Northern Lakes Senior Living.

Finding: Inconclusive 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 the resident when it failed to administer medications as prescribed. The medication administration record (MAR) did not include instructions that a medication should not be crushed. Staff crushed the medication, resulting in the resident being admitted to the hospital with an acute kidney injury. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was inconclusive. The resident took potassium, a medication that cannot be crushed. If the medication is crushed, it can impact absorption and cause high potassium levels. The RN failed to include instructions on the resident’s medication administration record (MAR) that the medication was not to be crushed. The facility investigation determined unlicensed personnel (ULP) crushed at least 9 of 16 doses of the medications. The resident was hospitalized with hyperkalemia (high potassium) and an acute kidney injury. However, due to other comorbidities, it could not be determined if the potassium being crushed led to the resident’s hospitalization. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted the primary care provider. The investigation included review of the resident record, hospital records, pharmacy records, facility internal investigation, facility incident reports, staff schedules, and related facility policy and procedures. Also, the investigator observed medication administration at the facility. The resident resided in an assisted living facility. The resident’s diagnoses included kidney disease and congestive heart failure. The resident’s service plan included assistance with activities of daily living and medication administration. The resident’s assessment indicated the facility managed the resident’s medications and her medications were to be crushed. The resident moved into the facility eight days before she was hospitalized. The facility’s internal investigation indicated after the resident was hospitalized for hyperkalemia, a RN noticed that all of the resident’s medications were being crushed and she wondered if the potassium was being crushed as that may have had an effect on the resident’s potassium level. The facility identified that 9 of 16 doses were likely crushed after interviewing staff. In reviewing the electronic medical record, the facility identified that “Do Not Crush” was not clicked on the medication, which would have alerted staff to not crush the medication. The facility determined staff did not review the medication card, which had a “Do Not Crush” sticker on it and that the RN failed to complete a full medication reconciliation for admission medications when it was entered into the medication administration record. The RN failed to check medications upon arrival from the pharmacy for warnings and indications. Hospital records indicated the resident was seen in the urgent care clinic two days before she was hospitalized for complaints of nausea and retching. The resident’s antibiotic for a urinary tract infection was discontinued and the resident returned to the facility. Upon arrival to the emergency room two days later, the resident’s potassium level was 7 (levels above 5 are considered high and can cause life-threatening heart problems, muscle weakness, or paralysis). The resident was diagnosed with an acute kidney injury and severe life-threatening hyperkalemia (high potassium). The resident was hospitalized for five days and discharged to a different facility. Unlicensed personnel (ULP) who administered some of the doses of potassium to the resident were interviewed. The ULP stated they were not previously aware potassium could not be crushed and they did not recall seeing instructions on the MAR or on the medication card. One ULP stated she brought the medication to the resident’s room and the resident said she wasn’t able to swallow it and it had to be crushed so she and the resident’s daughter crushed it with a spoon to make it easier for the resident to take. During an interview, a facility RN stated after the resident was hospitalized, another facility nurse was meeting with staff at shift change and while talking with the ULP, it was discovered at that point some staff were crushing the potassium. The RN stated the facility began investigating and determined the order was not written to include “do not crush” so it was not put on the MAR and staff did not catch it was not on the MAR. The RN stated the pharmacy had recently changed its labels and while the card had “do not crush” on it, it was written in a different spot and was very small and staff reported they had not seen that on there. In conclusion, the Minnesota Department of Health determined neglect was inconclusive. Inconclusive: Minnesota Statutes, section 626.5572, Subdivision 11. "Inconclusive" means there is less than a preponderance of evidence to show that maltreatment did or 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: Unable Family/Responsible Party interviewed: Yes Alleged Perpetrator interviewed: Not Applicable Action taken by facility: The facility identified the medication error after the resident was hospitalized and investigated the incident. The facility reported the incident to MAARC and retrained staff on medication administration. 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: 11/25/2025 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. WING _____________________________ 31987 09/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 8186 EXCELSIOR ROAD NORTHERN LAKES SENIOR LIVING BAXTER, MN 56425 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE PREFIX PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 000 Initial Comments 0 000 On September 25, 2025, the Minnesota Department of Health initiated an investigation of complaint #HL319875743M/ #HL319873628C. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 9J0M11 If continuation sheet 1 of 1

CORRECTION ORDERS The enclosed State Form documents the state correction orders. 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 . . ." 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; 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. Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, the following fines are assessed pursuant to this survey: An equal opportunity employer. Letter ID: IS7N REVISED 09/13/2021 Northern Lakes Senior Living September 19, 2025 Pa ge 2 St - 0 - 0775 - 144g.45 Subd. 2. (a) - Fire Protection And Physical Environment - $500.00 Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, the total amount you are assessed is $500.00. You will be invoiced approximately 30 days after receipt of this notice, subject to appeal. 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). 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 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 REQUESTING A 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 appeal fines via reconsideration, please follow the procedure outlined above. Please note that you may request a reconsideration or a hearing, but not both . If you wish to contest tags without fines in Northern Lakes Senior Living September 19, 2025 Pa ge 3 a reconsideration and tags with the fines at a hearing, please submit two separate appeals forms at the website listed above. The MDH Health Regulation Division (HRD) values your feedback about your experience during the survey and/or investigation process. Please fill out this anonymous provider feedback questionnaire at your convenience at this link: https://forms.office.com/g/Bm5uQEpHVa. Your input is important to us and will enable MDH to improve its processes and communication with providers. If you have any questions regarding the questionnaire, please contact Susan Winkelmann at susan.winkelmann@state.mn.us or call 651-201-5952. 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, Jessie Chenze, Supervisor State Evaluation Team Email: Jessie.Chenze@state.mn.us Telephone: 218-332-5175 Fax: 1-866-890-9290 CLN PRINTED: 09/19/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 31987 07/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 8186 EXCELSIOR ROAD NORTHERN LAKES SENIOR LIVING BAXTER, MN 56425 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 Facilities. The In accordance with Minnesota Statutes, section assigned tag number appears in the 144G.08 to 144G.95, these correction orders are far-left column entitled "ID Prefix Tag." The issued pursuant to a survey. state Statute number and the corresponding text of the state Statute out Determination of whether violations are corrected of compliance is listed in the "Summary requires compliance with all requirements Statement of Deficiencies" column. This provided at the Statute number indicated below. column also includes the findings which When Minnesota Statute contains several items, are in violation of the state requirement failure to comply with any of the items will be after the statement, "This Minnesota considered lack of compliance. requirement is not met as evidenced by." Following the evaluators ' findings is the INITIAL COMMENTS: Time Period for Correction. SL31987016 PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On July 28, 2025, through July 30, 2025, the STATES,"PROVIDER'S PLAN OF survey at the above provider and the following FEDERAL DEFICIENCIES ONLY. THIS correction orders are issued. At the time of the WILL APPEAR ON EACH PAGE. survey, there were 63 residents; 63 receiving services under the Assisted Living Facility with THERE IS NO REQUIREMENT TO Dementia Care license. 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. 0 485 144G.41 Subdivision 1.a (a) Minimum 0 485 SS=C requirements; required food services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 XG9H11 If continuation sheet 1 of 14 PRINTED: 09/19/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 31987 07/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 8186 EXCELSIOR ROAD NORTHERN LAKES SENIOR LIVING BAXTER, MN 56425 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) 0 485 Continued From page 1 0 485 (a) All assisted living facilities must offer to provide or make available at least three nutritious meals daily with snacks available seven days per week, according to the recommended dietary allowances in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables. The menus must be prepared at least one week in advance and made available to all residents. The facility must encourage residents' involvement in menu planning. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. The facility must not require a resident to include and pay for meals in the resident's contract.

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 the resident when the facility did not provide updated services resulting in multiple falls. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. Although the resident did fall multiple times during the last two months of his life, the facility did put interventions in place to prevent falls and/or injury. While the resident did have a decline, he was enrolled in hospice and the facility coordinated cares with hospice appropriately. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted the resident's family member, the ombudsman and hospice nurse. The investigation included review of resident's records, incident reports, and the resident's external medical record. The resident resided in a secured memory care building within an assisted living facility. The resident’s diagnoses included dementia and Parkinson’s disease. The service plan indicated he required assistance of one person for walking, personal hygiene, dressing, and toileting. The caregivers were to remind the resident to use the bathroom and/or change his clothes and provide incontinence cares as needed. Additionally, the service plan included nightly safety checks, with instructions from the family not to wake the resident up during the night. Caregivers provided redirection for the resident if he wandered. The resident’s medical record indicated he initially moved into the facility to reside in an assisted living apartment. After several years, as his dementia progressed, the family opted to transition him into memory care. During his seven months in memory care, his health deteriorated rapidly. During the last two months of his life, the resident had multiple falls with no reported injuries. The same documents indicated his behaviors became challenging for caregivers as he became resistive to cares with aggressive behaviors. The resident admitted to hospice and passed away two months later. During an interview, a family member stated the family shared their concerns about the care the resident received with the facility. The family had a camera in the resident’s room and observed caregivers did not check on the resident as frequently as expected. Instead, they just opened the door, glanced inside, and left. The family had to contact the facility multiple times to report when they observed the fall over the camera, which occurred seventeen times in the last two months of his life. The family member said after they voiced their concerns, caregivers would move the resident out of the room early in the morning and keep him in a wheelchair near the nursing station for the entire day, where the family could not monitor him via the camera. The family member stated they were concerned the facility did not provide adequate hydration or provide the services as outlined in the care plan. The family member stated the facility tried to raise the resident’s charges by raising his level of care from “four” to “eleven” [based on the facility’s rating system] without justification. At times, as many as five caregivers entered the resident’s room but only two of the five were actively assisting the resident with incontinence cares. The family member stated a concerning incident occurred when a caregiver held the resident’s arm down, which the family perceived as abusive. The family member stated the caregivers overmedicated the resident by excessive use of “as-needed” medications. The family member stated that on one occasion, the resident made a train-like noise loudly in his room for over half an hour, but no caregivers responded. The family member stated they reported the situation to adult protection services, who investigated and found no concerns regarding the care. During an interview, manager #1 stated the resident initially resided in assisted living but was moved to the memory care unit as his condition worsened. She said he became increasingly aggressive towards staff and required frequent redirection. At times, he would yell and scream in his room, prompting caregivers to accompany him to ensure his safety. The caregivers documented the cares the resident required, and this information was shared with the resident’s family however, the family expressed disbelief regarding the drastic changes in the resident's cares. Manager #1 stated this led to accusations towards staff members, which resulted in the facility filing a restraining order against one of the family members. Management staff #1 stated the facility informed the resident’s cares had increased from a level “four” to an “eleven” but the family insisted the resident required level “five” only. Manager #1 stated the family refused to sign the new service plan for level “eleven”. Manager #1 stated the resident’s cares generally required two caregivers, however because of the resident’s aggressiveness during cares often three to five caregivers present in the room, which was to help him calm down so the direct caregivers could do so effectively. During an interview, manager #2 said the resident did fall numerous times during the last two months of his life despite the implementation of various interventions to prevent them, such as shoes, grip socks, fall mats, and a Broda chair [a specialized chair for positioning and fall prevention]. At times, the caregivers kept the resident close to the nurse’s station for added supervision and safety. Manager #2 stated the resident was highly confused and restless, often attempting to get up by himself or lean over in his wheelchair. Despite staffing constraints, the facility conducted hours safety checks on the resident. Manager #2 stated the resident often became agitated at night and caregivers kept him at the nursing station for supervision. Manager #2 stated the family expressed dissatisfaction with the resident being placed in a chair at the nurse’s station at night and apparently view it as insufficient care. Manager #2 said the family requested one-on-one care, but the facility explained it could not provide this. Manager #2 stated that while the resident had “as-needed” medications for pain, but the family wanted the caregivers to seek approval from the family or hospice before each administration. Regarding care levels, manager #2 stated level 5 applied to someone who required stand-by assistance, but the resident required two-person physical assistance with a Hoyer lift, but the family would not agree to a higher level of care. Management staff #2 stated there were ongoing discussions with the family about the potential transition to a nursing home due to the facility's inability to provide one-on-one care. The family indicated they were exploring other options, although there no formal requests for transfer. During the same interview, manager #2 addressed an incident capture on the family’s camera. Manager #2 stated the family claimed a caregiver was restraining the resident, but further investigation led to conflicting interpretations. The video footage was reviewed by others, including a social worker, a resident advocate, and multiple members of the facility management who did not share the view it was evidence of abuse. Manager #2 stated caregivers did express that providing cares for the resident was made more difficult due to the limitations use of “as needed” medications especially when the resident exhibited agitation and aggression through behaviors like hitting, swinging and pulling at his caregivers. During an interview, a resident advocate familiar with the resident’s cares stated she had reviewed video footage provided by the family. The concerns included occasions when multiple caregivers entered the resident’s room which might have been intimidating to the resident. The advocate stated the facility's explanation for the presence of multiple caregivers was due to safety concerns and the resident’s potential aggressive behavior. The advocate stated the family said they were concerned because the facility would keep the resident outside of the room most of the day and family could not watch him via camera. The advocate did visit the resident but did not witness any aggressive behavior. The advocate stated she did ask caregivers how the resident transferred, and the responses varied with some saying he required a Hoyer lift and two-person assistance while others said one-person physical assistance, but this seemed to vary based on the physical strength of the caregiver. The advocate stated she also viewed video footage provided by the family in which the family felt a caregiver mistreated the resident.

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 and enforcement actions based on the level and scope of the violations; however, 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 An equal opportunity employer. Letter ID: IS7N REVISED 09/13/2021 Northern Lakes Senior Living June 8, 2023 Page 2 the specific statute(s). 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, Kelly Thorson, Supervisor State Evaluation Team Email: kelly.thorson@state.mn.us Telephone: 320-223-7336 Fax: 651-281-9796 PMB PRINTED: 06/08/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ 31987 B. WING _____________________________ 05/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 8186 EXCELSIOR ROAD NORTHERN LAKES SENIOR LIVING BAXTER, MN 56425 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 0 000 Initial Comments 0 000 ******ATTENTION****** Minnesota Department of Health is documenting the State Licensing ASSISTED LIVING PROVIDER LICENSING Correction Orders using federal software. CORRECTION ORDER(S) Tag numbers have been assigned to Minnesota State Statutes for Assisted In accordance with Minnesota Statutes, section Living License Providers. The assigned 144G.08 to 144G.95, these correction orders are tag number appears in the far left column issued pursuant to a survey. entitled "ID Prefix Tag." The state Statute number and the corresponding text of the Determination of whether violations are corrected state Statute out of compliance is listed in requires compliance with all requirements the "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. SL31987015 PLEASE DISREGARD THE HEADING OF On May 15, 2023, through May 17, 2023, the THE FOURTH COLUMN WHICH survey at the above provider, and the following CORRECTION." THIS APPLIES TO correction orders are issued. At the time of the FEDERAL DEFICIENCIES ONLY. THIS survey, there were 65 active residents; all WILL APPEAR ON EACH PAGE. 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. 0 480 144G.41 Subd 1 (13) (i) (B) Minimum 0 480 SS=F requirements (13) offer to provide or make available at least the LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 H3N411 If continuation sheet 1 of 22 PRINTED: 06/08/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ 31987 B. WING _____________________________ 05/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 8186 EXCELSIOR ROAD NORTHERN LAKES SENIOR LIVING BAXTER, MN 56425 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 0 480 Continued From page 1 0 480 following services to residents: (B) food must be prepared and served according to the Minnesota Food Code, Minnesota Rules, chapter 4626; and This MN Requirement is not met as evidenced by: Based on observation, interview and record review, the licensee failed to ensure food was prepared and served according to the Minnesota Food Code. This practice resulted in a level two violation (a violation that did not harm a resident's health or safety but had the potential to have harmed a resident's health or safety) and was issued at a widespread scope (when problems are pervasive or represent a systemic failure that has affected or has the potential to affect a large portion or all the residents). The findings include: Please refer to the included document titled, Food and Beverage Establishment Inspection Report dated May 15, 2023, for the specific Minnesota Food Code deficiencies. TIME PERIOD FOR CORRECTION: Twenty-one (21) days 0 510 144G.41 Subd. 3 Infection control program 0 510 SS=D (a) All assisted living facilities must establish and maintain an infection control program that complies with accepted health care, medical, and nursing standards for infection control. (b)The facility's infection control program must be consistent with current guidelines from the national Centers for Disease Control and Prevention (CDC) for infection prevention and control in long-term care facilities and, as applicable, for infection prevention and control in STATE FORM 6899 H3N411 If continuation sheet 2 of 22 PRINTED: 06/08/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ 31987 B. WING _____________________________ 05/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 8186 EXCELSIOR ROAD NORTHERN LAKES SENIOR LIVING BAXTER, MN 56425 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 0 510 Continued From page 2 0 510 assisted living facilities. (c) The facility must maintain written evidence of compliance with this subdivision. This MN Requirement is not met as evidenced by: Based on observation, interview, and record review, the licensee failed to ensure infection control standards were followed for two of two unlicensed personnel (ULP-C, ULP-F) during personal cares for R1.