The Waters of Eden Prairie.

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 The Waters of Eden Prairie December 4, 2024 Page 2 St - 0 - 1290 - 144g.60 Subdivision 1 - Background Studies Required - $3,000.00 Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, t he total amount you are assessed is $3,000.00. 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 The Waters of Eden Prairie December 4, 2024 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, Jess Schoenecker, Supervisor State Evaluation Team Email: Jess.Schoenecker@state.mn.us Telephone: 651-201-3789 Fax: 1-866-890-9290 HHH PRINTED: 12/04/2024 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 30812 10/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 431 PRAIRIE CENTER DRIVE THE WATERS OF EDEN PRAIRIE EDEN PRAIRIE, MN 55344 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 ASSSITED LIVING PROVIDER LICENSING using federal software. Tag numbers have CORRECTION ORDER been assigned to Minnesota State Statutes for Assisted Living Facilities with In accordance with Minnesota Statutes, section Dementia Care. The assigned tag number 144G.01 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 evaluators ' INITIAL COMMENTS: findings is the Time Period for Correction. Project # SL30812016 PLEASE DISREGARD THE HEADING OF On October 22, 2024, through October 24, 2024,, THE FOURTH COLUMN WHICH the Minnesota Department of Health conducted a STATES,"PROVIDER'S PLAN OF 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 89 residents receiving WILL APPEAR ON EACH PAGE. services under the provider's Assisted Living with Dementia Care license. THERE IS NO REQUIREMENT TO SUBMIT A PLAN OF CORRECTION FOR An immediate correction order was issued for tag VIOLATIONS OF MINNESOTA STATE identification 1290 on October 23, 2024. STATUTES. During the course of the survey, the licensee took THE LETTER IN THE LEFT COLUMN IS action to mitigate the imminent risk. USED FOR TRACKING PURPOSES AND Noncompliance remained and the scope and REFLECTS THE SCOPE AND LEVEL level remain unchanged. ISSUED PURSUANT TO 144G.31 SUBDIVISION 1-3. 0 480 144G.41 Subd 1 (13) (i) (B) Minimum 0 480 SS=F requirements LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 ELV711 If continuation sheet 1 of 13 PRINTED: 12/04/2024 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 30812 10/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 431 PRAIRIE CENTER DRIVE THE WATERS OF EDEN PRAIRIE EDEN PRAIRIE, MN 55344 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 (13) offer to provide or make available at least the following services to residents: (B) food must be prepared and served according to the Minnesota Food Code, Minnesota Rules, chapter 4626; and This MN Requirement is not met as evidenced by: Based on observation, interview, and record review, the licensee failed to ensure food was prepared and served according to the Minnesota Food Code.

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 the facility did not administer scheduled medications as ordered. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. The facility nurse notified hospice complex wound care was not a service provided at the facility. The facility nurse informed the hospice nurse that skilled nursing or hospice nursing would have to complete the wound care as ordered. The investigator conducted interviews with facility staff members, including nursing staff, and unlicensed staff. The investigator contacted hospice. The investigation included review of the resident record(s), hospice record(s), staff schedules, and related facility forms. The resident resided in an assisted living facility memory care unit. The resident’s diagnoses included left leg fracture and osteoporosis. The resident’s service plan included assistance with turning and repositioning and medication management. The resident’s assessment indicated the resident was not orientated, was receiving hospice services, was no longer getting out of bed, received wound cares to a wound on her butt and to a wound on her spine. The resident was enrolled in hospice. The facility’s Uniform Disclosure of Assisted Living Services and Amenities (a required document to describe the services, supports, and amenities available at the assisted living facility) indicated the facility provided basic wound care but did not provide complex wound care. This was indicated by an “x” in the “available” column next to basic wound care and no “x” in the “available” column next to complex wound care. The progress notes indicated an order was received for an antibiotic to be crushed and sprinkled on the wound bed once a day. The note included another order which indicated to do wound care to a pressure wound on the spine. The wound care included clean with cleanser, pat dry, apply calcium alginate to wound, cover with Opti foam dressing, hospice to do three times per week, facility to do all other days, and may replace if soiled or rolled. The same note indicated the facility nurse discussed the order with a hospice nurse and explained the facility did not manage complex wound care so it would need to be done by skilled nursing or hospice. The following day the progress notes indicated the resident was no longer verbally responding to questions, had Increased secretions, and was not able to swallow. The notes indicated staff members provided comfort measures to the resident and hospice was notified. The next three days of progress notes indicated the resident remained nonresponsive and staff continued providing comfort cares. The medication administration record indicated nursing was to change a spine dressing daily and as needed. The record indicated hospice nurse was to complete wound cares on Monday, Wednesday, and Friday. The medication notes section of the record included a note indicating the dressing change was to be done by the hospice nurse and it had been scheduled with hospice. The record had six open days for the wound cares to be completed, none of the days were signed off as completed. The hospice notes indicated the hospice nurse completed wound care one day (day #1) and the wound was draining a moderate amount of fluid and had a foul odor. The note indicated the hospice nurse notified the provider and an antibiotic and new wound care was ordered. On day #2 the hospice notes indicated the hospice nurse attempted to change the resident’s dressing, but it caused extreme pain, and the resident pushed the nurse’s hands away indicating refusal of wound care. On day #3, the hospice notes indicated the hospice nurse saw the resident, but nothing was documented regarding wound cares. On day #4, the hospice notes indicated the hospice nurse completed wound care to the pressure sore on the resident’s back. Nothing was documented regarding the antibiotic. On day #5, the hospice notes indicated the hospice nurse completed wound care to the pressure sore on the resident’s back. Nothing was documented regarding the antibiotic. A second hospice note on day #5 indicated the antibiotic was ordered and delivered on day #1, the facility misplaced the medication, so it had not been given. The note further indicated the resident was actively dying so the antibiotic was not reordered. During an interview, the nurse stated complex wound care was completed by skilled nursing or hospice and not done by the facility staff. The nurse stated the day the antibiotic was ordered she notified the hospice nurse the wound care was beyond the scope of practice completed by the nurses at the facility and needed to be completed by skilled nursing or the hospice nurse. 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. The resident was deceased. Family/Responsible Party interviewed: No. Attempts were made but unsuccessful. Alleged Perpetrator interviewed: Not Applicable. the Action taken by facility: The nurse notified the hospice nurse the facility only completed basic wound care. 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 Developm ental Disabilities PRINTED: 02/07/2024 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 _____________________________ 30812 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 431 PRAIRIE CENTER DRIVE THE WATERS OF EDEN PRAIRIE EDEN PRAIRIE, MN 55344 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 January 19,2024, the Minnesota Department of Health initiated an investigation of complaint #HL308128258C/#HL308124843M. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 WDM111 If continuation sheet 1 of 1