Havenwood of Burnsville.

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 necessar yto ensure the health, safety, and welfare of residents in your care. STATE CORRECTIO ONRDERS 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 Requiremen tis not met as evidenced by . . ." In accordance with Minn. Stat. § 144G3. 1 Subd .4, MDH may asses sfines based on the level and scope of the violations; however, no immediate fines are assesse dfor this survey of your facility. DOCUMENTATIO ONF ACTION TO COMPLY In accordance with Minn. Stat. § 144G3. 0, Subd .5(c), t he 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: An equal opportunity employer . Letter ID: IS7N REVISE 0D9/13/2021 Havenwood of Burnsville October 16, 2025 Page 2 x Identify how the area(s) of noncompliance was corrected related to the resident(s)/ employee(s) identified in the correction order. x 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. x Identify what changes to your systems and practices were made to ensure compliance with the specific statute(s). CORRECTIO ONRDER RECONSIDERATI OPRNOCESS In accordance with Minn. Stat. § 144G3. 2, Subd .2, you may challenge the correction order(s) issued, including the level and scope ,and any fine assesse dthrough 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 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/Bm5uQEpHV.a Your input is important to us and will enable MDH to improve its processe sand communication with providers. If you have any questions regarding the questionnaire ,please contact Susan Winkelmann at susanw. inkelmann@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 organizations’ Governing Body. If you have any questions ,please contact me. Sincerely, Jod iJohnson ,Supervisor State Evaluation Team Email: Jodi.Johnson@state.mn.us Telephone :507-344-2730 Fax :1-866-890-9290 HHH PRINTED: 10/ 16/ 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 _____________________________ 35795 09/ 24/ 2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 14401 GRAND AVENUE HAVENWOOD OF BURNSVILLE BURNSVILLE, MN 55306 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. SL235795016- 0 PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On September 22, 2025, through September 24, STATES, "PROVIDER' S PLAN OF 2025, the Minnesota Department of Health CORRECTION. " THIS APPLIES TO conducted a full survey at the above provider and FEDERAL DEFICIENCIES ONLY. THIS the following correction orders are issued. At the WILL APPEAR ON EACH PAGE. time of the survey, there were 58 residents; 58 receiving services under the Assisted Living THERE IS NO REQUIREMENT TO Facility with 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. 01700 144G. 71 Subd. 2 Provision of medication 01700 SS= F management services LABORATORY DIRECTOR' S OR PROVIDER/ SUPPLIER REPRESENTATIVE' S SIGNATURE TITLE (X6) DATE STATE FORM 6899 O1V311 If continuation sheet 1 of 6 PRINTED: 10/ 16/ 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 _____________________________ 35795 09/ 24/ 2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 14401 GRAND AVENUE HAVENWOOD OF BURNSVILLE BURNSVILLE, MN 55306 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) 01700 Continued From page 1 01700 (a) For each resident who requests medication management services, the facility shall, prior to providing medication management services, have a registered nurse, licensed health professional, or authorized prescriber under section 151. 37 conduct an assessment to determine what medication management services will be provided and how the services will be provided. This assessment must be conducted face- to- face with the resident. The assessment must include an identification and review of all medications the resident is known to be taking. The review and identification must include indications for medications, side effects, contraindications, allergic or adverse reactions, and actions to address these issues. (b) The assessment must identify interventions needed in management of medications to prevent diversion of medication by the resident or others who may have access to the medications and provide instructions to the resident and legal or designated representatives on interventions to manage the resident' s medications and prevent diversion of medications. For purposes of this section, "diversion of medication" means misuse, theft, or illegal or improper disposition of medications. This MN Requirement is not met as evidenced by: Based on interview and record review, the licensee failed to ensure the registered nurse (RN) conducted a medication management assessment which included all content prior to providing medication management services for two of two residents (R3, R5) . 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 STATE FORM 6899 O1V311 If continuation sheet 2 of 6 PRINTED: 10/ 16/ 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.

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 failed to provide staff assistance for transfers and the resident fell acquiring injuries to the face. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. The facility assessed the resident as an increased risk for falls and implemented several interventions to prevent the resident from falling before the incident. The resident was able to transfer independently using a walker. During the incident, a staff member assisted the resident to transfer between wheelchairs with a walker. The resident’s legs gave out and she fell during the transfer. After the incident, nursing and physical therapy assessed the resident and met with the family to discuss additional interventions including two staff assistance with a mechanical lift. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted the resident and their family member. The investigation included review of the resident’s record, personnel files including training records, facility incident reports, staff schedules, and related facility policy and procedures Also, the investigator toured the facility and observed staff members assisting with resident transfers. The resident resided in an assisted living facility. The resident’s diagnoses included multiple sclerosis, repeated falls, osteoporosis, and anxiety. The resident’s service plan indicated the resident received services including medication administration, stand by assist during bathing and toileting. The resident’s service plan indicated the resident was independent with transfers and mobility, utilizing a wheelchair and walked independently in her room with a walker; however, the resident also required stand by assistance for transfers to toilet. The service plan also identified fall risk interventions, which included educating the resident to use her call pendant, wear proper footwear, encourage use of her assistive device, keep environment safe from fall hazards, physical therapy services and provided staff training on proper transfers/lifting. The resident’s record included her fall history. The resident experienced several falls in the months prior to the incident. The resident had a history of self-transferring and calling staff for assistance after she had fallen. The facility provided education of importance to request help prior to transfers, the resident worked with physical therapy and installed a grab bar. The facility increased toileting assistance from four times per day to six times per day. Approximately one week prior to the incident, the facility had a care meeting with the resident, her family member, the facility nurse, and facility leadership. Discussion included concerns regarding difficulties transferring and requiring two unlicensed personnel (ULP), and physical therapy’s report of the resident’s declination of therapy appointments. The summary indicated the facility would assist the resident in finding a new facility that could support two-person transfer assistance. The facility incident report indicated an ULP was present with the resident in her room. The resident tried to transfer from a manual wheelchair to a motorized wheelchair with her walker. The resident was unable to support her weight and fell forward over her walker to the floor, hitting her nose and mouth. The resident’s nose had a small amount of bleeding. Facility staff sent the resident to the hospital for evaluation and updated family. The resident’s progress notes indicated the resident returned to the facility the same day. The facility’s internal investigation indicated ULP 1 was interviewed after the incident. ULP 1 stated she was assisting the resident and had the gait belt in place when the resident “got up” and fell forward. Per ULP 1’s training record, the facility provided training to ULP 1 on safe transfer techniques and resident care plans. The facility completed a change of condition assessment on the resident after the incident. The assessment indicated the resident had decreased mobility, balance and had an unsteady gait. The resident required extensive assistance with two ULP and a mechanical lift. The resident’s service plan was updated to reflect the change in transfer assistance. Per communication notes, following the incident, the resident declined physical therapy appointments for approximately two weeks. Physical therapy notes completed after the change in condition assessment indicated the resident’s fatigue level fluctuates and the resident can range from stand by assist to maximum assist for transfer. Physical therapy indicated the resident was unsafe with one person transfer assistance due to inconsistencies of strength and knee buckling. Approximately one month later, the resident discharged to a new facility. During an interview, ULP 1 said she assisted the resident during the incident. She applied a gait belt and the resident stood up with the walker in front of her. She positioned wheelchairs next to each other. The resident’s legs “legs gave out” and she fell forward. The facility called for emergency services because the resident was bleeding, and she was sent to the hospital. ULP 2 was present after the fall, and they did not move the resident because they were unsure of her injuries. During an interview, ULP 2 responded to a call for assistance. When she arrived, the resident was on the floor and had blood on her nose. They left the resident still and called for emergency medical services because they were unsure of her injuries. She said the resident had a transfer belt on when she arrived. She said the resident had many falls since admission. When the resident returned from the hospital, she was a mechanical lift, but the resident continued to transfer herself independently. She declined a mechanical lift and complained staff failed to use their full strength and could transfer her with their strength if they wanted. During an interview, a member of management said the resident was independent with transfers before the incident. The resident wanted to maintain her independence as long as possible despite several falls since her admission. The facility implemented several interventions to decrease the risk of falls. After the incident, the nurse and physical therapy assessed the resident, and the assessments indicated a mechanical lift was needed to safely transfer the resident. At times the resident’s legs would give out and the weight was too much for staff to bear. The resident and family declined to use of a mechanical lift. They wanted the resident to maintain her independence and felt a mechanical lift was unnecessary. During an interview, the family member said the resident reported she called for assistance with transferring. The resident used a walker and staff assist with transfer belt to transfer. The ULP who assisted with the transfer never applied a transfer belt and was untrained. She said when the resident pivot turned the ULP put her hand on her back and pushed her. She denied the staff member pushed the resident intentionally but said she should not have put her hand on the resident’s back. Sometimes people with multiple sclerosis, their legs give out. She said the facility waited two hours after the incident to call her. After the resident returned, the facility wanted the resident to use a mechanical lift for transfers, but the resident and family wanted to maintain the resident’s independence. During an interview, the resident said she asked ULP 1 to “boost” her up. She said ULP 1 said she could not boost her up. During the transfer ULP 1 placed her hand on the resident’s back to steady her. The resident fell forward over her walker. Facility staff called for emergency medical assistance. After she fell, the resident wanted ULP 1 and ULP 2 to get her up, but staff declined to move her. She said paramedics arrived and assisted her to the gurney. She said staff watched the paramedics but did not help them. She said staff should have helped get her off the floor when paramedics were present. After she returned from the hospital, the facility wanted her to use a mechanical lift. The resident felt a mechanical lift was unnecessary and she wanted to maintain her independence. 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.

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 resident fell multiple times. The resident’s health deteriorated, and the resident could no longer walk. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. Evidence did not indicate the facility neglected the resident. Although the resident died as a result of a recent fall, the resident had been on hospice due to his health declining. The facility implemented interventions after falls, contacted the provider, and communicated with family. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted hospice. The investigation included review of the resident record, death record, hospital records, hospice records, physical therapy notes, facility incident reports, personnel files, staff schedules, and related facility policy and procedures. Also, the investigator observed the memory care unit, as well as residents and how staff engaged with and assisted them. The resident resided in an assisted living memory care unit. The resident’s diagnoses included weakness and frequent falls. The resident’s service plan included assistance with safety checks every two hours, toileting, medication administration, and mobility. The resident’s service plan also included the potential or actual risk for falls and injuries. Interventions in place included educating and encouraging the resident to use his call button, encouraging the use of assistive devices, ensuring the resident had adequate lighting at night and supportive shoes, keeping the resident’s environment free of clutter and personal items nearby, and using a raised toilet seat. The resident’s assessment indicated he occasionally had poor judgement, made unsafe decisions, and had a high potential for falls. This assessment also indicated the resident required hands on assistance and used a wheelchair or walker for mobility. The resident’s record indicated the resident fell numerous times while at the facility. Generally, these falls were unwitnessed or witnessed by his wife. The facility encouraged the family to transfer the resident into the memory care unit for closer observation and increased care. An incident report indicated the resident fell, likely while attempting to use the bathroom. The resident denied pain but grimaced and said “ouch” when moved. At baseline, the resident did not need support to walk but required three staff to support him after the fall due to being unable to support his own body weight. The resident did not have a fever but had three loose stools that day and a history of clostridium difficile (an infection of the large intestine causing diarrhea), so the facility sent the resident to the emergency department with family approval. The resident’s hospital record indicated the resident had an elevated heart rate, fever, and reported a little bit of a cough, but he did not appear in acute distress overall or in respiratory distress while in the emergency department. The hospital diagnosed the resident with COVID. During his hospitalization, the resident developed a productive cough, low oxygen levels, and bacterial pneumonia. The resident returned to the facility after six days. A progress note indicated the resident returned from the hospital and required assistance of one staff with walking, transfers, and cares. Another progress note indicated the facility obtained an order from the resident’s provider for physical therapy (PT) to evaluate and treat for gait, balance, and strengthening. PT notes indicated the resident participated in therapy sessions but needed cues, became fatigued, and sometimes struggled to stay alert through the sessions. A progress note indicated the family chose to discontinue PT services and pursue hospice. The resident admitted onto hospice the next day. Another incident report indicated the resident had been found on the ground after experiencing an unwitnessed fall. The resident reported he tried standing up from his wheelchair to change the channel on his television. The facility and hospice assessed the resident and agreed he should have an x-ray completed. The facility notified the resident’s provider regarding the fall and asked for an order for the x-ray. The provider did not provide an order for an outside service to complete an x-ray but wanted the resident to go to the provider’s office for an assessment. The facility, family, and hospice agreed to continue comfort measures instead of bringing the resident into the provider’s office due to his pain level. A progress note indicated the family declined to have the resident sent to the emergency department for an x-ray and continue comfort cares through hospice. The medication administration record indicated he received narcotic pain medication and medication for muscle spasms and anxiety. The service delivery record indicated he received his scheduled services, including toileting and safety checks. A progress note indicated the resident died five days after this last fall. The resident’s death record indicated he died from complications of immobility due to a right leg fracture from a fall. The resident’s hospice records indicated the facility and hospice were in communication regarding the resident’s condition, pain, and medications during end of life. During an interview, the licensed assisted living director (LALD) stated the resident started falling after he initially moved into assisted living. A lot of the time, he either did not want to wait for assistance, or he did not use his call button. A couple of times he fell, his wife used her call button afterward to get help. The resident also had poor eating habits which made him thin and fragile. Staff at the facility were all concerned about his falls. They tried to help and work with him and encouraged the use of his call button. The facility held care conferences with family, encouraged them to move the resident to memory care, and get a different bed set up so the resident and staff could more easily maneuver around the bed. During an interview, nurse-1 stated the some of the resident’s falls seemed to be related to a lack of judgement and not drinking a lot of fluids. Additionally, the resident refused cares sometimes, although this improved after he moved to the memory care unit. The resident’s COVID diagnosis seemed to come out of nowhere, since he had not been displaying symptoms. After this, the resident seemed like a different person and could no longer transfer on his own. He slept most of the day and needed assistance with everything. COVID took a toll on the resident, and hospice was ultimately the best thing for him. During an interview, nurse-2 stated when the resident fell for the last time, staff tried to obtain an order for a portable x-ray company to complete an x-ray at the facility. The provider, however, declined to order this. Because the resident had been on hospice, the resident would have had to discharge off hospice if he went to the emergency department. They gave family the option to send him in or not, and the family chose to have hospice help manage his pain. There had been an issue with the resident’s narcotic orders being transcribed into the During an interview, a family member stated he felt like the resident did not get the care he should have received. 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. The resident is deceased. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Not Applicable. Action taken by facility: The facility contacted the provider, implemented interventions to attempt to help prevent future falls, and communicated with family and hospice.