Riley Crossing Senior Living.

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 . . ." 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), 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 An equal opportunity employer . Letter ID: IS7N REVISE 0D9/13/2021 Riley Crossing Senio rLiving October 8, 2025 Page 2 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 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 JMD PRINTED: 10/08/2025 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 _____________________________ 35195 08/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 620 ALDRICH DR RILEY CROSSING SENIOR LIVING CHANHASSEN, MN 55317 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 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. SL35195016 PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On August 25, 2025, through August 27, 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 153 residents; 76 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 subd. 1, 2, and 3. 01440 144G.62 Subd. 4 Supervision of staff providing 01440 SS=F delegated nurs LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 DG8U11 If continuation sheet 1 of 13 PRINTED: 10/08/2025 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 _____________________________ 35195 08/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 620 ALDRICH DR RILEY CROSSING SENIOR LIVING CHANHASSEN, MN 55317 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) 01440 Continued From page 1 01440 (a) Staff who perform delegated nursing or therapy tasks must be supervised by an appropriate licensed health professional or a registered nurse according to the assisted living facility's policy where the services are being provided to verify that the work is being performed competently and to identify problems and solutions related to the staff person's ability to perform the tasks. Supervision of staff performing medication or treatment administration shall be provided by a registered nurse or appropriate licensed health professional and must include observation of the staff administering the medication or treatment and the interaction with the resident. (b) The direct supervision of staff performing delegated tasks must be provided within 30 calendar days after the date on which the individual begins working for the facility and first performs the delegated tasks for residents and thereafter as needed based on performance. This requirement also applies to staff who have not performed delegated tasks for one year or longer. This MN Requirement is not met as evidenced by: Based on observation, interview, and record review, the licensee failed to ensure a registered nurse (RN) conducted direct supervision of staff performing a delegated task within 30 days of providing services for one of two employees (unlicensed personnel (ULP)-C). 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, but was not likely to cause serious injury, impairment, or death), and STATE FORM 6899 DG8U11 If continuation sheet 2 of 13 PRINTED: 10/08/2025 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 he got another resident’s regular food in the dining room. As a result, he aspirated, developed pneumonia, and passed away a week later. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. Although the resident did gain access to food from a regular diet, this was an isolated event which had not occurred before with this resident. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigation included review of the resident’s records, internal investigation documentation, hospice records, incident reports, death certificate, policies, and procedures. The resident resided in an assisted living secured memory care building. The resident’s diagnoses include dementia and chronic pain. The resident’s service plan included assistance with medication and meals. The resident was on hospice services. One evening, the resident was in the dining room eating dinner, and it was discovered by the unlicensed caregivers he had taken the meal of other residents which was not his prescribed diet. The next morning, when an unlicensed caregiver went to wake him up for breakfast, it was observed that he was very tired and having difficulty breathing. The nursing staff assessed the resident, and hospice was updated. The resident was diagnosed with aspiration pneumonia and was prescribed two oral antibiotics at that time. Unfortunately, he passed away six days later. According to hospice records, the resident was prescribed a pureed diet and nectar-thick liquids due to swallowing issues and aspiration pneumonia. The records also indicated that the resident found joy in food. A review of the resident’s medical record did not identify a similar incident occurring before this occasion. During an interview, the manager stated the resident was at the table with other residents who had regular food, and he took their food when one of them left the table. The unlicensed caregivers intervened when the realized this and notified nursing. Unfortunately, he aspirated. He returned to meals after the incident but sat at a different table with people who had a similar diet order where caregivers assisted him with meals. Over the course of about a week he began to decline and passed away. Following the incident, caregivers were instructed to seat all residents with the same diet together and the facility educated all staff members through verbal huddles during mealtimes. During an interview, a family member stated she was aware of the incident and said she did not view it as the facility's fault when the resident took his neighbor’s regular food. She stated the facility provided him with the soft food as per the doctor’s orders, and unfortunately, the incident occurred, contributed to his passing. During an interview, the registered nurse stated the resident did not like pureed diet and refused to eat it. While sitting at the table, at the end of the meal, he grabbed someone else's plate and ate their meal. The nurse was notified by caregivers about this incident, and he went to assess the situation. He then arranged for the resident to sit with others who had the same dietary restrictions to reduce the risk of this recurring. The resident was under hospice care, and both the family and hospice were notified of the situation. During an interview, an unlicensed caregiver stated the physician ordered the resident to be on a pureed diet, which he did not like. The resident sat at a table with others who had regular food and he ate some of the regular food at the table. Following the incident, he was placed with individuals who had similar diet restrictions. 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 was deceased. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Not Applicable. Action taken by facility: The family and hospice were notified of the situation, and an internal investigation was initiated. The facility provided dietary training update caregivers on dietary changes during daily huddles and review the communication plan regarding diets and liquid types which was posted in the kitchen cabinets and caregiver’s workspaces. Furthermore, the facility implemented a practice seating residents with similar diets together in the dining room to reduce the risk of recurrence of this type of incident. 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 Develo pmental Disabilities PRINTED: 05/08/2024 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 _____________________________ 35195 04/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 620 ALDRICH DR RILEY CROSSING SENIOR LIVING CHANHASSEN, MN 55317 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 April 3rd 2024, the Minnesota Department of Health initiated an investigation of complaints #HL351958826M/HL351956424C and #HL351958544M/HL351955922C. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 R7ZQ11 If continuation sheet 1 of 1

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 by failing to administer his gabapentin for six days, resulting in increased pain. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. Although the gabapentin was missed for six day the facility used other medications the resident had available to treat his pain. The occurrence was isolated. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigation included review of the resident’s records, internal investigation documentation, incident reports, personnel files, staff schedules, policies, and procedures. The resident resided in an assisted living secured memory care building. The resident’s diagnoses include dementia and chronic pain. The resident’s service plan included assistance with all activities of daily living, medications, meals, and housekeeping. One day the manager visited the memory care unit when the resident expressed pain to her. She instructed the unlicensed caregiver to administer pain medication to the resident. At that time, the unlicensed caregiver informed her that the resident was out of gabapentin and had been for six days. During an interview, the manager, who was a nurse, stated the resident had been without his gabapentin for six days while in hospice care. Initially, the resident received all his medications from one outside pharmacy, however it became necessary to change to a new pharmacy and the hospice pharmacy which led to confusion and the resident ran out of gabapentin. Despite the medication oversight, the resident did not require hospitalization. However, he experienced increasing pain so in response the facility caregivers gave him provided alternative “as needed” medications like Tylenol, Dilaudid, a lidocaine patch, and tramadol which helped to address his pain. The manager stated the resident reported suicidal thoughts, prompting nursing staff to send him to the hospital for evaluation, but he was discharged back to the facility on the same day. To address medication management issues, the manager initiated a refill medications binder system. This involved a pharmacy refill page, where the unlicensed caregiver would place stickers, which the nursing staff checked daily and submitted to the pharmacy. The nurses also conducted weekly cart checks. During an interview, the registered nurse stated he no longer worked at the facility and did not remember anything about the incident. However, when he worked at facility, he said that he used to audit the entire medication cart every Wednesday to ensure that medications were filled. He stated that the unlicensed caregiver would often call him on his work cell to request medication refills. Alternatively, they would return the old card to him and inform him to reorder medications. Typically, he would reorder medications if the supply was less than 7 days. During an interview, unlicensed caregiver #1 stated she could not remember the incident. However, she said there was a medication refill log, which the nurse checked daily. In instances where the nurse was unavailable, unlicensed caregivers would inform the triage. She also noted that the nurse frequently audited the medication cart. During an interview, unlicensed caregiver #2 said she remembered the incident. She said at the time, the resident was receiving medications from the outside pharmacy and caregivers would contact the pharmacy three days prior to the resident’s supply running low, but there was a delay in filling the prescription. She also stated when medication levels were low, she informed the nurses to reorder. Unlicensed caregiver #2 stated following the incident the facility implemented a binder system with refill pages. When medications reached five days or less, unlicensed caregivers were instructed to remove the label and place it in the binder or write it down. Nurses were responsible for checking the binder daily to refill medications. 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 was deceased. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Not Applicable. Action taken by facility: Staff promptly ordered medication to arrive right away from the pharmacy to address the situation. A medication error was processed, and an action plan was created. The manager reviewed the medication dashboard daily and followed up with support nurses regarding the status of all missed medications. Additionally, the nurse conducted daily checks with medication passers to obtain verbal reports on medications running low. Education was provided to unlicensed caregivers on completing re-order forms for the pharmacy and creating a binder for them to submit refill requests, ensuring medications could be ordered in a timely manner. 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: 05/08/2024 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 _____________________________ 35195 04/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 620 ALDRICH DR RILEY CROSSING SENIOR LIVING CHANHASSEN, MN 55317 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 April 3rd 2024, the Minnesota Department of Health initiated an investigation of complaints #HL351958826M/HL351956424C and #HL351958544M/HL351955922C. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 R7ZQ11 If continuation sheet 1 of 1

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 the specific statute(s). An equal opportunity employer. Letter ID: IS7N REVISED 09/13/2021 Riley Crossing Senior Living July 10, 2023 Page 2 CORRECTION ORDER RECONSIDERATION PROCESS In accordance with Minn. Stat. § 144G.32, Subd. 2, you may challenge the correction order(s) issued, including the level and scope, and any fine assessed through the correction order reconsideration process. The request for reconsideration must be in writing and received by the MDH within 15 calendar days of the correction order receipt date. A state correction order under Minn. Stat. § 144G.91, Subd. 8, Free from Maltreatment is associated with a maltreatment determination by the Office of Health Facility Complaints. If maltreatment is substantiated, you will receive a separate letter with the reconsideration process under Minn. Stat. § 626.557. Please email reconsideration requests to: Health.HRD.Appeals@state.mn.us. Please attach this letter as part of your reconsideration request. Please clearly indicate which tag(s) you are contesting and submit information supporting your position(s). Please address your cover letter for reconsideration requests to: Reconsideration Unit 85 East Seventh Place St. Paul, MN 55164-0970 You are encouraged to retain this document for your records. It is your responsibility to share the information contained in the letter and state form with your organization’s Governing Body. If you have any questions, please contact me. Sincerely, Kelly Thorson, Supervisor State Evaluation Team Email: kelly.thorson@state.mn.us Telephone: 320-223-7336 Fax: 651-281-9796 PMB PRINTED: 07/10/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ 35195 B. WING _____________________________ 06/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 620 ALDRICH DR RILEY CROSSING SENIOR LIVING CHANHASSEN, MN 55317 (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****** ASSISTED LIVING PROVIDER LICENSING CORRECTION ORDER(S) In accordance with Minnesota Statutes, section 144G.08 to 144G.95, these correction orders are issued pursuant to a survey. Determination of whether violations are corrected requires compliance with all requirements provided at the Statute number indicated below. When Minnesota Statute contains several items, failure to comply with any of the items will be considered lack of compliance. INITIAL COMMENTS: SL35195015 On June 6, 2023, through June 8, 2023, the survey at the above provider, and the following correction orders are issued. At the time of the survey, there were 69 active residents receiving services under the Assisted Living with Dementia Care license. 0 630 144G.42 Subd. 6 (b) Compliance with 0 630 SS=F requirements for reporting ma (b) The facility must develop and implement an individual abuse prevention plan for each vulnerable adult. The plan shall contain an individualized review or assessment of the person's susceptibility to abuse by another individual, including other vulnerable adults; the person's risk of abusing other vulnerable adults; and statements of the specific measures to be taken to minimize the risk of abuse to that person LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 8C1J11 If continuation sheet 1 of 8 PRINTED: 07/10/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ 35195 B. WING _____________________________ 06/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 620 ALDRICH DR RILEY CROSSING SENIOR LIVING CHANHASSEN, MN 55317 (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) 0 630 Continued From page 1 0 630 and other vulnerable adults. For purposes of the abuse prevention plan, abuse includes self-abuse. This MN Requirement is not met as evidenced by: Based on interview and record review, the licensee failed to ensure an individual abuse prevention plan (IAPP) was updated when a new risk of the resident causing harm to self and others was identified for one of one resident (R1). 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, but was not likely to cause serious injury, impairment, or death) and was issued at a widespread scope (when problems are pervasive or represent a systemic failure that has affected or has potential to affect a large portion or all the residents). The findings include: R1 was admitted to the facility on February 27, 2023, and received services which included assistance with hearing aid, medication administration, laundry, and housekeeping. R1's IAPP dated March 10, 2023, indicated R1 was not at risk for abuse, was not at risk to abuse others, and did not pose a risk of self-abuse. R1's record showed a request to R1's provider, dated April 28, 2023, requesting a PRN (as needed) anti-anxiety medication stating patient is "threatening to break things, yelling, verbal aggression. No physical behaviors yet but we are concerned. She has also threatened to take her own life but has no plan." The request was STATE FORM 6899 8C1J11 If continuation sheet 2 of 8 PRINTED: 07/10/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ 35195 B. WING _____________________________ 06/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 620 ALDRICH DR RILEY CROSSING SENIOR LIVING CHANHASSEN, MN 55317 (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) 0 630 Continued From page 2 0 630 granted with an order for Seroquel 12.5 mg four times a day as needed for anxiety, agitation. R1's May 2023 medication administration record showed the resident received this medication 15 times. R1's IAPP was not updated to reflect these changes. On June 7, 2023, at 1:00 p.m., CNS-B stated their process would be the support nurses monitor PRN medication usage and they should have contacted R1's provider for a follow up. A nurse should have reassessed the resident regarding the behaviors stating, "it was missed". Whoever did the assessment would also update the IAPP. The licensee's Assessments of Clients- Initial and Ongoing policy dated August 1, 2021, indicated ongoing client reassessment and monitoring will be conducted as needed, based on changes in the needs of the client. The comprehensive assessment will include the client's areas of vulnerability and susceptibility to maltreatment and whether the client poses a risk to other vulnerable adults.