Harmony Place.

Finding: Substantiated, individual 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 alleged perpetrator (AP) abused the resident when the AP engaged in a sexual relationship with the resident. Investigative Findings and Conclusion: The Minnesota Department of Health determined abuse was substantiated. The AP, while employed at the facility, engaged in a sexual relationship with the resident while he lived at the facility and received services. Both parties admitted to having a sexual relationship that lasted for months. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigation included review of the resident record, facility internal investigation, personnel files, staff schedules, and related facility policy and procedures. Also, the investigator toured the facility and observed resident and staff interactions. The resident resided in an assisted living facility. The resident’s diagnoses included anxiety, depression, and type two diabetes with loss of left leg below knee. The resident’s service plan included assistance with medication administration, meals, bathing reminders, safety checks, and housekeeping. The facility underwent a change in ownership after the relationship between the AP and the resident had ended. The current owners supplied all investigative records available from the previous ownership. The prior owners, inappropriately, allowed the relationship between the AP and resident and added the relationship to the resident’s care plan. The resident’s previous care plan implemented by the previous owners indicated “resident was in a consented relationship with a staff member.” The care plan indicated the facility had done an investigation and found no evidence of abuse, sexual or financial exploitation. The resident’s service notes indicated the resident was out of the facility for several overnight passes during his relationship with the AP. The service record indicated the resident was on a leave of absence “with a friend.” After the change in ownership, a grievance record indicated the resident expressed sadness over the ending of a recent relationship. Progress notes indicated the resident expressed anxiety keeping him in bed due to worry about his romantic relationship and lack of explanation of it ending. Per the resident’s progress notes, a staff member reported concerns about a relationship between the resident and AP. She reported the AP told her they were in love and planned to move in together. A few days later their relationship ended. The AP blamed the resident for being transferred to memory care and not being able to work on the assisted living side. A prior member of management, who was also a nurse, documented the relationship between the AP and the resident in the resident’s care plan. Service records indicated in the weeks following the ending of the relationship between the AP and the resident, he had an increase in using anti-anxiety medication. The AP’s training filed indicated the AP received maltreatment of vulnerable adults training before she engaged in a sexual relationship with the resident. During an interview, the resident said he met the AP while he lived at the facility and the AP worked at the facility. He said the relationship started as a friendship and developed into a sexual relationship a few months later. He said the sexual relationship lasted a few months and then the AP broke up with him. The resident said he notified the police after the AP’s husband called and threatened him. The resident said he gave the AP money for rent and food. When the facility changed ownership, the new owners told the resident the relationship was inappropriate. A police report indicated a relationship between the resident and AP ended and the AP and the AP’s husband were sending threatening and harassing text messages to the resident. The AP believed she was terminated because of the resident. During an interview, a member of the previous management-1, who was also a nurse, said she was made aware the AP and resident were in a relationship. She reported the relationship to corporate and another member of management, but she was unable to provide names of who she reported the relationship to. She thought the relationship was inappropriate as the resident resided at the facility and received services, but both the resident and the AP gave consent. She was unaware if the facility filed a vulnerable adult report at the time the incident was discovered. She said she added the relationship to the resident’s care plan as they both consented to their sexual relationship. During an interview, another member of the previous management-2 said several staff members reported the AP was spending long periods of time in the resident’s room at night. While the AP was on medical leave the resident requested a three-day pass to go camping with friends. While the resident was on pass, a facility staff member observed the resident’s vehicle at the AP’s house. When the AP and resident were confronted, they admitted to being in a relationship and wrote statements consenting to their relationship. When corporate was informed of the relationship, corporate directed facility management to add the relationship to the resident’s care plan and schedule to AP to work in memory care. However, at times the AP still worked on the assisted living unit. The member of management-2 said she received no training when given the management position and was unaware if a vulnerable adult report should have been filed. During an interview, a member of the current management team said when she was hired, the relationship between the AP and resident was documented in the resident’s care plan and the AP still worked at the facility. When the new ownership was effective less than one month later, the AP was not rehired. She said this was an inappropriate relationship. During an interview, the AP said she met the resident while working at the facility. The relationship started as friends and then progressed into a sexual relationship. She said the relationship was approved by management. She never considered the resident vulnerable as they were both consenting adults, of similar age. She said she never received money from the resident, but she bought the resident groceries with his money when the resident stayed at her home for ten days. In conclusion, the Minnesota Department of Health determined abuse 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. 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; or (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 unless authorized under applicable licensing requirements or Minnesota Rules, chapter 9544. (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.

STATE LICENSING COMPLIANCE REPORT Report #: HL215189790C Date Concluded: April 19, 2024 Name, Address, and County of Facility Investigated: Harmony Place 455 Main Avenue N Harmony, MN 55939 Facility Type: Assisted Living Facility with Evaluator’s Name: Deb Schillinger, RN Dementia Care (ALFDC) Special Investigator The Minnesota Department of Health conducted a complaint investigation to determine compliance with state laws and rules governing the provision of care under Minnesota Statutes, Chapter 144G (for ALL). The purpose of this complaint investigation was to review if facility policies and practices comply with applicable laws and rules. No maltreatment under Minnesota Statutes, Chapter 626 was alleged. To view a copy of the correction orders, if any, please visit: https://www.health.state.mn.us/facilities/regulation/directory/provcompselect.html Or call 651-201-4201 to be provided a copy via mail or email. If you are viewing this report on the MDH website, please see the attached state form. PRINTED: 04/23/2024 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 _____________________________ 21518 04/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 455 MAIN AVENUE NORTH HARMONY PLACE HARMONY, MN 55939 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 April 9, 2024, the Minnesota Department of Health initiated an investigation of complaint #HL215189790C and #HL215189964C. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 AIIN11 If continuation sheet 1 of 1

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. An equal opportunity employer. Letter ID: IS7N REVISED 09/13/2021 Harmony Place March 20, 2024 Page 2 The correction order documentation should include the following: Identify how the area(s) of noncompliance was corrected related to the resident(s)/employee(s) identified in the correction order. Identify how the area(s) of noncompliance was corrected for all of the provider’s resident(s)/employees that may be affected by the noncompliance. Identify what changes to your systems and practices were made to ensure compliance with the specific statute(s). CORRECTION ORDER RECONSIDERATION PROCESS In accordance with Minn. Stat. § 144G.32, Subd. 2, you may challenge the correction order(s) issued, including the level and scope, and any fine assessed through the correction order reconsideration process. The request for reconsideration must be in writing and received by MDH within 15 calendar days of the correction order receipt date. To submit a reconsideration request, please visit: https://forms.web.health.state.mn.us/form/HRDAppealsForm 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: 507-344-273 Fax: 1-866-890-9290 HHH PRINTED: 03/20/2024 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 _____________________________ 21518 02/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 455 MAIN AVENUE NORTH HARMONY PLACE HARMONY, MN 55939 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. SL21518016 PLEASE DISREGARD THE HEADING OF On February 26, 2024, through February 29, THE FOURTH COLUMN WHICH 2024, the Minnesota Department of Health STATES,"PROVIDER'S PLAN OF conducted a full survey at the above provider, and CORRECTION." THIS APPLIES TO the following correction orders are issued. At the FEDERAL DEFICIENCIES ONLY. THIS time of the survey, there were 28 residents; 27 WILL APPEAR ON EACH PAGE. receiving services under the Assisted Living with Dementia Care license. THERE IS NO REQUIREMENT TO SUBMIT A PLAN OF CORRECTION FOR VIOLATIONS OF MINNESOTA STATE STATUTES. The letter in the left column is used for tracking purposes and reflects the scope and level issued pursuant to 144G.31 subd. 1, 2, and 3. 0 480 144G.41 Subd 1 (13) (i) (B) Minimum 0 480 SS=F requirements (13) offer to provide or make available at least the LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 KUCZ11 If continuation sheet 1 of 45 PRINTED: 03/20/2024 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 _____________________________ 21518 02/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 455 MAIN AVENUE NORTH HARMONY PLACE HARMONY, MN 55939 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 following services to residents: (B) food must be prepared and served according to the Minnesota Food Code, Minnesota Rules, chapter 4626; and This MN Requirement is not met as evidenced by: Based on observation, interview, and record review, the licensee failed to ensure food was prepared and served according to the Minnesota Food Code. 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) and was issued at a widespread scope (when problems are pervasive or represent a systemic failure that has affected or has the potential to affect a large portion or all the residents). The findings include: Please refer to the document titled, Food and Beverage Establishment Inspection Report (FBEIR) dated February 27, 2024, for the specific Minnesota Food Code violations. The Inspection Report was provided to the licensee within 24 hours of the inspection. TIME PERIOD FOR CORRECTION: Please refer to the FBEIR for any compliance dates. 0 550 144G.41 Subd. 7 Resident grievances; reporting 0 550 SS=F maltreatment All facilities must post in a conspicuous place information about the facilities' grievance procedure, and the name, telephone number, and STATE FORM 6899 KUCZ11 If continuation sheet 2 of 45 PRINTED: 03/20/2024 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 _____________________________ 21518 02/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 455 MAIN AVENUE NORTH HARMONY PLACE HARMONY, MN 55939 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) 0 550 Continued From page 2 0 550 email contact information for the individuals who are responsible for handling resident grievances. The notice must also have the contact information for the Office of Ombudsman for Long-Term Care and the Office of Ombudsman for Mental Health and Developmental Disabilities and must have information for reporting suspected maltreatment to the Minnesota Adult Abuse Reporting Center.