Maple Woods Assisted 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 necessary to ensure the health, safety, and welfare of residents in your care. STATE CORRECTION ORDERS The enclosed State Form documents the state correction orders. MDH documents state licensing correction orders using federal software. Tag numbers are assigned to Minnesota state statutes for Assisted Living Facilities. The assigned tag number appears in the far left column entitled "ID Prefix Tag." The state statute number and the corresponding text of the state statute out of compliance are listed in the "Summary Statement of Deficiencies" column. This column also includes the findings that are in violation of the state statute after the statement, "This MN Requirement is not met as evidenced by . . ." In accordance with Minn. Stat. § 144G.31 Subd. 4, MDH may assess fines based on the level and scope of the violations; h owever, 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: An equal opportunity employer. Letter ID: IS7N REVISED 09/13/2021 Maple Woods Assisted Living April 3, 2025 Page 2 Identify how the area(s) of noncompliance was corrected related to the resident(s)/employee(s) identified in the correction order. Identify how the area(s) of noncompliance was corrected for all of the provider’s resident(s)/employees that may be affected by the noncompliance. Identify what changes to your systems and practices were made to ensure compliance with the specific statute(s). CORRECTION ORDER RECONSIDERATION PROCESS In accordance with Minn. Stat. § 144G.32, Subd. 2, you may challenge the correction order(s) issued, including the level and scope, and any fine assessed through the correction order reconsideration process. The request for reconsideration must be in writing and received by MDH within 15 calendar days of the correction order receipt date. To submit a reconsideration request, please visit: https://forms.web.health.state.mn.us/form/HRDAppealsForm 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: h ttps://forms.office.com/g/Bm5uQEpHVa. Your input is important to us and will enable MDH to improve its processes and communication with providers. If you have any questions regarding the questionnaire, please contact Susan Winkelmann at susan.winkelmann@state.mn.us or call 651-201-5952. You are encouraged to retain this document for your records. It is your responsibility to share the information contained in the letter and state form with your organization’s Governing Body. If you have any questions, please contact me. Sincerely, Jessie Chenze, Supervisor State Evaluation Team Email: Jessie.Chenze@state.mn.us Telephone: 218-332-5175 Fax: 1-866-890-9290 HHH PRINTED: 04/03/2025 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 _____________________________ 30666 02/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 40170 COUNTY ROAD 257 MAPLE WOODS ASSISTED LIVING 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 ASSISTED LIVING PROVIDER LICENSING Minnesota Department of Health is CORRECTION ORDER(S) documenting the State Correction Orders using federal software. Tag numbers have In accordance with Minnesota Statutes, section been assigned to Minnesota State 144G.08 to 144G.95, these correction orders are Statutes for Assisted Living Facilities. The issued pursuant to a survey. assigned tag number appears in the far-left column entitled "ID Prefix Tag." The Determination of whether violations are corrected state Statute number and the requires compliance with all requirements corresponding text of the state Statute out provided at the Statute number indicated below. of compliance is listed in the "Summary When Minnesota Statute contains several items, Statement of Deficiencies" column. This failure to comply with any of the items will be column also includes the findings which considered lack of compliance. are in violation of the state requirement after the statement, "This Minnesota INITIAL COMMENTS: requirement is not met as evidenced by." Following the evaluators ' findings is the SL30666016 Time Period for Correction. On February 3, 2025, 2024, through February 5, PLEASE DISREGARD THE HEADING OF 2025, the Minnesota Department of Health THE FOURTH COLUMN WHICH conducted a full survey at the above provider. At STATES,"PROVIDER'S PLAN OF the time of the survey, there were 14 residents CORRECTION." THIS APPLIES TO receiving services under the Assisted Living FEDERAL DEFICIENCIES ONLY. THIS Facility with Dementia Care license. WILL APPEAR ON EACH PAGE. THERE IS NO REQUIREMENT TO SUBMIT A PLAN OF CORRECTION FOR VIOLATIONS OF MINNESOTA STATE STATUTES. THE LETTER IN THE LEFT COLUMN IS USED FOR TRACKING PURPOSES AND REFLECTS THE SCOPE AND LEVEL ISSUED PURSUANT TO 144G.31 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 TM4K11 If continuation sheet 1 of 62 PRINTED: 04/03/2025 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 _____________________________ 30666 02/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 40170 COUNTY ROAD 257 MAPLE WOODS ASSISTED LIVING 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) 0 480 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. (b) For an assisted living facility with a licensed capacity of ten or fewer residents: (1) notwithstanding Minnesota Rules, part 4626.0033, item A, the facility may share a certified food protection manager (CFPM) with one other facility located within a 60-mile radius and under common management provided the CFPM is present at each facility frequently enough to effectively administer, manage, and supervise each facility's food service operation; (2) notwithstanding Minnesota Rules, part 4626.0545, item A, kick plates that are not removable or cannot be rotated open are allowed unless the facility has been issued repeated correction orders for violations of Minnesota Rules, part 4626.1565 or 4626.1570; (3) notwithstanding Minnesota Rules, part 4626.0685, item A, the facility is not required to provide integral drainboards, utensil racks, or tables large enough to accommodate soiled and clean items that may accumulate during hours of operation provided soiled items do not contaminate clean items, surfaces, or food, and clean equipment and dishes are air dried in a manner that prevents contamination before storage; (4) notwithstanding Minnesota Rules, part 4626.1070, item A, the facility is not required to install a dedicated handwashing sink in its existing kitchen provided it designates one well of a two-compartment sink for use only as a handwashing sink; (5) notwithstanding Minnesota Rules, parts 4626.1325, 4626.1335, and 4626.1360, item A, existing floor, wall, and ceiling finishes are STATE FORM 6899 TM4K11 If continuation sheet 2 of 62 PRINTED: 04/03/2025 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 _____________________________ 30666 02/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 40170 COUNTY ROAD 257 MAPLE WOODS ASSISTED LIVING 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) 0 480 Continued From page 2 0 480 allowed provided the facility keeps them clean and in good condition; (6) notwithstanding Minnesota Rules, part 4626.

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 alleged perpetrator (AP) abused the resident when he participated in sexual acts with the resident. Investigative Findings and Conclusion: The Minnesota Department of Health determined abuse was not substantiated. While the AP did enter the resident’s room twice during her scheduled care times on the overnight shift, the investigation did not find physical evidence of any inappropriate actions or sexual acts involving the resident. There was no witness to a sexual act made by the AP and staff reported the resident reporting she heard sexual noises was an unreliable reporter. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted a family member. The investigation included review of the resident records, facility internal investigation, facility incident reports, personnel files, staff schedules, and related facility policy and procedures. Also, the investigator observed staff assisting the resident with cares. The resident (resident 1) resided in an assisted living facility. The resident’s diagnoses included dementia. Resident 1’s service plan included assistance with repositioning, toileting, and safety checks. Resident 1’s assessment indicated she had limited ability to make requests and may not report abuse or neglect. Resident 1 used a Geri chair (medical wheeled recliner chair) which required staff assistance for mobility. One morning, a resident (resident 2) told staff she heard sex noises coming from the room next door the night before. Resident 2 stated the AP was having sex with the resident 1. Resident 2 was very adamant about what she heard and told several facility staff about the incident. During investigative interviews, multiple staff members stated resident 2 was not a reliable reporter due to her dementia. Multiple staff members stated there were no noted concerns or previous allegations of the AP. Multiple staff stated they had no concerns about how the AP treated residents. They also stated they did not note any emotional or physical signs of abuse to resident 1. During an interview, the registered nurse (RN) stated she reviewed video surveillance footage of the time frame of the allegation. The RN stated the AP entered the resident’s room twice during routine care times and was in the room for an insignificant amount of time each time. The RN stated there was no noises heard on the audio of the surveillance footage. During an interview, a family member stated she visited resident 1 three times a week and never noted any signs of abuse to resident 1. The family member stated she did not feel resident 2 was a reliable reporter due to the statements she heard resident 2 make when at the facility with resident 1. The family member stated she does not believe any abuse occurred to resident 1, and felt resident 1 was safe at the facility. Resident 1 was not able to complete an interview due to her dementia. Resident 2 was not able to complete an interview due to her dementia. R2 stated she did not recall ever reporting any abuse. The investigator was unable to contact the AP for an interview. In conclusion, the Minnesota Department of Health determined abuse 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. 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: (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: (c) Any sexual contact or penetration as defined in section 609.341, between a facility staff person or a person providing services in the facility and a resident, patient, or client of that facility. Vulnerable Adult interviewed: No, not able to complete interview due to dementia. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: No, unable to contact. the Action taken by facility: The facility reviewed camera security video when resident 2 reported allegations and interviewed staff. 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: 08/06/2024 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 _____________________________ 30666 06/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 40170 COUNTY ROAD 257 MAPLE WOODS ASSISTED LIVING 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 June 21, 2024, the Minnesota Department of Health initiated an investigation of complaint #HL306662321C/#HL306662760M. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 HUU511 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 facility neglected the resident when staff failed to perform wound care and dressing changes as ordered to a pressure ulcer on the resident’s left ankle. The resident’s wound worsened, and it was recommended the resident have a below the knee amputation. The resident experienced ten out of ten pain due to the wound; however, staff failed to administer as-needed pain medication. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was inconclusive. Although wound care was not consistently provided in accordance with physician’s orders, there was not a preponderance of evidence the actions, or inactions of facility staff, led to the resident requiring to have a below-the-knee amputation. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted the resident’s case managers, home care agency staff, and the resident’s primary care provider. The investigation included review of the resident’s records, hospital records, facility incident reports, and related facility policies and procedures. At the time of the onsite visit, the investigator observed care and services at the facility. The resident resided in an assisted living memory care unit. The resident’s diagnoses included cellulitis (skin infection) of the left lower limb and type two diabetes with diabetic neuropathy (nerve damage). The resident’s service plan included assistance with twice daily wound care and weekly wound care supervision. The resident’s assessment indicated the resident admitted to the facility with an open area to her left foot and later developed a mid-foot ulcer. The resident’s record indicated three months prior to the left leg below-the-knee amputation (BKA), a physician’s order was written to have compression wraps applied to the resident’s left lower extremities during the day and removed at night. Documentation over that three-month period indicated the resident refused application of the compression wraps on an almost daily basis. The resident also had an order for a pressure-relieving boot to be worn on her left foot at all times. Documentation indicated over that same three-month period, the resident also refused to wear the boot on an almost daily basis. Two months before the BKA, the resident developed a new pressure ulcer on her left ankle. Following the development of the new pressure ulcer, the resident’s physician wrote orders for a pressure relieving mattress and application of a Rooke boot (a specialized vascular boot that helps prevent skin breakdown) to the resident’s left foot. However, the Rooke boot and mattress could not be supplied immediately and due to the delay in delivery, the boot was never applied to the resident’s foot and the pressure relieving mattress was not delivered until four days prior to the resident’s amputation. Clinic records indicated the resident met with her primary care provider (PCP) approximately three weeks after orders for the Rooke boot and air mattress were prescribed. The resident decided at this visit that she wanted to proceed with a BKA due to ongoing pain, chronic osteomyelitis (bone infection), and difficulties with wound healing over time. During an interview, nursing staff acknowledged there were delays in communication with the resident’s provider, and wound care was not consistently completed as ordered; however, nursing staff stated they re-educated staff on how to perform wound care and the amputation was completed per the resident’s choosing. 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: Attempts to contact were unsuccessful. Family/Responsible Party interviewed: Attempts to contact were unsuccessful. Alleged Perpetrator interviewed: Not Applicable the Action taken by facility: The facility reeducated staff on proper wound care and dressing change orders. Action taken by the Minnesota Department of Health: The facility was found to be in noncompliance. To view a copy of the Statement of Deficiencies and/or correction orders, please visit: https://www.health.state.mn.us/facilities/regulation/directory/provcompselect.html If you are viewing this report on the MDH website, please see the attached Statement of Deficiencies. You may also call 651-201-4200 to receive a copy via mail or email cc: The Office of Ombudsman for Long Term Care The Office of Ombudsman for Mental Health and Developmental Disabilities PRINTED: 07/01/2024 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-C B. WING _____________________________ 30666 06/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 40170 COUNTY ROAD 257 MAPLE WOODS ASSISTED LIVING 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 June 4, 2024, the Minnesota Department of Health conducted a licensing order follow-up related to correction orders issued for complaint HL306661800M/HL306669602C and HL306661460M/ HL306668896C. Maple Woods Assisted Living has corrected the licensing orders related to the complaint investigations HL306661800M/HL306669602C and HL306661460M/ HL306668896C. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 IN2X12 If continuation sheet 1 of 1

Finding: Substantiated, facility responsibility 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 staff failed to provide adequate supervision to a resident who was at risk for elopement. The resident eloped after he followed someone out the door. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was substantiated. The facility was responsible for the maltreatment. The facility failed to provide adequate supervision in accordance with the resident’s service plan. Hourly safety checks were not completed as directed and the resident was not checked over a four-hour period of time. During that time, the resident eloped from the building when another resident’s family member opened the door. Facility staff failed to notice the resident was missing. An unrelated family member brought the resident back to the facility after they were unable to locate staff to help with the resident. Facility staff failed to report the elopement to the nurse. An equal opportunity employer. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator also contacted the case manager. The investigation included review of resident records including the service plan, assessments, progress notes, and documentation of services provided. At the time of the onsite visit, the investigator observed care and services provided in the facility. The resident resided in an assisted living memory care unit. The resident’s diagnoses included dementia, cognitive dysfunction, altered mental status, psychosis, and anxiety. The resident’s service plan included assistance with behavior management and directed staff to complete hourly safety checks. The resident’s assessment indicated the resident had a history of traumatic brain injury, had difficulty concentrating or paying attention, was easily disoriented, and had impaired judgment. The resident had a history of eloping and wandering. The assessment indicated the resident had "difficulty weighing advice, impaired judgment, and can be impulsive." The facility’s investigation summary was completed ten days after the resident’s elopement, as facility staff were unaware of the elopement until another resident’s family member reported it to them. The summary indicated the family of another resident had let the resident out of the door which re-set the alarm so staff were not aware the resident was out of the building. A different family member brought the resident back to the building. The investigation did not identify concerns with completion of hourly safety checks or other issues with the service plan not being followed at the time of the elopement. Timecards for the day the resident eloped indicated the maintenance employee was mowing the lawn from 1 p.m. to 2 p.m., and the unlicensed personnel (ULP) he reported the elopement to was working until 2:52 p.m. Two ULP were working at the time of the elopement but from 3:00 p.m. to 7:00 p.m., only one ULP was working. Documentation of hourly safety checks completed on the day of the elopement indicated the resident was last checked on at 10:11 a.m. and was not checked on until four hours later, after he had eloped. The 12:30 p.m. and 1:30 p.m. safety checks were completed at 2:39 p.m., the 2:30 p.m. safety check was completed at 2:47 p.m., 17 minutes later. The resident was not checked on again until 7:27 p.m. Five safety checks from 3:30 p.m. to 7:30 p.m. were all documented to have been completed at 7:27 p.m. During an interview, the family member who brought the resident back to the building stated he had been at the facility watching a football game with his relative at the facility. The family member stated he was in the dining room when he heard someone yell “there goes one!” The family member stated he tried to find staff but couldn’t locate anyone and no one was going after the resident, so he quickly ran after him. Since he did not have his cell phone on him, he just started walking with the resident and tried to convince him to go back inside. The family member stated the resident "took off towards the river, going through the woods, by the time I caught up with him he was already in the woods." The family member stated he walked about a quarter mile alongside the resident trying to get him to turn around. At one point, the resident got tired, so they sat down to take a rest and eventually turned back towards the facility. The family member stated, "it must have taken about 45 minutes" and they finally came across an employee who was outside mowing the lawn and flagged him down. The family member stated the employee helped get the resident back into the facility and he went back to visiting with his relative at the facility. During an interview, the maintenance employee who helped bring the resident back into the facility stated he was out mowing the lawn and saw the resident leave the building. He stated it wasn't uncommon for people to take him (the resident) out for a walk on nice days and since someone was with the resident, he wasn't too concerned. The staff member stated a little while later, he saw the resident and the individual again but this time the person with him was frantically waving his arms trying to get his attention. When the maintenance employee approached them, the individual asked him "did you lose someone?" The maintenance employee then told the family member he'd take the resident from there and brought the resident back to the building. The maintenance employee notified the ULP working that the resident had gotten out and another resident’s family member brought him back. The maintenance employee assumed since he reported the incident to someone working in nursing, they would handle the situation from there. During an interview, the licensed assisted living director (LALD) stated the resident got out of the facility when another resident’s family member opened the door and a different family member brought him back to the facility. The LALD stated the family member did not notify staff the resident had gotten out and just brought the resident back inside and left. During a later interview, the LALD stated she was aware the ULP working that day was notified the resident had eloped but failed to report it to the nurse. The LALD stated hourly safety checks should have been completed on time and staff usually knew of the resident’s location. The LALD stated they identified the issue of the elopement being related to a family member letting the resident out and everything had been done as it should. During an interview with the registered nurse (RN), she stated she was not aware a ULP working that day was aware the resident had left the building and failed to immediately report it to the nurse. During an interview, the clinical nurse supervisor (CNS) stated she didn’t know about the elopement until ten days after it happened because the family member who brought the resident back to the building didn’t tell staff about the incident. The CNS stated she did not interview the family member as part of their internal investigation because she did not have his phone number. The resident’s case manager stated the facility had not informed her of the resident’s elopement and she was not aware of any concerns related to the resident’s compliance with wearing a wander guard. The resident’s case manager stated she would have expected the facility to update her if the resident was able to get out of the secured facility. In conclusion, the Minnesota Department of Health determined neglect was substantiated. Substantiated: Minnesota Statutes, section 626.5572, Subdivision 19. “Substantiated” means a preponderance of evidence shows that an act that meets the definition of maltreatment occurred. Neglect: Minnesota Statutes, section 626.5572, subdivision 17 Neglect means neglect by a caregiver or self-neglect.

findings which are in violation of the state items, failure to comply with any of the items will requirement after the statement, "This be considered lack of compliance. Minnesota requirement is not met as evidenced by." Following the surveyors' INITIAL COMMENTS: findings is the Time Period for Correction. #HL306669745M /#HL306667782C PLEASE DISREGARD THE HEADING OF #HL306666044C THE FOURTH COLUMN WHICH STATES,"PROVIDER'S PLAN OF On November 27, 2023, the Minnesota CORRECTION." THIS APPLIES TO Department of Health conducted a complaint FEDERAL DEFICIENCIES ONLY. THIS investigation at the above provider. At the time of WILL APPEAR ON EACH PAGE. the complaint investigation, there were 18 residents receiving services under the provider's THERE IS NO REQUIREMENT TO Assisted Living with Dementia Care license. The SUBMIT A PLAN OF CORRECTION FOR following immediate correction order is issued. VIOLATIONS OF MINNESOTA STATE Correction orders with a period to correct that are STATUTES. not immediate may be issued at a later date during the investigation. The letter in the left column is used for tracking purposes and reflects the scope The following immediate correction order is and level issued pursuant to 144G.31 issued issued for #HL306666044C, tag subd. 1, 2, and 3. identification 2070. The immediacy was removed on December 4, 2023, however noncompliance remained at a lowered scope and severity of F. The following orders are issued issued for LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 O20711 If continuation sheet 1 of 67 PRINTED: 01/19/2024 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 _____________________________ 30666 11/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 40170 COUNTY ROAD 257 MAPLE WOODS ASSISTED LIVING 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 Continued From page 1 0 000 #HL306666044C, tag identification 0430, 0450, 0470, 0485, 0490, 0510, 0530, 0620, 0700, 1290, 1620, 2310, 2370, 2480. The following correction orders are issued for #HL306669745M/HL306667782C, tag identification 0620, 1640, 2360. 0 430 144G.40 Subd. 2 Uniform checklist disclosure of 0 430 SS=C services (a) All assisted living facilities must provide to prospective residents: (1) a disclosure of the categories of assisted living licenses available and the category of license held by the facility; (2) a written checklist listing all services permitted under the facility's license, identifying all services the facility offers to provide under the assisted living facility contract, and identifying all services allowed under the license that the facility does not provide; and (3) an oral explanation of the services offered under the contract. (b) The requirements of paragraph (a) must be completed prior to the execution of the assisted living contract. (c) The commissioner must, in consultation with all interested stakeholders, design the uniform checklist disclosure form for use as provided under paragraph (a). This MN Requirement is not met as evidenced by: Based on interview and record review, the licensee failed to ensure the uniform checklist disclosure of services (UDALSA) accurately reflected services provided by the licensee. This had the potential to affect all residents. STATE FORM 6899 O20711 If continuation sheet 2 of 67 PRINTED: 01/19/2024 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 _____________________________ 30666 11/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 40170 COUNTY ROAD 257 MAPLE WOODS ASSISTED LIVING 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) 0 430 Continued From page 2 0 430 This practice resulted in a level one violation (a violation that has no potential to cause more than a minimal impact on the resident and does not affect health or safety) and was issued at a widespread scope (when problems are pervasive or represent a systemic failure that has affected or has the potential to affect a large portion or all the residents). The findings include: The licensee's UDALSA, last updated May 1, 2023, indicated there was a licensed assisted living director on site full time. On November 29, 2023, at 4:35 p.m., licensed assisted living director (LALD)-D confirmed she was the director of record for two facilities and was not on site full time. No further information was provided. TIME PERIOD FOR CORRECTION: Twenty-One (21) days 0 450 144G.41 Subdivision 1 Minimum requirements 0 450 SS=F All assisted living facilities shall: (1) distribute to residents the assisted living bill of rights; (2) provide services in a manner that complies with the Nurse Practice Act in sections 148.171 to 148.285; (3) utilize a person-centered planning and service delivery process; (4) have and maintain a system for delegation of health care activities to unlicensed personnel by a registered nurse, including supervision and STATE FORM 6899 O20711 If continuation sheet 3 of 67 PRINTED: 01/19/2024 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 _____________________________ 30666 11/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 40170 COUNTY ROAD 257 MAPLE WOODS ASSISTED LIVING 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) 0 450 Continued From page 3 0 450 evaluation of the delegated activities as required by the Nurse Practice Act in sections 148.171 to 148.285; This MN Requirement is not met as evidenced by: Based on observation, interview, and record review, the licensee failed to provide services in a person-centered manner for four of four residents (R2, R3, R4, R7). 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 of the residents). The findings include: RESIDENTS LEFT AT TABLE AFTER MEALS R4 R4's diagnoses included dementia, memory loss, and late onset Alzheimer's disease without behavioral disturbance. R4's most recent assessment dated October 12, 2023, indicated the resident required an assist of two staff members and a mechanical lift to transfer. The resident was dependent on staff for wheelchair mobility. On November 27, 2023, at 10:10 a.m., R4 was observed sitting in her wheelchair at the dining room table of the memory care unit. STATE FORM 6899 O20711 If continuation sheet 4 of 67 PRINTED: 01/19/2024 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 _____________________________ 30666 11/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 40170 COUNTY ROAD 257 MAPLE WOODS ASSISTED LIVING 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) 0 450 Continued From page 4 0 450 On November 27, 2023, at 10:40 a.m., R4 was observed sitting in her wheelchair at the dining room table of the memory care unit. The resident's breakfast dishes were in front of her and she had finished eating breakfast. The resident appeared to be sleeping. On November 27, 2023, at 11:40 a.m., R4 was observed sitting in her wheelchair at the dining room table of the memory care unit. The resident's breakfast dishes were in front of her and she had finished eating breakfast. The resident appeared to be sleeping. On November 27, 2023, at 12:15 p.m.