Norbella Centerville.

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 Statemen tof 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 . . ." IMPOSITION OF FINES In accordance with Minn. Stat. § 144G3. 1, 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: Leve l1: no fines or enforcement; Leve l2: a fine of $500 per violation, in addition to any enforcement mechanism authorized in § 144G2. 0; Leve l3: a fine of $1,000 per incident, in addition to any enforcement mechanism authorized in § 144G2. 0; An equal opportunity employer . Letter ID: IS7N REVISE 0D9/13/2021 Norbella Centerville Novembe r5, 2025 Page 2 Leve l4: a fine of $3,000 per incident, in addition to any enforcement mechanism authorized in § 144G2. 0; Leve l5: a fine of $5,000 per violation, in addition to any enforcement mechanism authorized in § 144G2. 0. Therefore ,in accordance with Minn. Stat. §§ 144G0. 1 to 144G9. 999, the following fines are assessed pursuant to this survey: St - 0 - 0775 - 144g.45 Subd. 2. (a) - Fire Protection And Physica lEnvironment - $500.00 Therefore ,in accordance with Minn. Stat. §§ 144G0. 1 to 144G9. 999, the total amount you are assesse dis $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. § 144G3. 0, Subd .5(c), the licensee must docum ent 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: x Identify how the area(s) of noncompliance was corrected related to the resident(s)/ employees( ) 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 REQUESTIN AG HEARING Alternatively ,in accordance with Minn. Stat. § 144G3. 1, Subd .5(d), an assisted living provider that has been assesse da fine under this subdivision has a right to a reconsideration or a hearing under this section and chapter 14. Pursuan tto Minn. Stat. § 144G2. 0, 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. Norbella Centerville Novembe r5, 2025 Page 3 To submit a hearing request, please visit: https:/ / forms.web.health.state.mn.us/form/ HRDAppealsForm To appea lfines via reconside ration, please follow the pr ocedur e outlined above. Plea se note that you may request a reconsideration or a hearing, but not both. If you wish to contest tags without fines in 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/ 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, Kelly Thorson ,Supervisor State Evaluation Team Email: Kelly.Thorson@state.mn.us Telephone :320-223-7336 Fax :1-866-890-9290 CLN PRINTED: 11/05/2025 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 _____________________________ 39268 10/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2025 MICHAUD WAY NORBELLA CENTERVILLE CENTERVILLE, MN 55038 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 *****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." issued pursuant to a survey. The 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. SL39268016-0 PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On October 20, 2025, through October 22, 2025, STATES,"PROVIDER'S PLAN OF the Minnesota Department of Health conducted a CORRECTION." THIS APPLIES TO full survey at the above provider and the FEDERAL DEFICIENCIES ONLY. THIS following correction orders are issued. At the time WILL APPEAR ON EACH PAGE. of the survey, there were 38 residents; 38 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. 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 OM3S11 If continuation sheet 1 of 20 PRINTED: 11/05/2025 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 _____________________________ 39268 10/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2025 MICHAUD WAY NORBELLA CENTERVILLE CENTERVILLE, MN 55038 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) 0 480 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.

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 alleged perpetrator abused the resident when she swore at the resident. Investigative Findings and Conclusion: The Minnesota Department of Health determined abuse was inconclusive. While the alleged perpetrator was in the resident’s room when swearing was reportedly overheard. The findings available to the investigation were not sufficient to determine if the behavior the occurred nor if it met the definition of abuse. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted law enforcement, family members and outside care providers for the resident. The investigation included review of the resident record, facility records, employee records, law enforcement records and facility policies. Also, the investigator observed interactions between staff, residents, and visitors. The resident resided in an assisted living memory care unit The resident’s diagnoses included Alzheimer’s disease, recurrent falls, and occasional incontinence. The resident’s service plan included assistance with transferring, toileting, dressing and bathing. The resident’s assessment indicated the resident had falls related to impulsive moves to get out of her wheelchair. The resident’s assessment also indicated the resident was pleasant but confused with moderate disorientation to person, place and time. The resident’s record identified facility initiated an internal investigation after it was informed the alleged perpetrator, who was an unlicensed caregiver, was overheard swearing at the resident. The record also indicated the day after the incident, a bruise was noted on the residents left hand. The internal investigation included a statement from an employee who said she was working in the general area of the resident’s room when she overhead the AP swearing inappropriately. The same document indicated video footage showed the AP was in the resident’s room when this event allegedly took place. However, the footage did not include audio. During an interview, a nurse stated the resident was questioned about the incident, but the resident could not recall anything incident. The nurse also stated it is unclear how the bruise happened on the resident’s hand. During an interview, an unlicensed caregiver who was familiar with the resident stated she believed the bruise on the resident’s hand was from an intravenous infusion the resident had when she was at the emergency department. The residents record also indicated she had been sent to the emergency room three days before this incident. During an interview, the alleged perpetrator denied ever speaking to a resident in such a way. In conclusion, the Minnesota Department of Health determined abuse 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. Abuse: Minnesota Statutes section 626.5572, subdivision 2. "Abuse" means: (a) An act against a vulnerable adult that constitutes a violation of, an attempt to violate, or aiding and abetting a violation of: (1) assault in the first through fifth degrees as defined in sections 609.221 to 609.224; (2) the use of drugs to injure or facilitate crime as defined in section 609.235; (3) the solicitation, inducement, and promotion of prostitution as defined in section 609.322; and (4) criminal sexual conduct in the first through fifth degrees as defined in sections 609.342 to 609.3451. A violation includes any action that meets the elements of the crime, regardless of whether there is a criminal proceeding or conviction. (b) Conduct which is not an accident or therapeutic conduct as defined in this section, which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to, the following: (1) hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult; (2) use of repeated or malicious oral, written, or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening; Vulnerable Adult interviewed: attempted but cognitively impaired Family/Responsible Party interviewed: Yes Alleged Perpetrator interviewed: Yes Action taken by facility: The facility completed an internal investigation and then provided re-education to staff on what abuse can sound like. The facility no longer employed the alleged perpetrator. Action taken by the Minnesota Department of Health: No further action at this time. cc: The Office of Ombudsman for Long Term Care The Office of Ombudsman for Mental Health and Developmental Disabilities PRINTED: 10/17/2024 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 _____________________________ 39268 09/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2025 MICHAUD WAY NORBELLA CENTERVILLE CENTERVILLE, MN 55038 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 On September 24, 2024, the Minnesota Department of Health initiated an investigation of complaint #HL392687558C/#HL392685427M. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 NYYD11 If continuation sheet 1 of 1

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 alleged perpetrators (APs), three unlicensed caregivers, neglected the resident when the APs failed to follow the resident’s care plan and provide safety checks and comfort cares over the night shift. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was inconclusive. Although, the resident passed away, the resident was on hospice cares was expected to decline based on her hospice diagnosis. The investigation found insufficient evidence the resident’s cares were not provided nor evidence it affected the outcome for the resident. A care plan was created for services the resident required and the APs documented the tasks were completed on their shift. The investigator conducted interviews with facility staff members, including administrative staff and unlicensed staff. The investigator contacted a family member. The investigation included An equal opportunity employer. review of the resident’s medical record, employee records, facility policy and procedures. Also, the investigator completed an onsite visit. The resident resided in an assisted living facility. The resident lived alone in her own apartment. The resident’s diagnoses included encephalopathy (damage or disease that affects brain function), respiratory failure, and kidney disease. The resident’s care plan included safety checks, repositioning, and incontinence care every two hours. The same care plan failed to indicate staff should also perform tasks “as needed.” The resident’s care plan also indicated the resident was bed bound with limited speech, non-ambulatory, weakness related to dying process, and fully dependent on two staff for bed mobility. The resident’s admission assessment indicated resident did not report pain and skin was intact. This same assessment indicated resident currently in the dying process and on hospice services. The nursing progress note indicated the day shift staff entered the resident’s room for morning rounds and found the resident unresponsive. The facility nurse was notified, assessed the resident, and found the resident to be deceased. The facility investigation notes indicated facility management called the alleged perpetrators who worked the overnight shift to discuss that the resident was found by day shift caregivers passed away. Facility management inquired of the APs if overnight cares had been provided according to the care plan. The same document indicated each of the APs said the care plan had been followed and there were no concerns to report off to the next shift. The same facility investigation notes indicated from the time of the last safety check until the time of the next safety check to be completed by morning staff there was a little over two-hour period where staff did not have scheduled checks on the resident. A review of licensed staff member’s written statement indicated she assessed the resident not to be breathing, cool to touch, and based on physical observation of the resident concluded overnight staff had not completed scheduled tasks for this resident. The electronic documentation of cares indicated overnight staff documented four times performed safety checks/cares staff checked on the resident in correlation to care plan. A review of the overnight shift communication report indicated the resident was stable. During interviews, separately each one of the APs stated the resident acknowledged when staff were in the room during rounds as indicated with eye contact or wave of the hand. The staff stated no safety checks had been missed and all tasks were completed every two hours as care planned. During an interview, facility administration stated no video cameras are present in the assisted living side of the facility nor was there a camera present in the resident’s room. During an interview, an unlicensed caregiver stated communication between shift changes occurs both verbally and in writing. The same caregiver stated when staff come on shift, they receive report, prepare for the shift, and thereafter, start safety checks on residents. 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: No, deceased. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Yes the Action taken by facility: The alleged perpetrators are no longer employed at the facility. Action taken by the Minnesota Department of Health: No further action. cc: The Office of Ombudsman for Long Term Care The Office of Ombudsman for Mental Health and Developmental Disabilities PRINTED: 10/25/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ C B. WING _____________________________ 39268 06/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2025 MICHAUD WAY NORBELLA CENTERVILLE CENTERVILLE, MN 55038 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 On June 28, 2023, the Minnesota Department of Health initiated an investigation of complaint #HL392687128C/#HL392684164M. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 NDXC11 If continuation sheet 1 of 1

CORRECTION ORDERS The enclosed State Form documents the state correction orders. The Department of Health documents state correction orders using federal software. Tag numbers are assigned to Minnesota state statutes for Home Care Providers. 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 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 for widespread violations; Level 3: a fine of $3,000 per violation per incident, in addition to any enforcement mechanism authorized in § 144G.20. Level 4: a fine of $5,000 per incident, in addition to any enforcement mechanism authorized in § 144G.20. An equal opportunity employer. Letter ID: 9GJX Revise d04/20/2023 Norbella Centerville September 28, 2023 Page 2 In accordance with Minn. Stat. § 144G.20, Subd. 4(a)(5), the Department of Health imposes fine amounts of either $1,000 or $5,000 to licensees who are found to be responsible for maltreatment. The Department of Health imposes a fine of $1,000 for each substantiated maltreatment violation that consists of abuse, neglect, or financial exploitation according to Minn. Stat. § 626.5572. Subds. 2, 9, 17. The Department of Health also may impose a fine of $5,000 for each substantiated maltreatment violation consisting of sexual assault, death, or abuse resulting in serious injury. In accordance with Minn. Stat. § 144G.31, Subd. 4(a)(5)(b), when a fine is assessed against a facility for substantiated maltreatment, the commissioner shall not also impose an immediate fine under this chapter for the same circumstance. Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, the following fines are assessed pursuant to this survey: St - 0 - 0510 - 144g.41 Subd. 3 - Infection Control Program - $500.00 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 Per 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 residents/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 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 Department of Health 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. Norbella Centerville September 28, 2023 Page 3 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 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. Requests for hearing may be emailed to: H ealth.HRD.Appeals@state.mn.us. To appeal fines via reconsideration, please follow the procedure outlined above. P lease note that you may request a reconsideration or a hearing, but not both. 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. If you have any questions, please contact me. Sincerely, Jess Schoenecker, Supervisor State Evaluation Team Email: jess.schoenecker@state.mn.us Telephone: 651-201-3789 Fax: 1 -866-890-9290 HHH PRINTED: 09/28/2023 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 _____________________________ 39268 09/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2025 MICHAUD WAY NORBELLA CENTERVILLE CENTERVILLE, MN 55038 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. SL39268015-0 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 19 active residents WILL APPEAR ON EACH PAGE. receiving services under the provisional Assisted Living with Dementia Care license. THERE IS NO REQUIREMENT TO SUBMIT A PLAN OF CORRECTION FOR The immediacy of order 2310 was removed on VIOLATIONS OF MINNESOTA STATE September 13, 2023 based on supervisor review. STATUTES. The scope and level remain unchanged. 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. 0 510 144G.41 Subd. 3 Infection control program 0 510 SS=F (a) All assisted living facilities must establish and maintain an infection control program that LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 7PDD11 If continuation sheet 1 of 15 PRINTED: 09/28/2023 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.