Norris Square.

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 . . ." 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 for widespread violations; Level 3: a fine of $3,000 per violation per incident, in addition to any enforcement mechanism authorized in § 144G.20. Level 4: a fine of $5,000 per incident, in addition to any enforcement mechanism authorized in An equal opportunity employer. Letter ID: IS7N REVISED 09/13/2021 Norris Square April 10, 2025 Page 2 § 144G.20. Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, the following fines are assessed pursuant to this survey: St - 0 - 0775 - 144g.45 Subd. 2. (a) - Fire Protection And Physical Environment - $500.00 Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, t he total amount you are assessed is $500.00. You will be invoiced approximately 30 days after receipt of this notice, subject to appeal. DOCUMENTATION OF ACTION TO COMPLY 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). 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 REQUESTING A HEARING Alternatively, in accordance with Minn. Stat. § 144G.31, Subd. 5(d), an assisted living provider that has been assessed a fine under this subdivision has a right to a reconsideration or a hearing under this section and chapter 14. Pursuant to Minn. Stat. § 144G.20, Subd. 14 and Subd. 18, a request for a hearing must be in writing and received by the Department of Health within 15 business days of the correction order receipt date. The request must contain a brief and plain statement describing each matter or issue contested and any new information you believe constitutes a defense or mitigating factor. To submit a hearing request, please visit: Norris Square April 10, 2025 Page 3 https://forms.web.health.state.mn.us/form/HRDAppealsForm To appeal fines via reconsideration, please follow the procedure outlined above. P lease note that you may request a reconsideration o r a hearing, but not both. If you wish to contest tags without fines in a reconsideration and tags with the fines at a hearing, please submit two separate appeals forms at the website listed above. The MDH Health Regulation Division (HRD) values your feedback about your experience during the survey and/or investigation process. Please fill out this anonymous provider feedback questionnaire at your convenience at this link: 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, Renee L. Anderson, Supervisor State Evaluation Team Email: Renee.L.Anderson@state.mn.us Telephone: 651-201-5871 Fax: 1-866-890-9290 HHH PRINTED: 04/10/2025 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 _____________________________ 25676 03/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6995 80TH STREET SOUTH NORRIS SQUARE COTTAGE GROVE, MN 55016 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 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. SL#25676016-0 PLEASE DISREGARD THE HEADING OF On March 10, 2025, through March 14, 2025, the THE FOURTH COLUMN WHICH survey at the above provider, and the following CORRECTION." THIS APPLIES TO correction orders are issued. At the time of the FEDERAL DEFICIENCIES ONLY. THIS survey, there were 57 residents, all of whom were WILL APPEAR ON EACH PAGE. receiving services under the provider's Assisted Living with Dementia Care license. 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 pursuant to 144G.31 Subd. 1, 2 and 3. 0 480 144G.41 Subdivision 1 Subd. 1a (a-b) Minimum 0 480 SS=F requirements; required food services (a) Except as provided in paragraph (b), food must be prepared and served according to the Minnesota Food Code, Minnesota Rules, chapter LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 IHOS11 If continuation sheet 1 of 12 PRINTED: 04/10/2025 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 _____________________________ 25676 03/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6995 80TH STREET SOUTH NORRIS SQUARE COTTAGE GROVE, MN 55016 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 4626. (b) For an assisted living facility with a licensed capacity of ten or fewer residents: (1) 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), an unknown staff member, neglected the resident when the AP failed to provide showering services according to the resident’s plan of care. As a result, the resident fell and fractured her hip and knee. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. Although the resident fell during a shower, resulting in a fractured left hip and knee, the incident was an accident or a sudden, unforeseen, and unexpected occurrence. At the time of the shower, the AP was following the resident’s plan of care. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and the AP. The investigation included review of the resident record, hospital records, facility internal investigation, facility incident reports, personnel file, related facility policy and procedures. Also, the investigator observed the resident and staff interactions with the resident. The resident resided in an assisted living memory care unit. The resident’s diagnoses included Alzheimer’s disease, memory loss, depression, and anxiety. The resident’s service plan included bathroom assistance three times daily, weekly showering with standby assistance, and behavior management including managing the resident’s resistive tendencies and verbal aggression. The resident had a history of angry outbursts towards staff, was impulsive and responded to redirection. The resident was incontinent of bowel and bladder, wore incontinent briefs, and was independent with toileting but required encouragement, reminders, and cues to get up to go the bathroom. The resident was disoriented daily with moderately impaired decision making and ambulated without a walker in her room. Records indicated one evening the resident fell and sustained a fractured knee and hip. The fall was witnessed by staff (AP) in the bathroom during an attempt to give the resident a shower after an incontinent stool episode. Records indicated the AP responded to the resident’s family member’s call pendent (a family member who was a resident who lived with the resident in the memory care unit) and found the resident sitting in her recliner full of stool. The AP decided the only way to get the resident fully clean was to provide a shower. The AP turned on the shower to warm up the water and went back to the resident. The AP told the resident “Let’s go to the bathroom” to which the resident replied, “I’m not going anywhere.” The family member/resident who lived with the resident was also “pleading” with the resident to get up to go to the bathroom. The AP said one of the interventions staff used was to provide the resident compliments that usually motivated the resident to complete the task. The AP told the resident if she got cleaned up, she would “smell good for her hubby.” The resident smiled, got up out of her recliner, and walked to the bathroom without assistance. The AP assisted the resident to sit on the shower bench to remove her clothing. The AP said the resident was fine, not upset, until the AP tried to rinse the resident with water. The AP rinsed one arm and suddenly the resident became upset and yelled “I don’t want a shower!” and flung herself forward off the shower chair falling on her left knee, and crumpled forward. The AP placed a pillow under her head and called for help. The resident was laying on the floor shouting. Staff attempted to get the residents vital signs the resident resisted and kept yelling. Staff arranged for the resident to be evaluated at a hospital. Hospital records indicated the resident had surgical repair of a left hip fracture and five days later discharged back to the facility. The facility investigation concluded the resident sustained a witnessed fall during an attempt to shower the resident after the resident became behavioral and slid off the shower chair, onto the floor, landing on her knee. The AP provided cares and services according to the resident’s care plan and there was no evidence to suggest the resident’s injury was caused intentionally. During an interview, the AP stated she wanted to get the resident cleaned up. Initially, the resident did not want to go. The AP provided the resident compliments about wanting to “smell good.” If staff complimented the resident, the resident would laugh, clap her hands, and agree to go. After the compliment, the resident got up and agreed to go. The AP said she had the water running before the resident sat down. As soon as the AP used the running water on the resident, the resident “flung” herself off the shower chair. During an interview, leadership stated the month leading up to the residents fall, the resident was having behavioral issues with refusal of care, including showers. The facility addressed the concerns with the resident’s provider. 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. Unable due to cognition. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Yes. the Action taken by facility: The facility conducted an internal investigation. 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: 12/17/2024 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ C B. WING _____________________________ 25676 11/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6995 80TH STREET SOUTH NORRIS SQUARE COTTAGE GROVE, MN 55016 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 November 13, 2024, the Minnesota Department of Health initiated an investigation of complaint #HL256767323C/#HL256765285M. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 IPFR11 If continuation sheet 1 of 1