Deephaven Woods Senior Living.

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 the resident when she fell and layed on the floor for over four hours before staff found her. She was hospitalized and diagnosed with a femur and hip fracture. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. Staff followed the resident’s plan of care at the time of the incident. When staff found the resident on the floor of her room, they immediately notified a nurse, contacted 911, who transported the resident to the hospital for further evaluation. The resident was diagnosed with a left femoral neck fracture and was expected to return to her previous level of functioning. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted family and the hospital. The investigation included review of the resident record, hospital records, facility internal investigation documentation, facility incident reports, video footage, personnel files, staff schedules, and related facility policy and procedures. Also, the investigator observed staff cares and interactions with residents. The resident resided in an assisted living memory care unit. The resident’s diagnoses included dementia. The resident’s services included verbal cueing with activities of daily living (ADLs), meals, and medication management. The resident’s assessment indicated the resident was unable to make good decisions for self-preservation and wandered or acted impulsively. The resident’s gait and balance were assessed as normal. Upon admission to the facility’s memory care unit, nursing assessed the resident as independent with many activities including getting into and out of bed, walking, eating, grooming, and toileting. The resident’s signed service plan indicated staff provided verbal cues and set-up for activities including showering, dressing, and oral care. Routine safety checks were ordered twice a day, at lunch and dinner time. An incident report indicated a staff member entered the resident’s room one morning and found her on her bathroom floor. The resident’s pants were at her ankles, and her shoes were next to her bed. The resident could not recall how she fell or whether she hit her head. The resident’s cognition was at baseline, but she complained of severe pain in her left foot and could not move it. The staff member notified a nurse, who instructed the staff member to call 911. EMS transported the resident to the hospital for further assessment. Hospital records indicated the resident was diagnosed with a left femoral neck fracture. The fracture was successfully repaired via surgical intervention. After a 3-day hospital stay the resident admitted to a transitional care unit (TCU) for managed recovery and then moved to a new facility. When interviewed, a supervisor said the resident was independent with most ADLs, including toileting and walking. The resident was unable to use the call system (pendants), so her needs were met by her service plan. The resident’s services included verbal cueing and reminders, and safety checks twice a day. Staff also checked on the resident while providing cares and reminders. One morning staff entered the resident’s apartment and found her on her bathroom floor. It appeared she tried to get up to go to the bathroom at some point and had either lost her balance or tripped on a pant leg. Staff notified a triage nurse, who instructed her to call 911. EMS personnel transported the resident to the hospital via ambulance. When interviewed, family members said they were disappointed by the care the resident received while she lived at the facility. Family members described staff as rude and inattentive toward the resident and that they lacked a basic level of dementia-care comprehension. The family members believed the resident was supposed to receive safety checks every two hours and that the frequency of safety checks was changed without their consent. After her recovery at the TCU, the resident experienced cognitive decline but returned to her previous level of functioning. When the resident was discharged from the TCU, the family chose to move her to another facility. 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 cognitive impairment. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Not Applicable. the Action taken by facility: The facility completed an investigation and reviewed the resident’s service plan. 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: 04/ 29/ 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: ______________________ C B. WING _____________________________ 30474 03/ 10/ 2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 18025 MINNETONKA BOULEVARD DEEPHAVEN WOODS SENIOR LIVING DEEPHAVEN, MN 55391 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 March 10, 2026, the Minnesota Department of Minnesota Department of Health is Health initiated an investigation of complaint documenting the State Correction Orders #HL304745322C/ #HL304741180M. 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. " The state Statute number and the corresponding text of the state Statute out of compliance is listed in the "Summary Statement of Deficiencies" column. This column also includes the findings which are in violation of the state requirement after the statement, "This Minnesota requirement is not met as evidenced by." Following the evaluators' findings is the Time Period for Correction. PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH STATES, "PROVIDER' S PLAN OF CORRECTION. " THIS APPLIES TO FEDERAL DEFICIENCIES ONLY. THIS 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. LABORATORY DIRECTOR' S OR PROVIDER/ SUPPLIER REPRESENTATIVE' S SIGNATURE TITLE (X6) DATE STATE FORM 6899 V7EB11 If continuation sheet 1 of 1

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) neglected the resident during a transfer when the AP lowered the resident to the floor and the resident fractured her back. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. It was unforeseen the resident would become unsteady during a standing lift transfer and the AP lowered her to the floor for safety. Although a fracture was diagnosed a few days after the incident, the resident complained of back pain the day before the incident occurred. The x-ray confirmed cracks in several vertebrae and was possibly age related. The resident recovered from her injury and returned to her baseline health condition. 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’s record, hospital records, facility internal investigation, facility incident report, personnel files, staff schedules, related facility policy and procedures. Also, the investigator toured the facility and observed staff assisting residents with mechanical transfers. The resident resided in an assisted living facility. The resident’s diagnoses included osteoporosis, spondylosis of lumbar area (weakened bones in spine/ vertebrae), and weakness in both lower extremities. Spondylosis is breakdown of the vertebrae and causes the bones to become more brittle and prone to fractures, particularly stress fractures (cracks and breaks caused by stress and strain). The resident’s service plan included assist of one staff with dressing, grooming, and transferred with a standing lift and physical assist with staff at times. The resident’s progress notes indicated the resident had chronic back pain that became worse a week before the incident. The resident used ice packs and personal supply of over-the-counter medication to manage her pain. The nurse recommended the resident go to the hospital if the pain was unmanageable. The progress notes about the incident indicated the resident and AP reported the resident was lowered to the floor. The AP reported the resident was leaning too far forward during transfer to safely continue transfer. The resident denied any increased back pain after the incident. The primary care provider assessed the resident the day after the incident for routine visit. The provider ordered therapy and nonpharmacological interventions to manage pain. The internal investigation indicated the resident complained of pain several days before she was sent to the hospital. The resident said her back hurt because she sat in her chair too long the day before the pain began. The resident was wheelchair bound with “severe kyphosis.” Her primary care provider was notified, and she was treated with over-the-counter pain medication and ice. The resident’s care plan was followed. The resident’s hospital record indicated the resident’s vertebral fracture may have been a pathological fracture (due to underlying disease). The resident’s computerized tomography (CT) results indicated significant loss of bone mineral density, making bones weak and susceptible to fractures. The CT also indicated multiple subacute compression fractures (old fractures that have not healed completely). During an interview, the AP said he transferred the resident with the standing lift as per her care plan. During the transfer the resident complained of pain, and she was leaning to one side more than usual. He felt it was unsafe continue with the transfer, so he got behind the resident and lowered her to the floor with the standing lift. He said she never fell and never complained of pain while sitting on the floor. The AP called another unlicensed personnel (ULP) for assistance to help the resident off the floor. The AP and ULP assisted the resident off the floor with a gait belt and one on each side lifting her into her chair. He said the resident requested staff lift her that way because she did not want to use a lift. Once the resident was back in her chair, she reported she felt better. He said he used the standing lift to transfer her back into bed at night and she never complained of pain during that transfer. He reported the incident and the resident’s pain to the nurse. During an interview, ULP indicated the AP called him to assist with the resident. When he arrived at the resident’s room she was sitting on her apartment floor. The AP said he lowered her to the floor because she was weak and unable to transfer. The resident denied she fell. The ULP and AP physically assisted the resident back to her chair with a gait belt. He said the resident never complained of any injuries when they assisted her back to her chair. During an interview, the nurse said the resident complained of pain a day or two before the incident. During the incident, the AP lowered the resident to the floor mid transfer due to the resident’s positioning. The resident was leaning too far over and it was unsafe to continue with the standing lift transfer. The resident also reported the AP lowered her to the floor. The AP and ULP assisted the resident back into her chair. The resident continued to complain of pain and the provider assessed her. The resident declined to go to the hospital. The facility used pain medication and ice to alleviate discomfort. A couple days later the resident complained of abdominal discomfort along with back pain and the resident’s family took her to the hospital. The resident was diagnosed with a fracture in her spine, completed rehabilitation and transitional care unit, and has returned to the facility at a similar level of independence as before. During an interview, the family member said the x-ray completed at the hospital showed several cracked vertebrae. The hospital reported this was common for someone of the resident’s age. She said the resident had a good memory and would have reported a fall, injury, or abuse. The family member had no concerns with the facility and said the resident received good care. During an interview the resident said she loved living at the facility. She was unable to recall a specific event when she injured her back but said she never fell. She denied any abuse from staff and said they treated her “like a mother.” 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: Yes. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Yes. Action taken by facility: The facility alerted the provider of the resident’s increase pain. The primary care provider assessed the resident and ordered interventions for pain management. The facility conducted an internal investigation and sent the resident to the hospital when pain worsened. 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: 08/28/2025 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 _____________________________ 30474 07/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 18025 MINNETONKA BOULEVARD DEEPHAVEN WOODS SENIOR LIVING DEEPHAVEN, MN 55391 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 July 24, 2025, the Minnesota Department of Health initiated an investigation of complaint #HL304747348C/#HL304743802M.

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 necessar yto ensure the health, safety, and welfare of residents in your care. STATE CORRECTIO ONRDERS 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 Statemen tof Deficiencies "column. This column also includes the findings that are in violation of the state statute after the statement, "This MN Requiremen tis not met as evidenced by . . ." In accordance with Minn. Stat. § 144G3. 1 Subd .4, MDH may asses sfines based on the level and scope of the violations; however, no immediate fines are assesse dfor this survey of your facility. DOCUMENTATIO ONF ACTION TO COMPLY In accordance with Minn. Stat. § 144G3. 0, Subd .5(c), the licensee must docum ent 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: x Identify how the area(s) of noncompliance was corrected related to the An equal opportunity employer . Letter ID: IS7N REVISE 0D9/13/2021 Deephaven Woods Senio rLiving Septembe r29, 2025 Page 2 resident(s)/ employees( ) identified in the correction order. x 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. x Identify what changes to your systems and practices were made to ensure compliance with the specific statute(s). CORRECTIO ONRDER RECONSIDERATI OPRNOCESS In accordance with Minn. Stat. § 144G3. 2, Subd .2, you may challenge the correction order(s) issued, including the level and scope ,and any fine assesse dthrough 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: https:/ / forms.office.com/g/ Bm5uQEpHV.a Your input is important to us and will enable MDH to improve its processe sand communication with providers . If you have any questions regarding the questionnaire ,please contact Susan Winkelmann at susanw. inkelmann@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 organizations’ Governing Body. If you have any questions ,please contact me. Sincerely, Jess Schoenecke rS, upervisor State Evaluation Team Email: JessS. choenecker@state.mn.us Telephone :651-201-3789 Fax :1-866-890-9290 AH PRINTED: 09/29/2025 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 _____________________________ 30474 08/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 18025 MINNETONKA BOULEVARD DEEPHAVEN WOODS SENIOR LIVING DEEPHAVEN, MN 55391 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE PREFIX PREFIX 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 Facilities. The In accordance with Minnesota Statutes, section assigned tag number appears in the 144G.08 to 144G.95, these correction orders are far-left column entitled "ID Prefix Tag." issued pursuant to a survey. The state Statute number and the corresponding text of the state Statute out Determination of whether violations are corrected of compliance is listed in the "Summary requires compliance with all requirements Statement of Deficiencies" column. This provided at the Statute number indicated below. column also includes the findings which When Minnesota Statute contains several items, are in violation of the state requirement failure to comply with any of the items will be after the statement, "This Minnesota considered lack of compliance. requirement is not met as evidenced by." Following the evaluators' findings is the INITIAL COMMENTS: Time Period for Correction. SL30474016-0 PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On August 11, 2025, through August 13, 2025, STATES,"PROVIDER'S PLAN OF the Minnesota Department of Health conducted a CORRECTION." THIS APPLIES TO full survey at the above provider and the FEDERAL DEFICIENCIES ONLY. THIS following correction orders are issued. At the time WILL APPEAR ON EACH PAGE. of the survey, there were 81 residents; 49 receiving services under the Assisted Living THERE IS NO REQUIREMENT TO Facility with Dementia Care license. 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 I0VW11 If continuation sheet 1 of 6 PRINTED: 09/29/2025 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 _____________________________ 30474 08/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 18025 MINNETONKA BOULEVARD DEEPHAVEN WOODS SENIOR LIVING DEEPHAVEN, MN 55391 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE PREFIX PREFIX 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, STATE FORM 6899 I0VW11 If continuation sheet 2 of 6 PRINTED: 09/29/2025 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.

STATE LICENSING COMPLIANCE REPORT Report #: HL304749494C Date Concluded: July 12, 2024 Name, Address, and County of Facility Investigated: Deephaven Woods Senior Living 18025 Minnetonka Boulevard Deephaven, MN 55391 Hennepin County Facility Type: Assisted Living Facility (ALF) Evaluator’s Name: Holly German, RN Special Investigator The Minnesota Department of Health conducted a complaint investigation to determine compliance with state laws and rules governing the provision of care under Minnesota Statutes, Chapter 144G. The purpose of this complaint investigation was to review if facility policies and practices comply with applicable laws and rules. No maltreatment under Minnesota Statutes, Chapter 626 was alleged. To view a copy of the correction orders, if any, please visit: https://www.health.state.mn.us/facilities/regulation/directory/provcompselect.html, or call website, please see the attached state form. PRINTED: 07/15/2024 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 _____________________________ 30474 06/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 18025 MINNETONKA BOULEVARD DEEPHAVEN WOODS SENIOR LIVING DEEPHAVEN, MN 55391 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 11 2024, the Minnesota Department of Health initiated an investigation of complaint #HL304749494C. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 BQHN11 If continuation sheet 1 of 1

correction orders issued pursuant to the July 19, 2023 survey. The Department of Health concludes the licensee is in substantial compliance. State law requires the facility must take action to correct the state 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. In accordance with Minn. Stat. § 144G.31 Subd. 4 (a), state correction orders issued pursuant to the last survey, completed on July 19, 2023, found not corrected at the time of the June 20, 2024, follow-up survey and/or subject to penalty assessment are as follows: 0810-Fire Protection And Physical Environment-144g.45 Subd. 2 (b)-(f) - $500.00 The details of the violations noted at the time of this follow-up survey completed on June 20, 2024 (listed above), are on the attached State Form. Brackets around the ID Prefix Tag in the left hand column, e.g., {2 ----} will identify the uncorrected tags. 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. An equal opportunity employer. Letter ID: 8GKP Revised 04/14/2023 Deephaven Woods Senior Living July 15, 2024 Page 2 IMPOSITION OF FINES: 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 §144 G.20. 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. 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. 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 the website listed above. We urge you to review these orders carefully. If you have questions, please contact Rhylee Gilb at Deephaven Woods Senior Living July 15, 2024 Page 3 You are encouraged to retain this document for your records. It is your responsibility to share the information contained in the letter and/or state form with your organization’s Governing Body. Sincerely, Rhylee Gilb, Supervisor State Rapid Response Team Email: Rhylee.Gilb@state.mn.us Telephone: 218-232-8285 Fax: 1-800-337-9238 HHH PRINTED: 07/15/2024 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ R B. WING _____________________________ 30474 06/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 18025 MINNETONKA BOULEVARD DEEPHAVEN WOODS SENIOR LIVING DEEPHAVEN, MN 55391 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 11 2024, the Minnesota Department of Minnesota Department of Health is Health conducted a licensing order follow-up documenting the State Correction Orders related to correction orders issued for using federal software. Tag numbers have SL30474015-1. been assigned to Minnesota State Statutes for Assisted Living Facilities. The The following correction order is re-issued for assigned tag number appears in the far SL30474015-1 , tag identification 0810. left column entitled "ID Prefix Tag." The state Statute number and the corresponding text of the state Statute out of compliance is listed in the "Summary Statement of Deficiencies" column. This column also includes the findings which are in violation of the state requirement after the statement, "This Minnesota requirement is not met as evidenced by." Following the evaluators' findings is the Time Period for Correction. PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH STATES,"PROVIDER'S PLAN OF CORRECTION." THIS APPLIES TO FEDERAL DEFICIENCIES ONLY. THIS 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. {0 810} 144G.45 Subd. 2 (b)-(f) Fire protection and {0 810} SS=F physical environment LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 D63112 If continuation sheet 1 of 3 PRINTED: 07/15/2024 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ R B. WING _____________________________ 30474 06/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 18025 MINNETONKA BOULEVARD DEEPHAVEN WOODS SENIOR LIVING DEEPHAVEN, MN 55391 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) {0 810} Continued From page 1 {0 810} (b) Each assisted living facility shall develop and maintain fire safety and evacuation plans. The plans shall include but are not limited to: (1) location and number of resident sleeping rooms; (2) employee actions to be taken in the event of a fire or similar emergency; (3) fire protection procedures necessary for residents; and (4) procedures for resident movement, evacuation, or relocation during a fire or similar emergency including the identification of unique or unusual resident needs for movement or evacuation. (c) Employees of assisted living facilities shall receive training on the fire safety and evacuation plans upon hiring and at least twice per year thereafter. (d) Fire safety and evacuation plans shall be readily available at all times within the facility. (e) Residents who are capable of assisting in their own evacuation shall be trained on the proper actions to take in the event of a fire to include movement, evacuation, or relocation. The training shall be made available to residents at least once per year. (f) Evacuation drills are required for employees twice per year per shift with at least one evacuation drill every other month. Evacuation of the residents is not required. Fire alarm system activation is not required to initiate the evacuation drill. This MN Requirement is not met as evidenced by: Based on interview and document review the licensee failed to complete twice yearly fire safety training and monthly fire drills, as required.