Autumn Lane Inc.

STATE LICENSING COMPLIANCE REPORT Report #: HL237258622C Date Concluded: June 6, 2024 Name, Address, and County of Facility Investigated: Autumn Lane Inc 36858 Pincherry Road Cohasset, MN 55721 Itasca County Facility Type: Assisted Living Facility with Evaluator’s Name: James P. Larson, RN Dementia Care (ALFDC) Special Investigator The Minnesota Department of Health conducted a complaint investigation to determine compliance with state laws and rules governing the provision of care under Minnesota Statutes, Chapter 144G. The purpose of this complaint investigation was to review if facility policies and practices comply with applicable laws and rules. No maltreatment under Minnesota Statutes, Chapter 626 was alleged. To view a copy of the correction orders, if any, please visit: https://www.health.state.mn.us/facilities/regulation/directory/provcompselect.html, or call 651-201-4201 to be provided a copy via mail or email. If you are viewing this report on the MDH website, please see the attached state form. PRINTED: 06/11/2024 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 _____________________________ 23725 04/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 36858 PINCHERRY ROAD AUTUMN LANE INC COHASSET, MN 55721 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 23, 2024, the Minnesota Department of Health initiated an investigation of complaint #HL237257622C. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 8J1611 If continuation sheet 1 of 1

correction orders issued pursuant to the July 12, 2023 survey. In accordance with Minn. Stat. § 144G.31 Subd. 4 (a), state correction orders issued pursuant to the last survey, completed on July 12, 2023, found not corrected at the time of the October 4, 2023, follow-up survey are as follows: 0780-Fire Protection And Physical Environment- 144g.45 Subd. 2 (a) (1) 0800-Fire Protection And Physical Environment- 144g.45 Subd. 2 (a) (4) 2040-Fire Protection And Physical Environment- 144g.81 Subdivision 1 The details of the violations noted at the time of this follow-up survey completed on October 4, 2023 (listed above), are on the attached State Form. Brackets around the ID Prefix Tag in the left hand column, e.g., {2 ----} will identify the uncorrected tags. In accordance with Minn. Stat. § 144G.31 Subd. 4, MDH may assess fines based on the level and scope of the vi ol ati ons ; however, no immediate fines are assessed for this survey of your facility. DOCUMENTATIO ONF ACTION TO COMPLY In accorda nc e wi th Mi nn. Sta t. § 144G.30, Subd. 5(c), the licens ee mus t doc ument acti ons ta ken 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. CORRECTIO NORDER RECONSIDERATIO PNROCESS In accordance with Minn. Stat. § 144G.32, Subd. 2, you may challenge the correction order(s) issued, including the level and scope, and any fine assessed through the correction order reconsideration process. The request for reconsideration must be in writing and received by MDH within 15 calendar days of the correction order receipt date. A state correction order under Minn. Stat. § 144G.91, Subd. 8, Free from Maltreatment is associated An equal opportunity employer. Le tter ID: 8GKP Revised 04/14/2023 Autumn Lane, Inc. February 1, 2024 Pa ge 2 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. To submit a reconsideration request, please visit: https: / / forms. web. health. state. mn. us/ form/ HRDAppealsForm We urge you to review these orders carefully. If you have questions, please contact Tim Hanna at You are encouraged to retain this document for your records. It is your responsibility to share the information contained in the letter and/ or state form with your organization’s Governing Body. Sincerely, Tim Hanna, Interim Supervisor State Engineering Services Section Email: Tim.Hanna@state. mn.us Telephone: 507-208-8982 Fax: 1-866-890-9290 PMB PRINTED: 02/ 01/ 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: ______________________ R B. WING _____________________________ 23725 10/ 04/ 2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 36858 PINCHERRY ROAD AUTUMN LANE INC COHASSET, MN 55721 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****** ASSISTED LIVING PROVIDER LICENSING CORRECTION ORDER In accordance with Minnesota Statutes, section 144G. 08 to 144G. 95, this correction order( s) has been issued pursuant to a survey. Determination of whether a violation has been 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: Project # SL23725015- 1 On October 4, 2023, the Minnesota Department of Health conducted a revisit at the above provider to follow-up on orders issued pursuant to a survey completed between July 10, 2023, and July 12, 2023. At the time of the survey, there were nineteen (19) active resident receiving services under the Assisted Living Dementia Care llicense. As a result of the revisit, the following orders were reissued. {0 110} 144G. 10 Subdivision 1a Assisted living director {0 110} SS= C license required Each assisted living facility must employ an assisted living director licensed or permitted by the Board of Executives for Long Term Services and Supports. LABORATORY DIRECTOR' S OR PROVIDER/ SUPPLIER REPRESENTATIVE' S SIGNATURE TITLE (X6) DATE STATE FORM 6899 691K12 If continuation sheet 1 of 13 PRINTED: 02/ 01/ 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: ______________________ R B. WING _____________________________ 23725 10/ 04/ 2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 36858 PINCHERRY ROAD AUTUMN LANE INC COHASSET, MN 55721 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) {0 110} Continued From page 1 {0 110} This MN Requirement is not met as evidenced by: No further action needed. {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 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 assisted living facilities. (c) The facility must maintain written evidence of compliance with this subdivision. This MN Requirement is not met as evidenced by: No further action needed. {0 550} 144G. 41 Subd. 7 Resident grievances; reporting {0 550} SS= F maltreatment All facilities must post in a conspicuous place information about the facilities' grievance procedure, and the name, telephone number, and email contact information for the individuals who are responsible for handling resident grievances. The notice must also have the contact information for the Office of Ombudsman for Long- Term Care and the Office of Ombudsman for Mental Health and Developmental Disabilities and must have information for reporting suspected maltreatment to the Minnesota Adult Abuse Reporting Center. The notice must also STATE FORM 6899 691K12 If continuation sheet 2 of 13 PRINTED: 02/ 01/ 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: ______________________ R B. WING _____________________________ 23725 10/ 04/ 2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 36858 PINCHERRY ROAD AUTUMN LANE INC COHASSET, MN 55721 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) {0 550} Continued From page 2 {0 550} state that if an individual has a complaint about the facility or person providing services, the individual may contact the Office of Health Facility Complaints at the Minnesota Department of Health. This MN Requirement is not met as evidenced by: No further action needed. {0 630} 144G. 42 Subd. 6 (b) Compliance with {0 630} SS= D 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 and other vulnerable adults. For purposes of the abuse prevention plan, abuse includes self- abuse. This MN Requirement is not met as evidenced by: No further action needed. {0 650} 144G. 42 Subd. 8 Employee records {0 650} SS= E (a) The facility must maintain current records of each paid employee, each regularly scheduled volunteer providing services, and each individual contractor providing services.