Golden Horizons.

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 § 144G.20. Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, the following fines are assessed pursuant to this survey: An equal opportunity employer. Letter ID: IS7N REVISED 09/13/2021 Golden Horizons April 2, 2025 Page 2 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: 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 Golden Horizons April 2, 2025 Page 3 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, Jessie Chenze, Supervisor State Evaluation Team Email: jessie.chenze@state.mn.us Telephone: 218-332-5175 Fax: 1 -866-890-9290 JMD PRINTED: 04/02/2025 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 _____________________________ 30621 02/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 13631 E SHORE RD GOLDEN HORIZONS CROSS LAKE, MN 56442 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 SL30621016 Time Period for Correction. On February 24, 2025, through February 26, 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 31 residents; CORRECTION." THIS APPLIES TO 31 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. 0 470 144G.41 Subdivision 1 Minimum requirements 0 470 SS=F (11) develop and implement a staffing plan for LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 FC1411 If continuation sheet 1 of 37 PRINTED: 04/02/2025 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 _____________________________ 30621 02/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 13631 E SHORE RD GOLDEN HORIZONS CROSS LAKE, MN 56442 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) 0 470 Continued From page 1 0 470 determining its staffing level that: (i) includes an evaluation, to be conducted at least twice a year, of the appropriateness of staffing levels in the facility; (ii) ensures sufficient staffing at all times to meet the scheduled and reasonably foreseeable unscheduled needs of each resident as required by the residents' assessments and service plans on a 24-hour per day basis; and (iii) ensures that the facility can respond promptly and effectively to individual resident emergencies and to emergency, life safety, and disaster situations affecting staff or residents in the facility; (12) ensure that one or more persons are available 24 hours per day, seven days per week, who are responsible for responding to the requests of residents for assistance with health or safety needs.

Finding: Allegation 1 Abuse - Not Substantiated Allegation 2 Neglect - 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 abused resident #1 when the facility required resident #1’s transfer to a memory care unit only because resident #1 required a two-person mechanical sling lift. In addition, the facility neglected resident #2 when they failed to provide supervision and resident #2 eloped from the facility. Investigative Findings and Conclusion: The Minnesota Department of Health determined abuse and neglect was were substantiated. The facility was responsible for the maltreatment. The facility abused resident #1 by unreasonably confining resident #1 in a secured unit, without a way to exit the unit, when resident #1 did not require a secured unit. The facility neglected resident #2 when the facility failed to provide interventions and supervision to prevent resident #2’s elopements from the facility. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, unlicensed staff, and family members. The investigator contacted a case worker. The investigation included review of the resident records, facility incident reports, personnel files, staff schedules, staff communication logs, related facility policy and procedures. The investigator observed unlicensed staff interact with residents. Resident #1 resided in an assisted living memory care unit. Resident #1’s diagnoses included multiple sclerosis (MS). Resident #1 had a mental health diagnosis but was alert and oriented to person, place, time, and situation. Resident #1’s service plan included assistance with safety checks, transfers, and physical tasks. Resident #1’s assessment indicated resident #1 required two staff to transfer with a mechanical sling lift, experienced episodes of hypoxia (deprivation of adequate oxygen supply) and was unable to complete activities of daily living (ADLs) without staff assistance. Resident #1’s record indicated a slow progressive deterioration of resident #1’s mobility. Mid- summer, resident #1 experienced a hospitalization and returned to the facility. When resident #1 returned from the hospital she required a two-person mechanical sling lift for transfers. The facility did not allow a mechanical sling lift to be used in the non-secured area of the facility because only one staff member was scheduled in that area. Resident #1 was required to move into the secured memory care unit. Resident #1’s move into the secured unit limited resident #1’s ability to communicate with other residents of similar cognitive status and move freely within the building and grounds. Resident #1’s record did not indicate the facility helped with finding alternative placement at the time of resident #1’s hospital return. Resident #1’s record indicated resident #1 had utilized a mechanical sling lift for transfers in her assisted living apartment for a month and a half prior to her hospitalization. During investigative interviews, multiple staff members stated staff were injured during manual transfers when resident #1 resided in the assisted living area because the facility would not allow mechanical sling lifts to be used. Licensed and unlicensed staff stated resident #1 was able to assist with manual transfers on some days and required two to three staff on other days. Licensed and unlicensed staff stated the facility’s policy required residents to move into the secured memory care unit if they became a two-person transfer or required a mechanical sling lift, regardless of cognitive status. The facility’s memory care unit was the only area of the facility a mechanical sling lift was used. Staff stated resident #1 had “declined a lot” mentally and physically since the facility required resident #1 to transfer into the secured unit. During an interview, resident #1 stated she was not given a choice when she was moved into the secure memory care unit. Resident #1 stated she was moved to the secured memory care unit because she needed more assistance and a mechanical sling lift for transfers. Resident #1 stated the move was an unhealthy change that caused her to be more depressed, she was unable to communicate with residents in the memory care unit and her ability to move within the facility was limited. Resident #1 stated she felt confined and was concerned with retaliation if she shared her opinions. Resident #1 stated she was required to summon staff to let her out of the secured unit if she chose to go out. During an interview, resident #1’s family member stated when resident #1 was hospitalized, resident #1 experienced a temporary decline in health. The family member stated upon return from the hospital resident #1 required feeding assistance and two staff to transfer with a mechanical sling lift. The family member stated licensed staff told resident #1 and the family the facility could not provide staff assistance for feeding in the assisted living area. The family member stated licensed staff told the family and resident #1 she needed to move to the secured memory care unit or a long-term skilled nursing home because that was the only area of the facility the facility used a mechanical sling lift. The family member stated the staff had used the mechanical sling lift for resident #1 in her assisted living apartment for a month and a half prior to the hospitalization. The family member stated neither the family nor resident #1 was helped in locating an alternative assisted living that accommodated sling lift for transfers. Resident #1 was not given the key-code to freely come and go from the secured unit and was required to request staff’s assistance if resident #1 wanted to exit the secured area. The family member stated resident #1’s mental and physical health had suffered because of isolation in the secured memory care unit. Resident #2 resided in an assisted living facility. The resident’s diagnoses included dementia without behavioral disturbance. The resident’s service plan included safety checks twelve times daily, meal reminders and bathing assist. The resident’s assessment indicated staff assisted with peri-care, verbal cueing for hygiene, assistance with meals due to chewing and swallowing difficulties and communication was difficult due to word finding. The resident was vulnerable due to varied orientation and wandering. A review of resident #2’s record indicated during late winter staff were directed to conduct hourly safety checks and staff were to be aware of resident #2’s whereabouts “at all times”. Resident #2’s record indicated she had exited the front door of the facility on numerous occasions and had been redirected back into the building by staff. A review of resident #2’s hourly safety check log indicated staff had signed off multiple hours of safety checks all at one time indicating safety checks were not completed hourly as scheduled. Resident #2’s record did not indicate direction was given to unlicensed staff to accompany or supervise resident #2 when she was outside and incident reports were not completed when resident #2 exited the building without staff knowledge. Resident #2’s progress notes indicated dementia behaviors escalated since admission and resident #2 exhibited wandering, confusion, and high levels of anxiety. Resident #2’s progress notes indicated resident #2 cared for a dementia baby doll (a baby doll that emulates a human baby) and required close monitoring of toileting and hygiene cares. A review of staff communication logs indicated staff did not pass along information from shift to shift or notify licensed staff when resident #2 routinely exited the building without staff knowledge. During an interview, dietary staff stated one day resident #2 had been found outside by the trash cans when staff took garbage out. Dietary staff stated when found, resident #2 was shaking, unable to clearly communicate and answered “terrible” when asked by dietary staff how she was. Dietary staff stated resident #2 took their hand, walked back into the building and unlicensed staff were notified resident #2 was found standing by the garage. Dietary staff stated resident #2 did not appear to know where to go or how to get back into the building and was outside five to ten minutes. During an interview, unlicensed staff stated resident #2 liked to be outside and would often go outside unsupervised, but staff “usually found her right away”. Staff stated they would know when resident #2 got outside when hourly safety checks were conducted, and the resident was not found in the building.

Finding: Not Substantiated Nature of Investigation: The Minnesota Department of Health investigated an allegation of maltreatment, in accordance with the Minnesota Reporting of Maltreatment of Vulnerable Adults Act, Minn. Stat. 626.557, and to evaluate compliance with applicable licensing standards for the provider type. Initial Investigation Allegation(s): The facility neglected to provide services for the resident causing the resident to develop pressure sores and have a decline in health status. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. Facility staff provided care based on the resident’s plan of care, the resident’s preferences, and collaborated with outside agencies to support the resident’s needs. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, unlicensed staff, and a family member. The investigation included review of the resident record, death record, pharmacy records, facility incident reports, personnel files, staff schedules, hospice records, video, pictures and related facility policy and procedures. Also, the investigator observed interactions between staff members and residents. The resident resided in an assisted living facility. The resident’s diagnoses included stomach cancer and left sided stroke. The resident’s service plan included assistance with ambulation, toileting, transferring and repositioning. The resident’s assessment indicated he was slowly declining physically, refused position changes, and enjoyed sitting in his recliner. The resident had minor forgetfulness, weight was stable, and clearly communicated needs to staff. A review of the resident’s record indicated the resident had a steady decline in health. The resident often declined meals or consumed minimal amounts of food and when the resident declined facility meals family would bring him foods he preferred. A weight report indicated the resident had a ten-pound weight loss from admission in 2022 to discharge winter 2024. The resident often refused repositioning and preferred to sit in his recliner throughout the day. Due to immobility and refusals to “offload” (change position) as ordered by a provider, the resident intermittently developed pressure sores. When pressure sores appeared, nursing care was provided, wound care consults were implemented, and the resident’s pressure sores resolved over time. The facility recommended home care and hospice supplemental services on two occasions as the resident’s health declined. The resident’s family started and then stopped supplemental services the first time. The resident’s hospice records indicated the resident admitted to a hospice agency during the early fall of 2023 and discharged two months later due to “indecisiveness” about supplemental services. The day after discharge from the first hospice agency, a second home care and hospice agency admitted the resident and provided supplemental cares at the facility. Hospice and home health services included nursing and aide assistance with bathing, grooming, wound management, monitoring cares, and agency licensed nurses provided education to facility staff. The hospice agency provided medications to protect the resident’s skin from breakdown and supplied assistive medical devices to prevent pressure sores from developing. Hospice records indicated the resident’s skin condition was poor, he often refused to be weighed and refused showering. Preventions were put in place to prevent pressure sores and when pressure sores did develop, they were treated and resolved. During an interview, an unlicensed staff member stated the resident was frail, had a progressive health decline and spent a lot of time in bed towards the end. The staff member stated the resident had a pressure sore that was not healing and repositioning was offered or completed frequently at the direction of hospice. The staff member stated hospice assisted the facility with services and provided bathing, care monitoring and medications for the resident. The staff member stated at times the resident was verbal and would yell at staff to get out of his room, but services were offered. During an interview, a family member stated she eventually moved the resident to another facility type that provided the resident with a higher level of care. 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, deceased. FamilyResponsible Party interviewed: Yes. Alleged Perpetrator interviewed: Not applicable the Action taken by facility: The facility notified providers and collaborated with outside agencies to support the resident’s increasing care needs. 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: 09/10/2024 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 _____________________________ 30621 07/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 13631 E SHORE RD GOLDEN HORIZONS CROSS LAKE, MN 56442 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 144G. ASSISTED LIVING LICENSING CORRECTION Minnesota Department of Health is 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.01 to 144G.95, these correction orders are Statutes for Assisted Living Facilities. The issued pursuant to a complaint investigation. 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 #HL306211881M/#HL306219669C Time Period for Correction. #HL306213522M/#HL306213825C PLEASE DISREGARD THE HEADING OF On July 31, 2024, the Minnesota Department of THE FOURTH COLUMN WHICH Health conducted a complaint investigation at the STATES,"PROVIDER'S PLAN OF above provider, and the following correction CORRECTION." THIS APPLIES TO orders are issued. At the time of the complaint FEDERAL DEFICIENCIES ONLY. THIS investigation, there were 32 residents receiving WILL APPEAR ON EACH PAGE. services under the assisted living with dementia license. THERE IS NO REQUIREMENT TO SUBMIT A PLAN OF CORRECTION FOR The following correction order is issued for # VIOLATIONS OF MINNESOTA STATE HL306213522M/#HL306213825C, tag STATUTES. identification 1370, 1380 and 1460. 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. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 6K8411 If continuation sheet 1 of 9 PRINTED: 09/10/2024 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 _____________________________ 30621 07/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 13631 E SHORE RD GOLDEN HORIZONS CROSS LAKE, MN 56442 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) 01370 Continued From page 1 01370 01370 144G.61 Subd.