Arbor Garden Place.

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 began hallucinating and was verbally disruptive with drug paraphernalia in his room. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. While it was true drug paraphernalia was found in the resident’s room, the facility acted appropriately to the resident’s behavior and situation. The unlicensed notified the nurse, law enforcement was contacted, and emergency medical services transported resident for medical evaluation. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator also contacted a family member along with law enforcement and the social worker. The investigation included review of resident record, hospital records, hospital laboratory results, law enforcement notes, and related facility policies and procedures. Also, the investigator observed general interactions of staff and residents while on site and the location of the resident’s apartment in the facility. The resident resided in an assisted living facility. The resident’s diagnoses included tobacco abuse, depression, and history of substance abuse. The resident’s service plan included monitoring of vital signs and medication management. The individual abuse prevention plan indicated resident was vulnerable due to use of marijuana and at times displayed behaviors of agitation and verbal aggression towards staff members. One day on two separate occasions law enforcement was called to the facility. The first call was related to drug paraphernalia found in the resident’s room along with changes in the resident’s behaviors. A second call to law enforcement was related to the resident’s mental status, verbal outburst, and hallucinations. During the second occasion, emergency medical services were called to the facility to transport resident due to unusual body movements and agitation. The resident’s signed assisted living agreement indicated smoking was not allowed in the resident’s apartment, common areas or elsewhere on the facility’s premises. The same document indicated the resident could not possess nor manufacture controlled substances nor engage in any drug-related activity on or near the premises, or eviction proceedings would result. The presence of any illegal drug, in any amount, in the resident’s apartment constituted a violation. Hospital records indicated that the resident arrived at the emergency department with an altered mental status, slurred speech, and wounds on his legs. The record indicated a positive drug screen on admission. The resident was admitted, and a chemical assessment completed during inpatient stay with a recommendation for outpatient treatment upon discharge. During investigative interviews, multiple unlicensed caregivers stated the facility provided medication administration for medically prescribed medications. The caregivers gave a consistent account that the resident smoked on his deck which was a violation of the facility policy, and the caregivers were trained to notify the facility management of concerns regarding smoking and/or illegal drug use. During an interview, the facility nurse stated the resident displayed twitching movements, making strange noises, hallucinating, and saying “something bad” happened to family member. The nurse stated other residents voiced concerns of the erratic behaviors. The nurse stated the smoking and/or substance abuse on the premises was in violation of the facility’s policies. The facility staff members found drug paraphernalia in the resident’s room out in the open; the resident also did allow facility staff members to search his apartment with him inside. During an interview, a manager stated the facility discussed the facility policies with the resident but did not to follow the policies. During an interview, a family member stated the resident smoked marijuana out on his deck and the facility did offer substance abuse treatment. The family member stated he was aware of drug paraphernalia found in the apartment but stated he was not aware of where it came from. Family member stated the resident had wounds on his legs from scratching areas and pulling off scabs along with not taking care of his personal hygiene. Family member stated he was aware the facility did not provide wound care services. In conclusion, the Minnesota Department of Health determined neglect was not substantiated. 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, present when family member interviewed. Family/Responsible Party interviewed: Yes Alleged Perpetrator interviewed: NA the Action taken by facility: The facility took steps to discharge the resident. 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: 01/22/2025 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 _____________________________ 30217 12/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 535 CANYON DRIVE NW ARBOR GARDEN PLACE EYOTA, MN 55934 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 December 31, 2024, the Minnesota Department of Health initiated an investigation of complaint #HL302179553C/HL302176403M. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 QPZC11 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 alleged perpetrator (AP) abused the resident when she cut off skin a tag during a hair appointment. Investigative Findings and Conclusion: The Minnesota Department of Health determined abuse was inconclusive. While working with the resident the AP, who worked as a licensed cosmetologist, noticed a skin tag that had become mostly detached and causing the resident discomfort. The AP finished removal of the skin tag with a pair of scissors. While the AP should have informed the facility before taking this action to relieve the resident’s discomfort and taking it upon herself to remove the skin tag, it is not clear the action met the definition of abuse. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted a family member. The investigator contacted the AP. The investigation included review of the resident’s medical record, assessments, plan of care, service agreement, and the internal investigation. Also, the investigator made a visit to the facility and observed the resident in her memory care unit and assessed the skin on the resident’s face and back of her neck. The resident resided in an assisted living memory care unit. The resident’s diagnoses included cognitive impairment and anxiety. The resident’s service plan included assistance with showers, dressing, and toileting. The resident’s assessment indicated prior to the incident the resident’s skin was dry with poor skin turgor and no wounds present. The assessment indicated the resident required escorts to and from locations. The assessment indicated the resident is at risk to be abused and unable to make her own decisions. The facility provided a designated room within the facility for a licensed cosmetologist to provide services for the residents with a homebound servicer permit which allows a salon operator to offer services at an assisted living facility. The AP worked as a licensed cosmetologist and had an active homebound service permit. Areas of licensure under cosmetology listed under cosmetology included cosmetic care of the hair, skin, and nails on the body surface. One day the AP was providing cosmetic cares for the resident and the resident was having discomfort due to a skin tag on the back of her neck. During the appointment, the AP removed the skin tag with a pair of scissors. The progress notes indicated the facility caregivers noticed a small wound on the resident’s neck that was bleeding a little and notified the nurse. When the nurse spoke with the AP regarding the removed skin tag the resident’s family and medical provider were updated. The facility also monitored the area for any signs of infection. A review of the resident’s medical record did not identify any further concerns regarding an infection or complications with healing. The progress note stated the resident had a “minor” complaint of pain. The medical provider notes indicated the facility updated the medical provider on the day of the incident. The medical provider indicated no further intervention was needed. During an interview, unlicensed staff member #1 stated residents or their family members can sign up to receive services with the AP. Unlicensed staff member #1 stated the resident was signed up on a weekly basis for a wash and set. Unlicensed staff member #1 stated the resident also received haircuts and perms from the AP as needed. Unlicensed staff member #1 stated the memory care residents are escorted to the beauty shop located in the facility. Staff are then able to leave the resident and when the services are completed return to escort the resident back to the memory care unit. During an interview, a different unlicensed staff member #2 stated she worked in the memory care unit on the day of the incident. Unlicensed staff member #2 stated the facility staff member who brought the resident back to the unit the day of the incident, explained to unlicensed staff member #2 the resident had a spot on the back of her neck that was bleeding. Unlicensed staff member #2 stated the AP had stated she cut off a skin tag on the back of the resident’s neck. Unlicensed staff member #2 stated the area was no longer bleeding when the resident returned to the unit. During an interview, a nurse stated she was called down to the memory care unit and told the AP had cut off a skin tag located on the back of the resident’s neck. The nurse stated she checked the back of the resident’s neck and found 2 small lacerations the size of a fingernail which were open and bleeding. She spoke with the AP who admitted cutting off the skin tag. The nurse stated the AP said she used to get skin tags herself and her medical provider directed her to just cut them off. During an interview, the AP stated she provides residents at the facility haircuts, perms, hair colors, washes, and weekly sets. The AP stated the resident had a small dry hard spot which stuck out on the back of her neck and caused her pain during weekly hair washes. On the day of the incident the AP placed a towel between the resident’s neck and the wash bowl rim to soften the area where the resident’s neck rested. The AP stated when resident sat up after washing her hair the towel rubbed the area causing the spot to pull away from the neck skin. So that it was almost completely detached, barely hanging on, and causing the resident discomfort. The AP asked the resident what she would like the AP to do, and the resident stated to cut it off so the used scissors to remove the mostly detached skin tag. The AP stated the area did not bleed, she cleaned the area and reported it to the staff member who came to escort the resident back to her unit. The facility did not provide photos or diagrams of the resident’s skin appearance prior to the incident or immediately after the incident. During the investigation onsite visit, the investigator observed the resident’s face and neck. Those observations included a small area on the back of the resident’s neck that appeared to be the area where the skin tag was removed, and it appeared healed. 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 Vulnerable Adult interviewed: Attempted, unable to cognitive status Family/Responsible Party interviewed: Attempted Alleged Perpetrator interviewed: Yes Action taken by facility: The facility updated the resident’s family and medical provider. The facility also monitored the area for infection. The AP no longer offers services at the facility. Action taken by the Minnesota Department of Health: No further action required.

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 Arbor Garden Place May 10, 2024 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, Jodi Johnson, Supervisor State Evaluation Team Email: jodi.johnson@state.mn.us Telephone: 507-344-2730 Fax: 1-866-890-9290 HHH PRINTED: 05/10/2024 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 30217 04/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 535 CANYON DRIVE NW ARBOR GARDEN PLACE EYOTA, MN 55934 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 LICENSING using federal software. Tag numbers have CORRECTION ORDER(S) been assigned to Minnesota State Statutes for Assisted Living License In accordance with Minnesota Statutes, section Providers. The assigned tag number 144G.08 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 surveyors' INITIAL COMMENTS: findings is the Time Period for Correction. SL30217016-0 PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On April 22, 2024, through April 24, 2024, the STATES,"PROVIDER'S PLAN OF survey at the above provider, and the following FEDERAL DEFICIENCIES ONLY. THIS correction orders are issued. At the time of the WILL APPEAR ON EACH PAGE. survey, there were 34 residents; 34 receiving services under the provider's Assisted Living with THERE IS NO REQUIREMENT TO 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 subd. 1, 2, and 3. 0 470 144G.41 Subdivision 1 Minimum requirements 0 470 SS=C (11) develop and implement a staffing plan for determining its staffing level that: LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 OP9611 If continuation sheet 1 of 39 PRINTED: 05/10/2024 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 30217 04/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 535 CANYON DRIVE NW ARBOR GARDEN PLACE EYOTA, MN 55934 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 470 Continued From page 1 0 470 (i) includes an evaluation, to be conducted at least twice a year, of the appropriateness of staffing levels in the facility; (ii) ensures sufficient staffing at all times to meet the scheduled and reasonably foreseeable unscheduled needs of each resident as required by the residents' assessments and service plans on a 24-hour per day basis; and (iii) ensures that the facility can respond promptly and effectively to individual resident emergencies and to emergency, life safety, and disaster situations affecting staff or residents in the facility; (12) ensure that one or more persons are available 24 hours per day, seven days per week, who are responsible for responding to the requests of residents for assistance with health or safety needs. Such persons must be: (i) awake; (ii) located in the same building, in an attached building, or on a contiguous campus with the facility in order to respond within a reasonable amount of time; (iii) capable of communicating with residents; (iv) capable of providing or summoning the appropriate assistance; and (v) capable of following directions; This MN Requirement is not met as evidenced by: Based on observation, interview, and record review, the licensee failed to ensure the staff posting included all the required elements, potentially affecting all the licensee's current residents, staff, and visitors. This practice resulted in a level one violation (a violation that has no potential to cause more than a minimal impact on the resident and does not affect health or safety) and was issued at a widespread scope (when problems are pervasive STATE FORM 6899 OP9611 If continuation sheet 2 of 39 PRINTED: 05/10/2024 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 30217 04/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 535 CANYON DRIVE NW ARBOR GARDEN PLACE EYOTA, MN 55934 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 470 Continued From page 2 0 470 or represent a systemic failure that has affected or has potential to affect a large portion or all the residents).

Finding: Substantiated, facility responsibility 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 implement interventions to prevent falls resulting in serious injury. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was substantiated. The facility failed to re-assess the resident and implement interventions to prevent further falls. The resident did not return to baseline after the last fall with hospitalization. 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 facility progress notes, incident reports, service plan, assessments, and hospital records. During an onsite visit, the investigator made observations of staff interactions with residents. The resident resided in an assisted living facility. The resident’s diagnoses included dementia, history of falls, and chronic low back pain. The resident’s master care plan included stand by assistance with showers, medication administration, meal reminders, and safety checks twice a day. The resident’s admission assessment indicated the resident had a history of falls recently prior to admission and was at risk for falls. The same assessment indicated the resident required assistance in removing clutter in her apartment due to fall risk, had decreased strength and endurance, and impaired decision-making. The resident used a walker for ambulation. The medical record indicated the resident fell four times within a three-week period. The first fall occurred approximately two weeks after admission and required evaluation at the emergency department. The incident report indicated the fall was unwitnessed but occurred at the elevator and the resident had been walking. The same document indicated there was suspected head trauma and the resident transferred to the emergency department. A review of the medical record identified the facility made no changes to the resident’s care plan nor focused falls assessment after this fall. Approximately two weeks later the resident fell three more times within a three day time-period. The second fall required evaluation at the emergency department related to hip and rib pain. The third fall occurred a day later resident when the resident was found on the floor in her apartment. The fourth and final fall happened yet another day later and resulted in the resident admitting to the hospital where she was diagnosed with a hip fracture and multiple fractured ribs. The resident did not return to the facility. A review of the electronic medical record indicated unlicensed caregivers completed the falls in the medical record, however the time stamp for the follow-up by the facility for each of these three falls did not occur until more than two weeks after the resident had discharged from the facility. During an interview, an unlicensed caregiver stated resident required meal reminders and at times escort to meals. The unlicensed caregiver stated resident cares and interventions are located on the care plan and staff use the care plan to determine resident cares and vulnerabilities. During an interview, a manager stated the facility did not complete the required assessments at resident admission or after falls. The manager stated updates or changes were not made to the plan of care after each fall to prevent a future fall. In conclusion, the Minnesota Department of Health determined neglect was substantiated. Substantiated: Minnesota Statutes, section 626.5572, Subdivision 19. “Substantiated” means a preponderance of evidence shows that an act that meets the definition of maltreatment occurred. 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 Family/Responsible Party interviewed: Yes Alleged Perpetrator interviewed: Not Applicable Action taken by facility: The administration and licensed staff member are no longer employed by the facility. Action taken by the Minnesota Department of Health: No further action taken at this time. 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 cc: The Office of Ombudsman for Long Term Care The Office of Ombudsman for Mental Health and Developmental Disabilities Olmsted County Attorney Eyota City Attorney Eyota Police Department PRINTED: 03/27/2024 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 _____________________________ 30217 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 535 CANYON DRIVE NW ARBOR GARDEN PLACE EYOTA, MN 55934 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 HOME CARE PROVIDER/ASSISTED LIVING using federal software. Tag numbers have PROVIDER CORRECTION ORDER been assigned to Minnesota State Statutes for Assisted Living Facilities. The In accordance with Minnesota Statutes, section assigned tag number appears in the far 144G.08 to 144G.95, these correction orders are 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. #HL302173684C/#HL302177208M PLEASE DISREGARD THE HEADING OF #HL302176688C THE FOURTH COLUMN WHICH STATES,"PROVIDER'S PLAN OF On March 4, 2024, through March 5, 2024, the CORRECTION." THIS APPLIES TO complaint investigation at the above provider, and WILL APPEAR ON EACH PAGE. the following correction orders are issued. At the time of the complaint investigation, there were 37 THERE IS NO REQUIREMENT TO residents receiving services under the provider's SUBMIT A PLAN OF CORRECTION FOR Assisted Living with Dementia Care license. VIOLATIONS OF MINNESOTA STATE STATUTES. For #HL302176688C there were no correction orders issued. THE LETTER IN THE LEFT COLUMN IS USED FOR TRACKING PURPOSES AND The following correction orders are issued for REFLECTS THE SCOPE AND LEVEL #HL302173684C/#HL302177208M, tag ISSUED PURSUANT TO 144G.31 identification 1610, 1620, 2310, and 2360. SUBDIVISION 1-3. 01610 144G.70 Subd. 2 (a-b) Initial reviews, 01610 SS=D assessments, and monitoring LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 DRC111 If continuation sheet 1 of 11 PRINTED: 03/27/2024 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 _____________________________ 30217 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 535 CANYON DRIVE NW ARBOR GARDEN PLACE EYOTA, MN 55934 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) 01610 Continued From page 1 01610 (a) Residents who are not receiving any assisted living services shall not be required to undergo an initial nursing assessment. (b) An assisted living facility shall conduct a nursing assessment by a registered nurse of the physical and cognitive needs of the prospective resident and propose a temporary service plan prior to the date on which a prospective resident executes a contract with a facility or the date on which a prospective resident moves in, whichever is earlier.

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. #HL302173684C/#HL302177208M PLEASE DISREGARD THE HEADING OF #HL302176688C THE FOURTH COLUMN WHICH STATES,"PROVIDER'S PLAN OF On March 4, 2024, through March 5, 2024, the CORRECTION." THIS APPLIES TO complaint investigation at the above provider, and WILL APPEAR ON EACH PAGE. the following correction orders are issued. At the time of the complaint investigation, there were 37 THERE IS NO REQUIREMENT TO residents receiving services under the provider's SUBMIT A PLAN OF CORRECTION FOR Assisted Living with Dementia Care license. VIOLATIONS OF MINNESOTA STATE STATUTES. For #HL302176688C there were no correction orders issued. THE LETTER IN THE LEFT COLUMN IS USED FOR TRACKING PURPOSES AND The following correction orders are issued for REFLECTS THE SCOPE AND LEVEL #HL302173684C/#HL302177208M, tag ISSUED PURSUANT TO 144G.31 identification 1610, 1620, 2310, and 2360. SUBDIVISION 1-3. 01610 144G.70 Subd. 2 (a-b) Initial reviews, 01610 SS=D assessments, and monitoring LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 DRC111 If continuation sheet 1 of 11 PRINTED: 03/27/2024 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 _____________________________ 30217 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 535 CANYON DRIVE NW ARBOR GARDEN PLACE EYOTA, MN 55934 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) 01610 Continued From page 1 01610 (a) Residents who are not receiving any assisted living services shall not be required to undergo an initial nursing assessment. (b) An assisted living facility shall conduct a nursing assessment by a registered nurse of the physical and cognitive needs of the prospective resident and propose a temporary service plan prior to the date on which a prospective resident executes a contract with a facility or the date on which a prospective resident moves in, whichever is earlier. If necessitated by either the geographic distance between the prospective resident and the facility, or urgent or unexpected circumstances, the assessment may be conducted using telecommunication methods based on practice standards that meet the resident's needs and reflect person-centered planning and care delivery. This MN Requirement is not met as evidenced by: Based on document review and interview, the licensee failed to ensure a registered nurse (RN) conducted a pre-admission assessment prior to the resident move-in-date for one of one residents (R1) with records reviewed. This practice resulted in a level two violation (a violation that did not harm a residents health or safety but had the potential to have harmed a resident's health or safety, but was not likely to cause serious injury, impairment, or death), and was issued at an isolated scope (when one or a limited number of residents are affected or one or a limited number of staff are involved or the situation has occurred only occasionally). The findings include: Review of R1's medical record on March 4, 2024, STATE FORM 6899 DRC111 If continuation sheet 2 of 11 PRINTED: 03/27/2024 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 _____________________________ 30217 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 535 CANYON DRIVE NW ARBOR GARDEN PLACE EYOTA, MN 55934 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) 01610 Continued From page 2 01610 at 3:15 p.m., indicated R1's diagnoses included dementia, history of falls, and chronic low back pain. The facility's medical record lacked evidence of the following: - pre-admission assessment prior to admission. - 14-day assessment - Focused Falls Assessments and Screening after falls - care plan updates after initial move in date. During an interview on March 5, 2024, at 10:00 a.m., ADM/RN-B confirmed the licensee did not complete nursing assessments within the timeframe required. The licensee 6.01 Assessments, Reviews & Monitoring policy, dated August 1, 2022, indicated resident reassessment and monitoring must be conducted no more than 14 calendar days of services initiated and ongoing based on changes in needs and cannot exceed 90 calendar days from the last date of assessments. TIME PERIOD FOR CORRECTION: Twenty-one (21) days 01620 144G.70 Subd. 2 (c-e) Initial reviews, 01620 SS=D assessments, and monitoring (c) Resident reassessment and monitoring must be conducted no more than 14 calendar days after initiation of services. Ongoing resident reassessment and monitoring must be conducted as needed based on changes in the needs of the resident and cannot exceed 90 calendar days from the last date of the assessment. (d) For residents only receiving assisted living STATE FORM 6899 DRC111 If continuation sheet 3 of 11 PRINTED: 03/27/2024 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 _____________________________ 30217 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 535 CANYON DRIVE NW ARBOR GARDEN PLACE EYOTA, MN 55934 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) 01620 Continued From page 3 01620 services specified in section 144G.08, subdivision 9, clauses (1) to (5), the facility shall complete an individualized initial review of the resident's needs and preferences. The initial review must be completed within 30 calendar days of the start of services. Resident monitoring and review must be conducted as needed based on changes in the needs of the resident and cannot exceed 90 calendar days from the date of the last review. (e) A facility must inform the prospective resident of the availability of and contact information for long-term care consultation services under section 256B.0911, prior to the date on which a prospective resident executes a contract with a facility or the date on which a prospective resident moves in, whichever is earlier. This MN Requirement is not met as evidenced by: Based on interview and record review, the licensee failed to complete the required 14-day assessment and ongoing focused falls assessments and screenings for one of one residents (R1) reviewed. This practice resulted in a level two violation (a violation that did not harm a resident's health or safety but had the potential to have harmed a resident's health or safety, but was not likely to cause serious injury, impairment, or death), and was issued at an isolated scope (when one or a limited number of residents are affected or one or a limited number of staff are involved or the situation has occurred only occasionally). The findings include: R1's start of care date for services was May 28, 2023. R1's diagnoses included dementia, chronic back pain, and history of falls. STATE FORM 6899 DRC111 If continuation sheet 4 of 11 PRINTED: 03/27/2024 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 _____________________________ 30217 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 535 CANYON DRIVE NW ARBOR GARDEN PLACE EYOTA, MN 55934 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) 01620 Continued From page 4 01620 Review of R1's initial assessment dated May 12, 2023, indicated R1 had fallen in the previous three months prior to admission, ambulated with a walker, and needed assistance to reduce falls by removing clutter in the resident's apartment.

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 resident was found in his room kneeling with upper body resting on the seat of a chair with chest pain after an apparent unwitnessed fall. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. The facility discovered the resident on the floor with injuries. The facility responded appropriately by contacting 911 and sent the resident to the emergency room. 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 resident incidents, emergency room summaries, individual abuse prevention assessment, progress notes, and nursing reviews. Also, the investigator observed facility staff and resident interactions. An equal opportunity employer. The resident resided in an assisted living facility. The resident’s diagnoses included osteoporosis, hypertension, osteoarthritis of the hip, and abnormalities of gait and mobility. The resident’s service plan included assistance with medication administration, staff to provide cues for use of walker, assistance with showers and dressing. The resident’s assessment indicated cognitive decline and falls. The resident’s progress notes indicated facility staff entered the resident’s room to give him his morning pills and found him kneeling in front of a chair in his bedroom with his upper body on the seat of the chair with his face down. The resident complained of chest pain and a bruise around his right eye. The resident also had increased confusion. The facility staff contacted 911 and transferred him to the emergency room. During an interview, facility nurses stated the resident was experiencing cognitive decline and was on fall protocols due to history of falls with injuries. The resident refused assistance from staff regarding showers and dressing. Wellness checks were completed multiple times throughout the day including during mealtimes, daily when he would visit his wife in memory care, and during medication administration times. During interviews, multiple unlicensed personnel (ULPs) stated the resident had become more forgetful and wandered on overnights. The resident was found in his bedroom apartment the morning of the incident with his walker located in the bathroom. The resident was not able to give an accurate description of what had happened as his speech was incoherent stating he did not fall and then stating he fell. 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 Family/Responsible Party interviewed: No, but provided information through email Alleged Perpetrator interviewed: N/A Action taken by facility: The facility staff, per facility protocol, contacted licensed nurse immediately when finding resident on the floor. 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: 06/30/2023 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 _____________________________ 30217 03/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 535 CANYON DRIVE NW ARBOR GARDEN PLACE EYOTA, MN 55934 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 28, 2023, the Minnesota Department of Health initiated an investigation of complaint #HL302174062C/#HL302172361M and #HL302174063C/#HL302172362M. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 1P4V11 If continuation sheet 1 of 1