Personal Care Senior Living.

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 . . ." 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 may be 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; Level 3: a fine of $1,000 per incident, in addition to any enforcement mechanism authorized in § 144G.20; Level 4: a fine of $3,000 per incident, in addition to any enforcement mechanism authorized in § 144G.20; Level 5: a fine of $5,000 per violation, in addition to any enforcement mechanism authorized in § 144G.20. Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, the following fines are assessed An equal opportunity employer. Letter ID: IS7N REVISE D09/13/2021 Personal Care Senior Living April 7, 2026 Page 2 pursuant to this survey: St - 0 - 0775 - 144g.45 Subd. 2. (a) - Fire Protection And Physical Environment - $500.00 St - 0 - 1290 - 144g.60 Subdivision 1 - Background Studies Required - $1,000.00 The refor e, in accor danc e wit h Minn. Sta t. §§ 144G.01 to 144G.999 9, the total amount you are assessed is $1,500.00. You will be invoiced approximately 30 days after receipt of this notice, subject to appeal . DOCUMENTATIO ONF ACTION TO COMPLY In accorda nce with Min n. Stat. § 144G.30, Sub d. 5(c), th e lic ens ee mus t docum ent ac tions taken t o 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). 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. To submit a reconsideration request, please visit: https: / / forms. web. health. state. mn.us/ form/ HRDAppealsForm REQUESTIN GA 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. To submit a hearing request, please visit: https: / / forms. web. health. state. mn. us/ form/ HRDAppealsForm Personal Care Senior Living April 7, 2026 Page 3 To appe al fi nes via re cons iderat ion , pl ease follow the procedu r e outl ined abo ve. Plea se no te tha t you may re que st a rec onside rati on or a hearing, bu t not bot h. If you wish to cont est ta gs with out fine s 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 conv enien ce at thi s link: https: / / forms. office.com/ g/ Bm5uQEpHVa. Your inpu t is import ant 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, Kelly Thorson, Supervisor State Evaluation Team Email: KellyT. horson@state. mn.us Telephone: 320-223-7336 Fax: 1-866-890-9290 HHH PRINTED: 04/ 07/ 2026 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 _____________________________ 38983 03/ 12/ 2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3850 JEFFERSON STREET NE PERSONAL CARE SENIOR LIVING FRIDLEY, MN 55432 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. SL38983016- 0 PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On March 9, 2026, through March 12, 2026, the STATES, "PROVIDER' S PLAN OF survey at the above provider and the following FEDERAL DEFICIENCIES ONLY. THIS correction orders are issued. At the time of the WILL APPEAR ON EACH PAGE. survey, there were twenty- three (23) residents; twenty- three (23) receiving services under the THERE IS NO REQUIREMENT TO Assisted Living with Dementia license. SUBMIT A PLAN OF CORRECTION FOR VIOLATIONS OF MINNESOTA STATE An immediate correction order was identified on STATUTES. March 11, 2026, issued for SL38983016- 0, tag identification 1290. THE LETTER IN THE LEFT COLUMN IS USED FOR TRACKING PURPOSES AND During the course of the survey, the licensee took REFLECTS THE SCOPE AND LEVEL action to mitigate the imminent risks. ISSUED PURSUANT TO 144G. 31 Noncompliance remained and the scopes and SUBDIVISION 1-3. levels remain unchanged. 0 470 144G. 41 Subdivision 1 Minimum requirements 0 470 SS= F LABORATORY DIRECTOR' S OR PROVIDER/ SUPPLIER REPRESENTATIVE' S SIGNATURE TITLE (X6) DATE STATE FORM 6899 0LMI11 If continuation sheet 1 of 17 PRINTED: 04/ 07/ 2026 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: 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 (AP), facility staff, financially exploited the resident when he stole the resident’s narcotic pain medication for personal use. Investigative Findings and Conclusion: The Minnesota Department of Health determined financial exploitation was inconclusive. The resident said she did not receive her pain medication (hydrocodone) one evening when the AP was working; and also stated there were multiple other times she did not receive her hydrocodone when she requested it. A nurse who reviewed video footage said she saw the AP ingest the resident’s hydrocodone. An administrator who reviewed the same video footage said she did not see the AP ingest the hydrocodone. The video was not available for investigator review. It could not be determined if an inconsistency in documentation between the resident’s electronic medication administration record (eMAR) and the narcotic count logbook were the result of deliberate medication diversion or a documentation error. The AP denied the allegation. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted law enforcement. The investigation included review of the resident record, pharmacy records, facility internal investigation, facility incident reports, personnel files, staff schedules, law enforcement report, and related facility policy and procedures. Also, the investigator observed resident cares provided by staff. The resident resided in an assisted living facility. The resident’s diagnoses included coronary artery disease. The resident’s services included assistance with medication administration. The resident’s assessment indicated the resident required minimal assistance with activities of daily living. The facility’s internal investigation indicated the resident reported she had a problem getting her hydrocodone the day before, although she believed she had gotten some in the afternoon. A nurse reviewed video footage and observed the AP opening the narcotic medication box and removing medication. The AP then entered the resident’s room. After exiting the resident’s room, video footage revealed the AP grabbing something out of his pocket and putting it into his mouth. The nurse reviewed the narcotic logbook and saw the AP had signed out two tablets of hydrocodone for the resident. The nurse reviewed documentation in the resident’s eMAR and there was no correlating documentation of the hydrocodone being administered to the resident. The AP’s employment was terminated. The resident’s eMAR indicated she had an order for hydrocodone 5/325mg, 1-2 tablets every four hours as needed (PRN). On the date in question, the eMAR indicated the resident received a total of six tablets of hydrocodone, none of which were signed out by the AP. The resident’s individual narcotic record in the narcotic logbook, which recorded the hydrocodone tablet count, correlated with the three administration times documented in the eMAR, signed out and administered by other staff members. That evening, the AP signed out two tablets of the resident’s hydrocodone from the narcotic logbook. However, the two tablets of hydrocodone were not documented in the resident’s eMAR. The AP did, however, document administering the resident’s scheduled medications in the eMAR that evening. The AP’s training files indicated he received both classroom and observed competency trainings in medication administration and documentation. A corrective action indicated the AP was terminated due to medication concerns. The corrective action indicated the AP signed out the resident’s hydrocodone in the narcotic log, but did not document it in the resident’s eMAR. The resident said she did not receive her hydrocodone at that time. The AP left medication cart drawers open after he walked away, and he touched medications with hands. The AP also placed medications outside a room on a handrail while going into another room, and he placed medications in his pockets. After the medication pass, staff observed the AP via video footage sit in a recliner and appear to fall asleep. The corrective action did not mention the AP ingesting any resident’s medication. The police department said no report was on file for this incident. When interviewed, a nurse said the resident reported she did not get her pain medication for a significant amount of time the day before. The nurse found a discrepancy in documentation between the narcotic logbook and the resident’s eMAR. The AP documented signing out two tablets of hydrocodone in the narcotic logbook but did not document administering the medication in the resident’s eMAR. The nurse reviewed video footage and said there was a period when the AP moved back and forth, looking at people, looking around, going back and forth from the medication cart to the desk. Then the AP turned around and the nurse said she saw him take medication out and enter the resident’s room. After leaving the resident’s room, the nurse said she saw the AP take medication out of his pocket and put it into his mouth. After that, the AP sat in a recliner and appeared to go to sleep. When interviewed, an administrator said she, too, reviewed video footage of the AP’s medication pass. The AP had a cup of pills in his pocket, went into the resident’s room, and came back outs. The administrator said she did not see the AP ingest medication on the video. When interviewed, the AP denied taking or ingesting the resident’s pain medication. The AP said it took staff three days to tell him his employment was being terminated, and there was no mention of him taking the resident’s medication in the termination notice. The AP believed his termination was retaliation for a complaint he had filed. When interviewed, the resident did not recall one specific date in which she did not receive hydrocodone, as she said there were several times she did not receive her pain medication when she requested it. The resident said she had many conversations with the nurse about not getting her pain medication as requested, but the issue had since improved. In conclusion, the Minnesota Department of Health determined financial exploitation 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. Financial exploitation: Minnesota Statutes, section 626.5572, subdivision 9 "Financial exploitation" means: (b) In the absence of legal authority a person: (1) willfully uses, withholds, or disposes of funds or property of a vulnerable adult; (2) obtains for the actor or another the performance of services by a third person for the wrongful profit or advantage of the actor or another to the detriment of the vulnerable adult; (3) acquires possession or control of, or an interest in, funds or property of a vulnerable adult through the use of undue influence, harassment, duress, deception, or fraud; or (4) forces, compels, coerces, or entices a vulnerable adult against the vulnerable adult's will to perform services for the profit or advantage of another. Vulnerable Adult interviewed: Yes. Family/Responsible Party interviewed: No, the resident is her own guardian. Alleged Perpetrator interviewed: Yes. the Action taken by facility: The AP is no longer employed by the facility. 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: 07/24/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ C B. WING _____________________________ 38983 06/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3850 JEFFERSON STREET NE PERSONAL CARE SENIOR LIVING FRIDLEY, MN 55432 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 25, 2025, the Minnesota Department of Minnesota Department of Health is Health initiated an investigation of complaint documenting the State Correction Orders #HL389834568C/#HL389832602M. No correction using federal software. Tag numbers have orders are issued. been assigned to Minnesota State Statutes for Assisted Living Facilities. The assigned tag number appears in the far-left column entitled "ID Prefix Tag.

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 and the alleged perpetrator (AP) neglected the resident when facility staff found the resident face down on the floor with medical equipment on top of her. The resident had bleeding on her hand and vomited. Emergency medical services (EMS) transferred the resident to the hospital. The AP left the facility before staff found the resident on the floor and did not return. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. The resident did not fall from a mechanical lift but fell from a power lift chair onto the floor. An error in therapeutic conduct occurred by failing to assess and implement an intervention to help prevent the resident from inadvertently pressing the chair’s remote. However, the resident did not require significant medical intervention or treatment. The Minnesota Department of Health determined neglect was not substantiated against the AP. The AP left the facility before the resident fell, and only left after a miscommunication between her and facility staff. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted law enforcement. The investigation included review of the resident record, death record, hospital records, facility internal investigation, facility incident reports, personnel files, staff schedules, law enforcement report, related facility policy and procedures. Also, the investigator observed transfers with the use of a mechanical lift. The resident resided in an assisted living facility. The resident’s diagnoses included dementia. The resident’s service plan included assistance with eating and medication administration. The resident’s assessment indicated the resident needed help with sitting up, turning and repositioning, transferring with the use of a mechanical lift, and all activities of daily living. This assessment identified the resident as disoriented to place and time, and had moderately impaired decision-making. An incident report indicated unlicensed personnel (ULP)-1 found the resident lying face down on the floor of her apartment with her head under the bed and sling for the mechanical lift on her back. The resident had a skin tear on her right hand and bruising on her face. Staff called 911 and notified the licensed assisted living director (LALD). This report indicated the resident did not fall from the mechanical lift. The facility-provided power reclining chair’s remote had been on the arm rest. The resident inadvertently lifted the chair and fell when her arm rested on the remote. To prevent future falls, the facility would ensure the remote for the chair would be placed in the side pocket. The resident’s hospital record indicated the resident received a diagnosis of a closed head injury. She spent less than 48 hours in the hospital, having various tests and imaging completed to rule out injury. The trauma workup completed had been completely negative. The resident discharged and returned to the facility. The facility internal investigation included interviews with staff and review of video surveillance. During an interview, the AP stated she last helped the resident around 6:00 p.m. when she assisted the resident with eating dinner. At that time, the resident remained in the power lift chair. After that, ULP-2 instructed the AP to leave and told her another staff person would come in to finish the shift. As the AP left the facility, she saw another staff member coming into the facility and assumed that was her replacement. Video surveillance showed the AP left the facility around 6:10 p.m. The staff member and ULP-3 came to the facility around 6:00 p.m., but not to work. Another resident had a birthday party the same evening as the incident, so ULP-3 and the other staff member came for the party. At about 6:30 p.m., ULP-3 entered the resident’s room for a few seconds, looking for ULP-1. ULP-3 stated the resident had been seated in the power lift chair and appeared comfortable, noting the mechanical lift had not been near the resident. At 8:25 p.m., ULP-1 found the resident face down on the floor of her apartment with the mechanical lift sling on her back. The resident vomited and had blood on her right hand. ULP-1 called ULP-2, and they called 911. Emergency medical services arrived and transported the resident to the hospital. Hospital staff reported the resident had no injuries other than the skin tear on the right hand and bruising around the left eye. During an interview, ULP-3 stated she went to the facility the evening of the incident for another resident’s birthday party. ULP-3 had been looking for a coworker and peeked into the resident’s room. She saw the resident sitting in the power lift chair with the mechanical lift sling underneath her back. The resident faced the television and had either been watching a show or sleeping. During an interview, the LALD stated part of the internal investigation included a reenactment of how the resident could have fallen. The LALD sat in the power lift chair and used the remote to raise the chair until she fell out. The LALD fell forward onto the ground, and the mechanical lift sling stayed on her back. Her position on the floor and sling on her back looked the same as how the resident looked. The LALD stated the resident returned to her baseline after the incident occurred. During an interview, a nurse stated he did not complete an assessment to determine if the resident could use the power lift chair safely and as intended before the incident. The nurse thought the resident would not have been able to grab the remote and use it. Prior to the incident, the nurse did not determine a specific place for the remote to be kept. After the incident, the nurse instructed staff to keep the remote out of the resident’s reach. During an interview, the AP stated she did not transfer the resident herself with the mechanical lift because that required two staff. The AP fed the resident dinner in the chair within her apartment. After that, the resident wanted to get into bed. The AP left to find someone to help her with the transfer. The AP then spoke with ULP-2 who told her to go home, and someone would come in to cover the rest of the shift. After seeing another staff member come to the facility, the AP left between 6:00 p.m. and 6:15 p.m. The last time she saw the resident, the resident had been in the reclining chair. 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. (4) an individual makes an error in the provision of therapeutic conduct to a vulnerable adult which does not result in injury or harm which reasonably requires medical or mental health care; Vulnerable Adult interviewed: No. The resident is deceased. Family/Responsible Party interviewed: No. Attempts to reach the family were unsuccessful. Alleged Perpetrator interviewed: Yes. Action taken by facility: The facility completed an internal investigation and implemented the intervention of keeping the remote out of the resident’s reach while in the power lift chair. 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: 07/17/2024 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.

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 . . ." In accordance with Minn. Stat. § 144G.31 Subd. 4, MDH may assess fines based on the level and scope of the violati ons; however, no immediate fines are assessed for this survey of your facility. DOCUMENTATIO ONF ACTION TO COMPLY Per Mi nn. Stat. § 144G. 30, Subd. 5( c), th e lice ns e e must docu ment acti ons tak e n to co mply with th e 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). An equal opportunity employer. Letter ID: 9GJX Revised 04/20/2023 Personal Care Senior Living December 11, 2023 Pa ge 2 CORRECTIO NORDER RECONSIDERATIO PNROCESS 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. Please email reconsideration requests to: Health. HRDA. ppeals@ 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/ or state form with your organization’ s Governing Body. If you have any questions, please contact me. Sincerely, Jonathan Hill, Supervisor State Evaluation Team Email: jonathan. hill@state. mn. us Telephone: 651-201-3993 Fax: 1-866-890-9290 PMB PRINTED: 12/ 11/2023 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 _____________________________ 38983 11/08/ 2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3850 JEFFERSON STREET NE PERSONAL CARE SENIOR LIVING FRIDLEY, MN 55432 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 been assigned to Minnesota State Statutes for Assisted Living with Dementia In accordance with Minnesota Statutes, section licensed providers. The assigned tag 144G. 08 to 144G. 95 this correction order( s) has number appears in the far- left column been issued pursuant to a survey. entitled "ID Prefix Tag. " The state Statute number and the corresponding text of the Determination of whether a violation has been state Statute out of compliance is listed in corrected requires compliance with all the "Summary Statement of Deficiencies" requirements provided at the Statute number column. This column also includes the indicated below. When Minnesota Statute findings which are in violation of the state contains several items, failure to comply with any requirement after the statement, "This of the items will be considered lack of Minnesota requirement is not met as compliance. evidenced by." Following the surveyors' findings is the Time Period for Correction. INITIAL COMMENTS: SL38983015- 0 PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On November 6, 2023, to November 8, 2023, the STATES, "PROVIDER' S PLAN OF initial survey at the above provider, and the FEDERAL DEFICIENCIES ONLY. THIS following correction orders are issued. At the WILL APPEAR ON EACH PAGE. time of the survey, there were fifteen (15) residents, all of whom received services under THERE IS NO REQUIREMENT TO the provider' s Provisional Assisted Living with SUBMIT A PLAN OF CORRECTION FOR Dementia Care license. 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. 0 330 144G. 30 Subd. 4 Information provided by facility 0 330 SS= F (a) The assisted living facility shall provide accurate and truthful information to the LABORATORY DIRECTOR' S OR PROVIDER/ SUPPLIER REPRESENTATIVE' S SIGNATURE TITLE (X6) DATE STATE FORM 6899 X19W11 If continuation sheet 1 of 16 PRINTED: 12/ 11/2023 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 _____________________________ 38983 11/08/ 2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3850 JEFFERSON STREET NE PERSONAL CARE SENIOR LIVING FRIDLEY, MN 55432 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) 0 330 Continued From page 1 0 330 department during a survey, investigation, or other licensing activities. (b) Upon request of a surveyor, assisted living facilities shall within a reasonable period of time provide a list of current and past residents and their legal representatives and designated representatives that includes addresses and telephone numbers and any other information requested about the services to residents. This MN Requirement is not met as evidenced by: Based on observation and interview, the licensee failed to provide annual inspection reports of the fire sprinkler system and automatic fire alarm system at in a timely fashion. This had the potential to directly affect all residents and staff. 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) 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 of the residents) . The findings include: On November 6, 2023, at 12: 30 p.m. , survey staff requested the most recent inspection reports for the fire sprinkler system and the automatic fire alarm system from licensed assisted living director (LALD)-A. On November 6, 2023, at 12: 30 p.m. , LALD-A explained these reports were not available on- site. LALD-A explained that these reports would be emailed to survey staff once received and stated that these reports would be kept on STATE FORM 6899 X19W11 If continuation sheet 2 of 16 PRINTED: 12/ 11/2023 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.