The Harbors Senior Living of F.

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 staff did not follow the resident’s plan of care and the resident’s skin condition and wounds worsened. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. There was not a preponderance of evidence to attribute the resident’s worsening wounds to staff not following the resident’s care plan. In addition, the resident’s wounds improved after the incident and other concerns related to services received, failed to rise to the level of neglect. The investigator conducted interviews with facility staff members, including administrative staff and nursing staff. The investigator contacted the resident’s hospice agency staff. The investigation included review of the resident record(s), facility internal investigation, facility incident reports, personnel files, staff schedules and related facility policy and procedures. Also, the investigator observed the facility environment, medication and treatment administration, cares and staff interactions with the resident. The resident resided in an assisted living memory care unit. The resident’s diagnoses included senile degeneration, rhabdomyolysis (a serious condition where damaged skeletal muscle tissue breaks down, releasing harmful substances into the bloodstream which can lead to kidney failure), and hydrocephalus (excess cerebral spinal fluid in the brain leading to problems with cognition and mobility). The resident’s service plan included weekly bathing, linen changes, laundry, medication management, dressing, grooming, mobility, transfers, toileting, skin treatments, catheter care and repositioning. The resident’s wound dressings were monitored, and wound care was provided as needed. Additionally, the resident received hospice services for bathing, wound care, and catheter care. The resident’s assessment indicated the resident was oriented to self, had a Foley catheter (a flexible tube inserted through the urethra into the bladder to drain urine continuously), used a mechanical lift with assistance of two staff, had a history of falls, used positioning pillows, an air mattress, heel protectors, and a reclining chair for skin pressure reduction and edema. A complaint report indicated the resident was found lying on his catheter with feces on his catheter tubing and heel protectors. The complaint report also indicated the resident was not bathed, had socks that were hard and stuck to the resident’s feet and when staff attempted to remove the socks, dry skin was ripped off. Additionally, the complaint report indicated staff were not cleaning the resident’s perineal area properly, and staff had not repositioned the resident properly which caused the resident’s leg wounds. Although care was not fully documented on the date of the incident, documentation available indicated that the following cares on the date of the incident were provided: dressing, repositioning, catheter care, incontinent care, safety checks, skin treatment and wound care. The resident’s medical records indicated the resident had a history of skin and wound issues that affected the resident’s buttocks and lower extremities. The resident’s medical records indicated the resident was admitted with lower extremity edema and later developed lower extremity blisters that would open, heal and reappear on various areas of the lower extremities. The resident also had a history of refusing cares such as baths, transfers out of bed and wearing heel protectors. Facility staff monitored the resident’s skin and wounds, reported changes in condition, assessed skin and wound concerns and provided treatment as ordered. The resident’s medical records indicated staff monitored the resident for changes in condition, reported the changes, assessed the resident, treated and/or transported the resident to the hospital for evaluation. Facility records indicated facility administrative nursing staff provided re-education to nursing staff that included the documentation process, provision of wound care and repositioning. During an interview, a facility administrative nurse stated that although there were challenges regarding staff documentation, the facility worked on interventions that included: on-the-spot audits, education, change in processes and exploration of new devices that would make real time documentation more convenient for staff. The facility administrative nurse stated hospice monitored and assessed the resident’s wounds and provided catheter care. Hospice also changed the resident’s wound dressings at least twice per week and facility staff completed cares as needed. The facility administrative nurse stated the facility monitored the resident’s skin and catheter care daily, reported any changes in condition and continued to collaborate with the resident’s hospice agency and followed recommendations regarding the resident’s care. During an interview, facility administrative staff stated the facility met with staff to educate on documentation of catheter output collection. Facility administrative staff stated that staff were instructed to always put a measurement of output in documentation even if the measurement equals zero. In addition, facility administration staff stated staff re-education was on-going in the facility. During interview, hospice administrative staff stated although there were concerns with the facility staff delivering proper care to the resident, care had improved and there was improved collaboration with facility staff and the hospice agency. The hospice administrative staff stated the resident’s wounds improved, facility staff were now providing cares that kept the resident clean and following hospice recommendations. The hospice administrative staff stated facility staff were very professional and prepared with a developed plan of care at the resident’s most recent care conference. During an interview, the resident’s family member stated the resident had skin concerns regarding the buttocks and lower extremity edema upon admission as this was one of the reasons for admitting to the facility. The family member stated the resident had a history of refusals for care and refused to wear heel protectors. The family member stated the resident’s wounds had improved and felt the services in place are aiding in the improvements. The family member recalled the resident’s right ankle wound getting infected but stated the wound improved with the collaboration of facility and hospice staff. The resident’s family stated, although there was always room for improvement, she had no concerns regarding any of the care the resident had received throughout his stay at the facility. The family member stated the facility overall did a good job. 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 or explanatory comment Family/Responsible Party interviewed: Yes or explanatory comment Alleged Perpetrator interviewed: Yes, Not Applicable, or explanatory comment the Action taken by facility: The facility developed and implemented turning and repositioning documentation. Documentation, wound care and repositioning re-education and training was provided after the incident. The facility hired additional staff to facilitate with audits, and to identify and correct concerns regarding care. Action taken by the Minnesota Department of Health: No further action taken at this time. cc: The Office of Ombudsman for Long Term Care The Office of Ombudsman for Mental Health and Developmental Disabilities PRINTED: 02/ 20/ 2026 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/ SUPPLIER/ CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ C B. WING _____________________________ 33169 01/ 07/ 2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5300 4TH STREET NE THE HARBORS SENIOR LIVING FRID FRIDLEY, MN 55421 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER' S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS- REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 000 Initial Comments 0 000 On January 7, 2026, the Minnesota Department of Health initiated an investigation of complaint #HL331695124C/ #HL331696382M. No correction orders are issued. LABORATORY DIRECTOR' S OR PROVIDER/ SUPPLIER REPRESENTATIVE' S SIGNATURE TITLE (X6) DATE STATE FORM 6899 93NJ11 If continuation sheet 1 of 1

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 _____________________________ 33169 07/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5300 4TH STREET NE THE HARBORS SENIOR LIVING FRID FRIDLEY, MN 55421 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 been assigned to Minnesota State Statutes for Assisted Living Facilities. The INITIAL COMMENTS assigned tag number appears in the far-left column entitled "ID Prefix Tag." The SL40044015-1 state Statute number and the corresponding text of the state Statute out On July 28, 2025, the Minnesota Department of of compliance is listed in the "Summary Health conducted a follow-up survey at the above Statement of Deficiencies" column. This provider to follow-up on orders issued pursuant to column also includes the findings which a survey completed on May 1, 2025. As a result are in violation of the state requirement of the follow-up survey, the licensee is in after the statement, "This Minnesota substantial compliance. requirement is not met as evidenced by." Following the evaluators ' findings is the Time Period for Correction. PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH STATES,"PROVIDER'S PLAN OF CORRECTION." THIS APPLIES TO FEDERAL DEFICIENCIES ONLY. THIS WILL APPEAR ON EACH PAGE. THERE IS NO REQUIREMENT TO SUBMIT A PLAN OF CORRECTION FOR VIOLATIONS OF MINNESOTA STATE STATUTES. THE LETTER IN THE LEFT COLUMN IS USED FOR TRACKING PURPOSES AND REFLECTS THE SCOPE AND LEVEL ISSUED PURSUANT TO 144G.31 SUBDIVISION 1-3. {0 500} 144G.41 Subd. 2 Policies and procedures {0 500} SS=F Each assisted living facility must have policies LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 2ZEW12 If continuation sheet 1 of 18 PRINTED: 09/03/2025 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 _____________________________ 33169 07/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5300 4TH STREET NE THE HARBORS SENIOR LIVING FRID FRIDLEY, MN 55421 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) {0 500} Continued From page 1 {0 500} and procedures in place to address the following and keep them current: (1) requirements in section 626.557, reporting of maltreatment of vulnerable adults; (2) conducting and handling background studies on employees; (3) orientation, training, and competency evaluations of staff, and a process for evaluating staff performance; (4) handling complaints regarding staff or services provided by staff; (5) conducting initial evaluations of residents' needs and the providers' ability to provide those services; (6) conducting initial and ongoing resident evaluations and assessments of resident needs, including assessments by a registered nurse or appropriate licensed health professional, and how changes in a resident's condition are identified, managed, and communicated to staff and other health care providers as appropriate; (7) orientation to and implementation of the assisted living bill of rights; (8) infection control practices; (9) reminders for medications, treatments, or exercises, if provided; (10) conducting appropriate screenings, or documentation of prior screenings, to show that staff are free of tuberculosis, consistent with current United States Centers for Disease Control and Prevention standards; (11) ensuring that nurses and licensed health professionals have current and valid licenses to practice; (12) medication and treatment management; (13) delegation of tasks by registered nurses or licensed health professionals; (14) supervision of registered nurses and licensed health professionals; and STATE FORM 6899 2ZEW12 If continuation sheet 2 of 18 PRINTED: 09/03/2025 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 _____________________________ 33169 07/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5300 4TH STREET NE THE HARBORS SENIOR LIVING FRID FRIDLEY, MN 55421 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) {0 500} Continued From page 2 {0 500} (15) supervision of unlicensed personnel performing delegated tasks. This MN Requirement is not met as evidenced by: No further action required. {0 660} 144G.42 Subd. 9 Tuberculosis prevention and {0 660} SS=F control (a) The facility must establish and maintain a comprehensive tuberculosis infection control program according to the most current tuberculosis infection control guidelines issued by the United States Centers for Disease Control and Prevention (CDC), Division of Tuberculosis Elimination, as published in the CDC's Morbidity and Mortality Weekly Report. The program must include a tuberculosis infection control plan that covers all paid and unpaid employees, contractors, students, and regularly scheduled volunteers. The commissioner shall provide technical assistance regarding implementation of the guidelines. (b) The facility must maintain written evidence of compliance with this subdivision. This MN Requirement is not met as evidenced by: No further action required. {0 680} 144G.42 Subd. 10 Disaster planning and {0 680} SS=F emergency preparedness (a) The facility must meet the following requirements: (1) have a written emergency disaster plan that contains a plan for evacuation, addresses elements of sheltering in place, identifies STATE FORM 6899 2ZEW12 If continuation sheet 3 of 18 PRINTED: 09/03/2025 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 _____________________________ 33169 07/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5300 4TH STREET NE THE HARBORS SENIOR LIVING FRID FRIDLEY, MN 55421 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) {0 680} Continued From page 3 {0 680} temporary relocation sites, and details staff assignments in the event of a disaster or an emergency; (2) post an emergency disaster plan prominently; (3) provide building emergency exit diagrams to all residents; (4) post emergency exit diagrams on each floor; and (5) have a written policy and procedure regarding missing residents. (b) The facility must provide emergency and disaster training to all staff during the initial staff orientation and annually thereafter and must make emergency and disaster training annually available to all residents. Staff who have not received emergency and disaster training are allowed to work only when trained staff are also working on site. (c) The facility must meet any additional requirements adopted in rule. This MN Requirement is not met as evidenced by: No further action required. {0 775} 144G.45 Subd. 2. (a) Fire protection and physical {0 775} SS=F environment Each assisted living facility must comply with the State Fire Code in Minnesota Rules, chapter 7511, and: This MN Requirement is not met as evidenced by: No further action required. {0 790} 144G.45 Subd. 2 (a) (2-3) Fire protection and {0 790} SS=C physical environment STATE FORM 6899 2ZEW12 If continuation sheet 4 of 18 PRINTED: 09/03/2025 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.