Suite Living Sr of Igh.

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 Suite Living Senior Care of Inver Grove Heights May 2, 2025 Page 2 resident(s)/employee(s) identified in the correction order. Identify how the area(s) of noncompliance was corrected for all of the provider’s resident(s)/employees that may be affected by the noncompliance. Identify what changes to your systems and practices were made to ensure compliance with the specific statute(s). CORRECTION ORDER RECONSIDERATION PROCESS In accordance with Minn. Stat. § 144G.32, Subd. 2, you may challenge the correction order(s) issued, including the level and scope, and any fine assessed through the correction order reconsideration process. The request for reconsideration must be in writing and received by MDH within 15 calendar days of the correction order receipt date. To submit a reconsideration request, please visit: https://forms.web.health.state.mn.us/form/HRDAppealsForm The MDH Health Regulation Division (HRD) values your feedback about your experience during the survey and/or investigation process. Please fill out this anonymous provider feedback questionnaire at your convenience at this link: h ttps://forms.office.com/g/Bm5uQEpHVa. Your input is important to us and will enable MDH to improve its processes and communication with providers. If you have any questions regarding the questionnaire, please contact Susan Winkelmann at susan.winkelmann@state.mn.us or call 651-201-5952. You are encouraged to retain this document for your records. It is your responsibility to share the information contained in the letter and state form with your organization’s Governing Body. If you have any questions, please contact me. Sincerely, Jodi Johnson, Supervisor State Evaluation Team Email: Jodi.Johnson@state.mn.us Telephone: 507-344-2730 Fax: 1-866-890-9290 KKM PRINTED: 05/02/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 36603 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 7900 AUSTIN WAY SUITE LIVING SR OF IGH INVER GROVE HEIGHTS, MN 55077 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 000 Initial Comments 0 000 ASSISTED LIVING PROVIDER LICENSING Minnesota Department of Health is CORRECTION ORDER(S) documenting the State Correction Orders using federal software. Tag numbers have In accordance with Minnesota Statutes, section been assigned to Minnesota State 144G.08 to 144G.95, these correction orders are Statutes for Assisted Living Facilities. The issued pursuant to a survey. assigned tag number appears in the far-left column entitled "ID Prefix Tag." The Determination of whether violations are corrected state Statute number and the requires compliance with all requirements corresponding text of the state Statute out provided at the Statute number indicated below. of compliance is listed in the "Summary When Minnesota Statute contains several items, Statement of Deficiencies" column. This failure to comply with any of the items will be column also includes the findings which considered lack of compliance. are in violation of the state requirement after the statement, "This Minnesota INITIAL COMMENTS: requirement is not met as evidenced by." Following the evaluators ' findings is the SL36603016-0 Time Period for Correction. On April 7, 2025, through April 10, 2025, the PLEASE DISREGARD THE HEADING OF survey at the above provider. At the time of the STATES,"PROVIDER'S PLAN OF survey, there were 31 residents; 31 receiving CORRECTION." THIS APPLIES TO services under the Assisted Living Facility with FEDERAL DEFICIENCIES ONLY. THIS Dementia Care license. WILL APPEAR ON EACH PAGE. THERE IS NO REQUIREMENT TO SUBMIT A PLAN OF CORRECTION FOR VIOLATIONS OF MINNESOTA STATE STATUTES. THE LETTER IN THE LEFT COLUMN IS USED FOR TRACKING PURPOSES AND REFLECTS THE SCOPE AND LEVEL ISSUED PURSUANT TO 144G.31 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 J1TL11 If continuation sheet 1 of 37 PRINTED: 05/02/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 36603 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 7900 AUSTIN WAY SUITE LIVING SR OF IGH INVER GROVE HEIGHTS, MN 55077 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 J1TL11 If continuation sheet 2 of 37 PRINTED: 05/02/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 36603 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 7900 AUSTIN WAY SUITE LIVING SR OF IGH INVER GROVE HEIGHTS, MN 55077 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 480 Continued From page 2 0 480 allowed provided the facility keeps them clean and in good condition; (6) notwithstanding Minnesota Rules, part 4626.

Finding: Not Substantiated S N O Nature of Investigation: C The Minnesota Department of Health investigated an allegation of maltreatment, in accordance E with the Minnesota Reporting of MRaltreatment of Vulnerable Adults Act, Minn. Stat. 626.557, and to evaluate compliance with applicable licensing standards for the provider type. R O F Initial Investigation Allegation(s): T The facility neglected the resident when the resident sustained a femur fracture and died. S E Investigative FinUdings and Conclusion: Q The Minnesota Department of Health determined neglect was not substantiated. Although the E resident sustained a fracture, there was not a preponderance of evidence the incident was R caused by the failure of facility staff to provide necessary care or services. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator also contacted the hospice nurse. The investigation included review of the resident records, death record, facility incident reports, staff schedules, law enforcement report, and related facility policy and procedures. Also, the investigator observed interactions between staff and residents. The resident resided in an assisted living facility. The resident’s diagnoses included respiratory failure and morbid obesity. The resident’s service plan included assistance with repositioning every two hours, and transfer assistance. The resident’s assessment indicated the resident displayed deficits in judgement. Review of video footage showed the night of the incident facility staff #1 was walking outside the resident’s room. The resident was heard yelling “ahhhhhh.” Facility staff #1 turned on the light and entered the resident’s room and stated “Hey”, “Hey, hey, hey, hey.” D The incident report indicated the resident was lowered to the floor by facility staff #1. E V I During an interview, facility staff #1 stated when she was going to complete her rounds, the E C resident was hanging off the bed. She sat with the resident for a while but couldn’t continue to E hold her in that position, so she lowered her to the ground. Once the resident was on the R ground, she went to get facility staff #2 for assistance to get the resident off the ground. Facility N staff #1 stated she called the on-call nurse who advised her to give the resident ibuprofen and O fill out an incident report. I T A R During an interview, facility staff #2 stated when she entered the room, the resident’s head was E towards the bottom of the bed and her legs were towards the top of the bed, underneath the D air conditioning unit. Facility staff #2 stated facility staff #1 left the room to call the on-call nurse I S and she attempted to get the resident’s legs out from under the air conditioning unit, but the N resident was in too much pain. The resideOnt was later lifted off the floor with the mechanical lift C and made comfortable. E R During an interview, facility management stated the video footage was reviewed, and the R incident was investigated. Facility management stated their investigation did not identify O neglect by staff. F T S The law enforcement report indicated there was no indication facility staff #1 caused the E resident to fall, caused any injuries, knew of any injuries, or tried to hide any injury. Facility staff U #1 reported the incident to the facility nurse and documented appropriately. Q E R 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, resident deceased. D Family/Responsible Party interviewed: Yes. E Alleged Perpetrator interviewed: Not Applicable. V I E Action taken by facility: C E The facility investigated the incident and coordinated with the hospice agency to manage the R resident’s pain. N O Action taken by the Minnesota Department of Health: I T No further action taken at this time. A R E cc: D The Office of Ombudsman for Long Term Care I S The Office of Ombudsman for Mental Health and Developmental Disabilities N O C E R R O F T S E U Q E R PRINTED: 01/23/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ C B. WING _____________________________ 36603 01/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 7900 AUSTIN WAY SUITE LIVING SR OF IGH INVER GROVE HEIGHTS, MN 55077 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 D E On January 6, 2025, the Minnesota Department V of Health initiated an investigation of complaint I #HL366039471C/#HL366036285M. No correction E orders are issued. C E R N O I T A R E D I S N O C E R R O F T S E U Q E R LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 5LLB11 If continuation sheet 1 of 1

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 incontinence care was not provided causing worsening of skin condition. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. The facility’s plan of care was not followed due to the resident’s refusals for incontinence care and repositioning. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted the home health care nurse and the resident’s family member. The investigation included review of the resident record, facility incident reports, staff schedules, and related facility policy and procedures. Also, the investigator toured the facility and observed staff to resident interactions. The resident resided in an assisted living facility. The resident’s diagnoses included multiple sclerosis (a central nervous system disorder causing weakness, numbness, and a progressive loss of muscle coordination), incontinence and chronic pressure ulcers (a skin injury where prolonged pressure breaks down skin and underlying tissues). The resident’s service plan included assistance with medication management, and dependence on incontinence care and mobility. The resident’s assessment indicated the resident was oriented but did not always follow the medical provider’s instructions or recommendations, was incontinent of bowel and bladder and had wound care provided by an outside home health care agency. One day, a concern arose that care was not being provided per the resident’s plan of care, as the resident was found incontinent multiple times before wound care was to be provided. The resident’s medical record indicated the resident refused cares many times on the days surrounding when wound care was scheduled. During an interview, the facility nurse stated the resident did refuse repositioning and incontinence cares as offered by unlicensed caregivers. The unlicensed caregivers were instructed to reapproach the resident in an attempt to provide cares, but the resident at times continued to refuse cares. During an interview, the home health nurse stated the resident should be repositioned and changed every two hours, but the resident does refuse cares. During an interview, the unlicensed caregiver stated the resident’s care plan was to reposition the resident and provide incontinent care as needed, however the resident refused cares many times and typically refused cares two to three times per shift. The unlicensed caregiver stated even with reapproach attempts the resident continues to refuse cares offered. During an interview, the resident stated he has had chronic skin breakdown for a long time. The resident stated if he was tired or comfortable he refused the care he was offered because he did not want to be moved. During an interview, a family member stated the facility provided the resident good care and communication with the family regularly. The family member stated the resident has had chronic pressure ulcers for approximately the four years. She is aware the resident refuses care at times when offered. 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. (c) For purposes of this section, a vulnerable adult is not neglected for the sole reason that: (1) the vulnerable adult or a person with authority to make health care decisions for the vulnerable adult under sections 144.651, 144A.44, chapter 145B, 145C, or 252A, or sections 253B.03 or 524.5-101 to 524.5-502, refuses consent or withdraws consent, consistent with that authority and within the boundary of reasonable medical practice, to any therapeutic conduct, including any care, service, or procedure to diagnose, maintain, or treat the physical or mental condition of the vulnerable adult, or, where permitted under law, to provide nutrition and hydration parenterally or through intubation; this paragraph does not enlarge or diminish rights otherwise held under law by: (i) a vulnerable adult or a person acting on behalf of a vulnerable adult, including an involved family member, to consent to or refuse consent for therapeutic conduct Vulnerable Adult interviewed: Yes Family/Responsible Party interviewed: Yes Alleged Perpetrator interviewed: Not Applicable Action taken by facility: Facility continued to reapproach resident to provide cares as listed on the plan of 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: 09/23/2024 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 _____________________________ 36603 09/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 7900 AUSTIN WAY SUITE LIVING SR OF IGH INVER GROVE HEIGHTS, MN 55077 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 9, 2024, the Minnesota Department of Health initiated an investigation of complaint #HL366035564C/#HL366034541M. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 1I7711 If continuation sheet 1 of 1