Vernon Terrace of Edina.

Finding: Inconclusive Nature of Investigation: The Minnesota Department of Health investigated an allegation of maltreatment, in accordance with the Minnesota Reporting of Maltreatment of Vulnerable Adults Act, Minn. Stat. 626.557, and to evaluate compliance with applicable licensing standards for the provider type. Initial Investigation Allegation: The facility neglected the resident when they failed to provide her with a way to summon help. The resident fell in her apartment, was hospitalized with dehydration and acute kidney injury. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was inconclusive. The facility did not provide their emergency call pendants to all their housing only residents, only residents who chose to have services. Instead, the facility offered an additional elective service that provided a call pendant and once daily safety check phone call for a monthly fee, creating the option to waive the facility’s minimum requirement to provide a means for residents to summon staff for assistance or emergencies. The resident owned a call pendant from an outside service but was not wearing it when she fell because she was charging it. It was inconclusive if she had a facility-provided pendant if she would have worn the pendant not having a need to charge it, therefore having an ability to summon staff to assist her sooner. The resident laid on the floor for a long period of time she laid on the floor before a kitchen staff found her. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted the resident’s family member. The investigation included review of the resident record, hospital records, facility incident reports, staff schedules and related facility policy and procedures. Also, the investigator observed a housing only resident wearing her call pendant and front door staff monitoring an emergency alarm panel for fire alarms. The resident lived in an apartment as a housing only resident; not receiving services. Her diagnoses included macular degeneration and corneal transplants. She walked with a four wheeled walker and had a private caregiver visit once weekly to help with bathing and homemaking. She received one meal (breakfast) delivered daily to her door. She had a call pendant purchased through an outside service. A few days before the resident fell, she was assessed to begin assisted living services. Record review indicated the resident, and her family, had the nursing assessment completed but they wanted time to discuss the possible change and would follow up with nursing if still interested. The resident’s hospital record indicated she went to the hospital by ambulance after she fell in her apartment three days earlier. The resident admitted with dehydration, rhabdomyolysis (a serious condition with muscle breakdown after being in the same position for a long period of time) and a gastrointestinal bleed. The resident did not return to the facility after her hospitalization. During an interview, the resident’s family member said the resident called him from the hospital and said she fell ill over the weekend. Sometime during the night, or early the next morning she had a sudden urge to vomit and as she got out of bed she tripped on her blankets and fell. She was unable to get up and her emergency call pendant and cell phone were not in reach. She told the family member either the pendant was not working or needed a battery charge which was why she was not wearing it when she fell. The resident remained on the floor until Monday morning when a staff member saw a delivered meal package still outside her door. The family member said the resident had to discharge to a new facility that provided higher levels of care. He said the resident was happy at the facility while she lived there and was treated “like a queen.” He did not blame the staff for her fall but wished someone had checked on her. During an interview, the culinary manager said a virus went through the building around the time the resident fell ill. The dining room was closed, and meals were delivered. The resident already had her breakfast delivered daily. Culinary staff packed her meal into a container and then into a brown bag. They hung the bag on the door, knocked and moved on. Culinary staff were not allowed into resident apartments for any reason. The manager said none of the staff reported untouched meal packages outside the resident’s door or any calls for help from her when the delivered the meals. During an interview, the manager said a few years ago the facility had emergency pull cord alerts in all the apartment bathrooms, but the owners removed them. Various emergency alert pendant systems were researched and tried with mixed success. The housing only residents had a choice if they want an emergency call pendant or not. Many opted out because they have cell phones to summon help. In conclusion, the Minnesota Department of Health determined neglect was inconclusive. Inconclusive: Minnesota Statutes, section 626.5572, Subdivision 11. "Inconclusive" means there is less than a preponderance of evidence to show that maltreatment did or did not occur. 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, not available. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Not Applicable. the Action taken by facility: The facility sent the resident to the hospital when she was found. Action taken by the Minnesota Department of Health: The facility was found to be in noncompliance. To view a copy of the Statement of Deficiencies and/or correction orders, please visit: https://www.health.state.mn.us/facilities/regulation/directory/provcompselect.html If you are viewing this report on the MDH website, please see the attached Statement of Deficiencies. You may also call 651-201-4200 to receive a copy via mail or email cc: The Office of Ombudsman for Long Term Care The Office of Ombudsman for Mental Health and Developmental Disabilities Minnesota Board of Executives for Long Term Services and Supports PRINTED: 05/06/2025 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 _____________________________ 28216 04/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5250 VERNON AVENUE SOUTH VERNON TERRACE OF EDINA EDINA, MN 55436 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 000 Initial Comments 0 000 ******ATTENTION****** Minnesota Department of Health is documenting the State Correction Orders ASSISTED LIVING PROVIDER CORRECTION using federal software. Tag numbers have ORDER 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." The issued pursuant to a complaint investigation. state Statute number and the corresponding text of the state Statute out Determination of whether a violation is 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 a Minnesota Statute contains several are in violation of the state requirement items, failure to comply with any of the items will after the statement, "This Minnesota be considered lack of compliance. requirement is not met as evidenced by." Following the evaluators' findings is the INITIAL COMMENTS: Time Period for Correction. HL282168041C/HL282169302M PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On April 17, 2025, the Minnesota Department of STATES,"PROVIDER'S PLAN OF Health conducted a complaint investigation at the CORRECTION." THIS APPLIES TO above provider, and the following correction FEDERAL DEFICIENCIES ONLY. THIS orders are issued. At the time of the complaint WILL APPEAR ON EACH PAGE.

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 . . ." In accordance with Minn. Stat. § 144G.31 Subd. 4, MDH may assess fines based on the level and scope of the violations; h owever, no immediate fines are assessed for this survey of your facility. 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 An equal opportunity employer. Letter ID: IS7N REVISED 09/13/2021 Vernon Terrace of Edina April 23, 2025 Page 2 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. 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, Casey DeVries, Supervisor State Evaluation Team Email: Casey.DeVries@state.mn.us Telephone: 651-201-5917 Fax: -866-890-9290 HHH PRINTED: 04/23/2025 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 _____________________________ 28216 01/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5250 VERNON AVENUE SOUTH VERNON TERRACE OF EDINA EDINA, MN 55436 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 Licensing Correction Orders using federal software. In accordance with Minnesota Statutes, section Tag numbers have been assigned to 144G.08 to 144G.95, these correction orders are Minnesota State Statutes for Assisted issued pursuant to a survey. Living License Providers. The assigned tag number appears in the far-left column Determination of whether violations are corrected entitled "ID Prefix Tag." The state Statute requires compliance with all requirements number and the corresponding text of the provided at the Statute number indicated below. state Statute out of compliance is listed in When Minnesota Statute contains several items, the "Summary Statement of Deficiencies" failure to comply with any of the items will be column. This column also includes the considered lack of compliance. findings which are in violation of the state requirement after the statement, "This INITIAL COMMENTS: Minnesota requirement is not met as evidenced by." Following the surveyors' SL28216016-0 findings is the Time Period for Correction. On January 6, 2025, through January 7, 2025, the PLEASE DISREGARD THE HEADING OF survey at the above provider. At the time of the STATES,"PROVIDER'S PLAN OF survey, there were 149 residents; 43 receiving CORRECTION." THIS APPLIES TO services under the Assisted Living Facility with FEDERAL DEFICIENCIES ONLY. THIS 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 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 LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 PFVL11 If continuation sheet 1 of 6 PRINTED: 04/23/2025 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 _____________________________ 28216 01/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5250 VERNON AVENUE SOUTH VERNON TERRACE OF EDINA EDINA, MN 55436 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 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, existing floor, wall, and ceiling finishes are allowed provided the facility keeps them clean STATE FORM 6899 PFVL11 If continuation sheet 2 of 6 PRINTED: 04/23/2025 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 _____________________________ 28216 01/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5250 VERNON AVENUE SOUTH VERNON TERRACE OF EDINA EDINA, MN 55436 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 2 0 480 and in good condition; (6) notwithstanding Minnesota Rules, part 4626.