursuant to the last survey, completed on August 28, 2025, found not corrected at the time of the November 25, 2025, follow-up survey and/ or subject to penalty assessment are as follows: 0775-Fire Protection And Physical Environment- 144g.45 Subd. 2. (a) - $500.00 The details of the violations noted at the time of this follow-up survey completed on November 25, 2025 (listed above), are on the attached State Form. Brackets around the ID Prefix Tag in the left hand column, e.g., {2 ----} will identify the uncorrected tags. Therefo re , in acc ordanc e with Minn. Stat. §§ 144 G.01 to 144G .99 99 , the total amount you are assessed is $500.00. You will be invoiced approximately 30 days after receipt of this notice, subject to appeal . DOCUMENTATIO ONF 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 outlined on the state form; however, plans of correction are not required to be submitted for approval. IMPOSITION OF FINES In accordance with Minn. Stat. § 144G.31, Subd. 4, fines and enforcement actions may be imposed based on the level and scope of the violations and may be imposed immediately with no opportunity to correct the violation first as follows: Level 1: no fines or enforcement; An equal opportunity employer. Letter ID: 8GKP Revised 04/14/2023 Golden Hearts Inc December 26, 2025 Page 2 Level 2: a fine of $500 per violation, in addition to any enforcement mechanism authorized in § 144G.20; Level 3: a fine of $1,000 per incident, in addition to any enforcement mechanism authorized in § 144G.20; Level 4: a fine of $3,000 per incident, in addition to any enforcement mechanism authorized in § 144G.20; Level 5: a fine of $5,000 per violation, in addition to any enforcement mechanism authorized in § 144G.20. CORRECTIO NORDER RECONSIDERATIO PNROCESS 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 MDH within 15 calendar days of the correction order receipt date. To submit a reconsideration request, please visit: https: / / forms. web. health. state. mn. us/ form/ HRDAppealsForm REQUESTIN GA HEARING Alternatively, in accordance with Minn. Stat. § 144G.31, Subd. 5(d), an assisted living provider that has been assessed a fine under this subdivision has a right to a reconsideration or a hearing under this section and chapter 14. Pursuant to Minn. Stat. § 144G.20, Subd. 14 and Subd. 18, a request for a hearing must be in writing and received by the Department of Health within 15 business days of the correction order receipt date. The request must contain a brief and plain statement describing each matter or issue contested and any new information you believe constitutes a defense or mitigating factor. To submit a hearing request, please visit: https: / / forms. web. health. state. mn. us/ form/ HRDAppealsForm To appea l fines via rec onsiderati o n, ple ase fol lo w the pro cedure outlined abo ve. Please no te tha t you may reques t a reco ns ide ratio n or a he aring, but no t bo th. If you wish to conte st tags witho ut fines in a reconsideration and tags with the fines at a hearing, please submit two separate appeals forms at the website listed above. We urge you to review these orders carefully. If you have questions, please contact Tim Hanna at You are encouraged to retain this document for your records. It is your responsibility to share the information contained in the letter and/ or state form with your organization’s Governing Body. Sincerely, Tim Hanna, Supervisor State Evaluation Team Email: Tim.Hanna@state. mn.us Telephone: 507-208-8982 Fax: 1-866-890-9290 KKM PRINTED: 12/ 26/ 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: ______________________ R B. WING _____________________________ 38174 11/25/ 2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 602 MARION DRIVE GOLDEN HEARTS INC ARLINGTON, MN 55307 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 FOLLOW UP using federal software. Tag numbers have SURVEY WITH RE- ISSUE OF ORDERS been assigned to Minnesota State Statutes for Assisted Living Facilities. The INITIAL COMMENTS assigned tag number appears in the far-left column entitled "ID Prefix Tag. " The SL38174016- 1 state Statute number and the corresponding text of the state Statute out On November 24, 2025, the Minnesota of compliance is listed in the "Summary Department of Health conducted a follow-up Statement of Deficiencies" column. This survey at the above provider to follow-up on column also includes the findings which orders issued pursuant to a survey completed on are in violation of the state requirement August 28, 2025. At the time of the survey, there after the statement, "This Minnesota were 15 residents; 15 receiving services under requirement is not met as evidenced by." the Assisted Living with Dementia Care license. Following the evaluators ' findings is the As a result of the follow-up survey, the following Time Period for Correction. orders were reissued. PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH STATES, "PROVIDER' S PLAN OF CORRECTION. " THIS APPLIES TO FEDERAL DEFICIENCIES ONLY. THIS WILL APPEAR ON EACH PAGE. 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 SUBDIVISION 1-3. {0 480} 144G. 41 Subdivision 1 Subd. 1a (a-b) Minimum {0 480} SS= F requirements; required food services LABORATORY DIRECTOR' S OR PROVIDER/ SUPPLIER REPRESENTATIVE' S SIGNATURE TITLE (X6) DATE STATE FORM 6899 YSLI12 If continuation sheet 1 of 16 PRINTED: 12/ 26/ 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: ______________________ R B. WING _____________________________ 38174 11/25/ 2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 602 MARION DRIVE GOLDEN HEARTS INC ARLINGTON, MN 55307 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) {0 480} Continued From page 1 {0 480} (a) Except as provided in paragraph (b), food must be prepared and served according to the Minnesota Food Code, Minnesota Rules, chapter 4626. (b) For an assisted living facility with a licensed capacity of ten or fewer residents: (1) notwithstanding Minnesota Rules, part 4626. 0033, item A, the facility may share a certified food protection manager (CFPM) with one other facility located within a 60- mile radius and under common management provided the CFPM is present at each facility frequently enough to effectively administer, manage, and supervise each facility's food service operation; (2) notwithstanding Minnesota Rules, part 4626. 0545, item A, kick plates that are not removable or cannot be rotated open are allowed unless the facility has been issued repeated correction orders for violations of Minnesota Rules, part 4626. 1565 or 4626. 1570; (3) notwithstanding Minnesota Rules, part 4626.