Elmore Assisted Living.

correction orders issued pursuant to the January 9, 2025 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 January 9, 2025, found not corrected at the time of the April 4, 2025, follow-up survey and/or subject to penalty assessment are as follows: 0550-Resident Grievances; Reporting Maltreatment-144g.41 Subd. 7 0970-Waivers Of Liability Prohibited-144g.50 Subd. 5 2550-Restrictions Under Home And Community-Based W-144g.911 - $500.00 The details of the violations noted at the time of this follow-up survey completed on April 4, 2025 (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, the 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 outlined on the state form; however, plans of correction are not required to be submitted for approval. 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 An equal opportunity employer. Letter ID: 8GKP Revised 04/14/2023 Elmore Assisted Living April 30, 2025 Page 2 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. 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. Please 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 Jodi Johnson at 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, Jodi Johnson, Supervisor State Evaluation Team Email: Jodi.Johnson@state.mn.us Telephone: 507-344-2730 Fax: 1-866-890-9290 HHH PRINTED: 04/30/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ R B. WING _____________________________ 31417 04/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 202 EAST NORTH STREET ELMORE ASSISTED LIVING ELMORE, MN 56027 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 FOLLOW UP using federal software. Tag numbers have SURVEY WITH RE-ISSUE OF ORDERS been assigned to Minnesota State Statutes for Assisted Living Facilities. The INITIAL COMMENTS assigned tag number appears in the SL#31417016-1 far-left column entitled "ID Prefix Tag." The state Statute number and the On April 2, 2025, through April 4, 2025, the corresponding text of the state Statute out follow-up survey at the above provider to Statement of Deficiencies" column. This follow-up on orders issued pursuant to a survey column also includes the findings which completed on January 9, 2025. At the time of the are in violation of the state requirement survey, there were 46 residents; 46 receiving after the statement, "This Minnesota services under the Assisted Living License. As a requirement is not met as evidenced by." result of the follow-up survey, the following orders Following the evaluators ' findings is the were reissued: 0550, 0970, 2550. 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. {0 480} 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 VL6O12 If continuation sheet 1 of 15 PRINTED: 04/30/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ R B. WING _____________________________ 31417 04/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 202 EAST NORTH STREET ELMORE ASSISTED LIVING ELMORE, MN 56027 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} (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, existing floor, wall, and ceiling finishes are STATE FORM 6899 VL6O12 If continuation sheet 2 of 15 PRINTED: 04/30/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ R B.

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: The alleged perpetrator (AP) abused the resident when the AP grabbed a cigarette out of the resident’s mouth, pulled the resident through the lobby and common area, and then physically forced the resident back into his room, shut the door and walked away. Investigative Findings and Conclusion: The Minnesota Department of Health determined abuse was not substantiated. While bringing the resident back in the building from a smoking area, the resident began moving in his chair to prevent entering the building, almost fell out of the chair, and the AP had to reposition him in the chair as he brought him through the doorway. The resident was not harmed during the incident but became upset. Although the AP had other options to resolve the situation, the incident does not meet criteria for abuse. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigation included review of the resident record, death record, facility internal investigation, facility incident reports, personnel files, staff schedules, related facility policy and procedures Also, the investigator observed the outdoor smoking area at the facility. The investigator reviewed the facility video of the incident. The police department did not return a request for a police report. The resident resided in the assisted living facility with diagnoses which included multiple mental health disorder, a history of stroke with residual weakness, and a right arm amputation. The plan indicated the resident required behavior management for physical and verbal aggression, delusions, and agitation. While the resident smoked at the facility, he had a history of not following the smoking guidelines. The resident’s assessment indicated he was alert and oriented but could be socially inappropriate and required redirection. At the time of the incident, the resident could move around independently in a specialized Broda type chair. One day the AP removed the resident from the courtyard area and brought the resident inside the facility after the resident was smoking in the area at the time reserved for the memory care residents. The resident resisted the AP’s efforts, became upset and called police after the incident. The resident’s nursing progress notes indicated the resident said the AP did not ask him to come inside the building, but rather the AP grabbed the cigarette out of his mouth and threw it away, reached around the resident’s upper body and pulled him into the facility. The same document indicated the AP brought the resident to his room, shut the door, and left him. The resident called 911 and reported the incident. The facility security video captured the outdoor portion of the incident showed the AP and the resident conversed briefly and the AP looked at his watch twice. The AP then removed the cigarette from the resident’s mouth, and the resident turned away attempting to stop him. The AP held the resident in his chair with one hand while trying to open the door with his other hand. The AP appeared to reposition the resident in the chair using both hands as the resident almost slid out of the chair and backed the resident into the building. The video did not include audio. During interview, the AP stated staff members were directed to clear the courtyard to allow the memory care residents their time for smoke break. The AP stated the resident, who was not a memory care resident, needed to re-enter the facility to allow the other residents access to the courtyard. The AP stated he asked the resident to come in, but the resident did not cooperate. The AP stated he did place reach under the resident’s armpits but only to sit him up in his chair. The AP stated he had been instructed by several supervisors to remove the resident’s cigarette and bring the resident inside. The AP stated other staff had done the same thing if the resident and that at times the resident did not want to leave when it was time, but this was the process to follow. The AP stated he had heard a message over the radio that the resident needed to come inside. The AP stated that the memory care residents have only a set amount of smoke time and that becomes a frustration for those residents if they are not allowed their time. During interview, the house manager stated the resident did at times defy or argue about the smoking schedule to accommodate himself and others. The manager stated she felt it was a difficult situation when the resident flailed himself in the chair like that and it may have been better if the AP had stopped. She stated the AP had other options and could have radioed for more time to clear the courtyard. During an interview, a nurse stated the resident did at times defy the smoking schedule and at times could be difficult to reason with. During interview, another nurse stated she completed a physical assessment on the resident after the incident. The resident had no marks and did not appear to be harmed but was upset about coming back into the building. She stated it was typical behavior for this resident who was not memory care, and knew he was not to be in the courtyard area when it was time for the memory care residents to be out there. The resident could have gone to two other areas to smoke at that time. She stated that although she believed the AP had the best of intentions the interaction did not go well. In conclusion, the Minnesota Department of Health determined abuse 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. Abuse: Minnesota Statutes section 626.5572, subdivision 2. "Abuse" means: (a) An act against a vulnerable adult that constitutes a violation of, an attempt to violate, or aiding and abetting a violation of: (1) assault in the first through fifth degrees as defined in sections 609.221 to 609.224; (2) the use of drugs to injure or facilitate crime as defined in section 609.235; (3) the solicitation, inducement, and promotion of prostitution as defined in section 609.322; and (4) criminal sexual conduct in the first through fifth degrees as defined in sections 609.342 to 609.3451. A violation includes any action that meets the elements of the crime, regardless of whether there is a criminal proceeding or conviction. (b) Conduct which is not an accident or therapeutic conduct as defined in this section, which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to, the following: (1) hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult; (2) use of repeated or malicious oral, written, or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening. Vulnerable Adult interviewed: No, the resident was deceased. Family/Responsible Party interviewed: No, multiple attempts to contact were made. Alleged Perpetrator interviewed: Yes. Action taken by facility: The facility conducted an internal investigation of the incident and reviewed intervention to address the resident’s refusals with staff members. The AP no longer worked at the facility. Action taken by the Minnesota Department of Health: No 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: 09/03/2024 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.

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 failed to properly supervise the resident and subsequently the resident jumped from a third story window. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. While the resident did jump from a third story window, the facility could not have reasonably anticipated this action the resident’s attempt to leave the building through this means and had performed safety checks as outlined in his service plan. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted the resident’s guardian, family member, ambulance staff, hospital staff and law enforcement. The investigation included review of the resident’s record, staff schedules, facility policies, facility incident reports and An equal opportunity employer. internal investigation. Also, the investigator toured the facility and observed interactions between residents and staff. The resident resided in an assisted living memory care unit. The resident’s diagnoses included history of alcohol use disorder with impaired decision making. The resident’s service plan included assistance with medication management, and verbal reminders to complete personal cares. The resident’s assessment indicated the resident had no mobility issues and was able to walk independently. The facility incident report indicated the resident attempted to scale down the building from a third story window using blankets tied to a broom. An unlicensed caregiver heard the resident calling for help when she went outside on a break and found the resident on the ground with visible injuries. The resident stated his intention was to leave and go to a store. The facility contacted emergency medical services, who transported the resident to the hospital. There was no facility video available. The resident’s care plan indicated scheduled wellness checks three times daily, one time on each shift. The resident’s risk assessments indicated he was a low risk for elopement and falls. During an interview, an unlicensed caregiver stated he observed the resident, and a fellow resident were walking down the hallway minutes before the incident. The two residents went into the sensory room to listen to music, meanwhile the unlicensed caregiver went to provide a third resident cares. A few minutes later he learned the resident was found on the ground outside over the walkie-talkie. The unlicensed caregiver stated the resident was not exit-seeking earlier that day, received a medication earlier for acting anxious, and gave no indication of attempting to leave through the window. During an interview with the nurse, who was on-call at the time of the incident, stated the third story window in the sensory room was examined just after the incident and was found slid open from its tracks inward with the screen was out of the window. The nurse presented the investigator with the bracket which was found after the incident that had been pried off the window. During an interview, the resident stated he found the window open and decided to try to get outside by using a broom with a blanket tied to it. Unfortunately, this did not hold, and he fell to the ground. 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: Not Applicable Action taken by facility: The facility added additional brackets to all the windows in the secured unit to prevent unauthorized opening. 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: 10/31/2023 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 _____________________________ 31417 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 202 EAST NORTH STREET ELMORE ASSISTED LIVING ELMORE, MN 56027 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 September 20, 2023, the Minnesota Department of Health initiated an investigation of complaint HL314172185C/ HL314176465M. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 QWKK11 If continuation sheet 1 of 1

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(s): The resident was abused when an unknown male sexually assaulted the resident at the facility. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was inconclusive. The resident indicated an unwanted sexual encounter occurred while she resided at the facility but did not provide further information. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted law enforcement. The investigation included review of the resident’s medical records, staff lists, and policies. The resident resided in an assisted living facility. The resident’s diagnoses included schizoaffective disorder, bipolar, and opioid and stimulant dependence. The resident’s service An equal opportunity employer. plan included assistance with medication management, reminders, behavior management and interventions, and orientation related to confusion and delusions. The resident’s assessment indicated the resident refused medications at times and obtained medications and drugs that were not prescribed to her for usage. The assessment indicated the resident was sexually active and able to give consent for sexual activity. The assessment also indicated the resident occasionally needed redirection when mildly disoriented to person, place, or time. Review of the resident’ record during the time in question indicated the resident took an outing into the community and chose not to return to the facility the same day as expected. Because the overnight stay was not expected, staff did not set up the resident medications. When the resident returned to the facility, the resident stated she wanted to be evaluated and pointed to her genitals. The record indicated the resident initially denied being sexually assaulted, however, the day after returning the resident made comments to a nurse that suggested the resident may have been sexually assaulted. Because the resident initially denied being sexually assaulted until the following day, facility staff did not arrange for the resident to have a sexual assault examination. Review of provider progress notes during the time in question indicated six days prior to the alleged assault, the resident was seen by her provider and prescribed a steroid cream for irritation to the resident’s vaginal area. Facility staff arranged for a provider visit seven days after the alleged assault and the resident was diagnosed with a vaginal yeast infection and prescribed anti-fungal medications. The provider note did not mention the possibility of the resident being sexually assaulted. During investigative interviews, multiple staff members stated the resident alluded to having been sexually assaulted but refused to provide further information regarding the incident. During an interview, the resident stated she was sexually assaulted while residing at the facility but did not want to discuss further or provide additional details. In conclusion, the Minnesota Department of Health determined abuse 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. Abuse: Minnesota Statutes section 626.5572, subdivision 2. "Abuse" means: (a) An act against a vulnerable adult that constitutes a violation of, an attempt to violate, or aiding and abetting a violation of: (1) assault in the first through fifth degrees as defined in sections 609.221 to 609.224; (2) the use of drugs to injure or facilitate crime as defined in section 609.235; (3) the solicitation, inducement, and promotion of prostitution as defined in section 609.322; and (4) criminal sexual conduct in the first through fifth degrees as defined in sections 609.342 to 609.3451. A violation includes any action that meets the elements of the crime, regardless of whether there is a criminal proceeding or conviction. (b) Conduct which is not an accident or therapeutic conduct as defined in this section, which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to, the following: (1) hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult; (2) use of repeated or malicious oral, written, or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening; Stop here if it is not a restraints issue or sexual abuse. (3) use of any aversive or deprivation procedure, unreasonable confinement, or involuntary seclusion, including the forced separation of the vulnerable adult from other persons against the will of the vulnerable adult or the legal representative of the vulnerable adult; and (4) use of any aversive or deprivation procedures for persons with developmental disabilities or related conditions not authorized under section 245.825. (c) Any sexual contact or penetration as defined in section 609.341, between a facility staff person or a person providing services in the facility and a resident, patient, or client of that facility. (d) The act of forcing, compelling, coercing, or enticing a vulnerable adult against the vulnerable adult's will to perform services for the advantage of another. Vulnerable Adult interviewed: Yes Family/Responsible Party interviewed: Not applicable. Alleged Perpetrator interviewed: Not Applicable Action taken by facility: Facility encouraged the resident to seek medical attention and conducted an internal review of the allegation. 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: 06/16/2023 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 _____________________________ 31417 05/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 202 EAST NORTH STREET ELMORE ASSISTED LIVING ELMORE, MN 56027 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 May 16, 2023, the Minnesota Department of Health initiated an investigation of complaint HL314174683C/HL314172806M. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 YO4B11 If continuation sheet 1 of 1