The Moments of Lakeville.

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 catheter care, skin monitoring and bathing was not provided. As a result, the resident was hospitalized with a UTI infection and later died. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. The facility followed their Uniform Disclosure of Assisted Living Services & Amenities (UDALSA) and provided the appropriate services to the resident. The home health provider, a provider separate from the facility, was notified of catheter issues and changed four times in the last twenty-four days the resident resided in the facility, exceeding the orders to change every 3-4 weeks as provided by the urologist. Additionally, no notes or reports from the facility nor the home care provider indicated skin breakdown or wounds were present. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigation included review of the resident record, death record, hospital records, home health care records, facility internal investigation, facility incident reports, staff schedules, and related facility policy and procedures. Also, the investigator observed resident and facility staff interactions during an onsite visit. The resident resided in a secured assisted living memory care unit. The resident’s diagnoses included progressive dementia, history of bladder cancer, urinary retention, chronic atrial fibrillation (a heart rhythm disorder where the upper chambers of the heartbeat irregularly and rapidly) and took a medication to thin his blood. The resident had a home health provider to manage is urinary catheter. The resident’s service plan included reporting any urinary catheter leaking, pain, concerns and catheter care including cleansing, emptying and changing the catheter bag. The same service plan included safety checks every two hours by facility staff to anticipate needs and provide support. The resident’s assessment indicated the resident was oriented to person and walked using a walker. A concern arose the facility did not have trained caregivers to manage the resident’s urinary catheter, complete skin checks or bathe the resident. The facility UDALSA indicated care of the catheter would be coordinated with and managed by the home health provider elected to provide skilled nursing care, but the facility caregivers could empty and change the catheter bags. Catheter care orders provided by the urologist indicated the order to change the urinary catheter every 3-4 weeks. The resident’s medical record indicated the urinary catheter had been changed twice in the 18 days following the order. Progress notes indicated the resident’s pulled out his urinary catheter four times in the twenty-three days before the resident was transferred to the hospital. The last time was on the day before the resident was transferred to the hospital. The medical record indicated signs and symptoms of the urinary catheter not functioning properly all four times the device was pulled and required the home health provider to reinsert the urinary catheter after the resident pulled out the catheter. The common theme of the incidents were statements from the resident needing to urinate, increased anxiety, and blood or blood clots in the catheter tubing, indicating a catheter disfunction. The day before the resident was sent to the hospital, progress notes indicated the resident had demonstrated increased agitation and had pulled out the catheter. The progress note indicated there was blood and blood clots in the catheter bag and the catheter was removed, the home health care provider and power of attorney (POA) were notified. The progress note indicated the POA declined to send the resident to the hospital. The home health care provider reinserted the urinary catheter in the early afternoon that same day. Later that day, the resident became increasingly weaker, falling asleep during the evening meal, and with ongoing anxiety and agitation, stating “I want to rip this thing out”. The progress notes indicated that through the night the resident experienced at least two episodes of vomiting. By the next morning, staff reported an ongoing decline and reported a change in condition to the facility nurse. EMS was contacted after the POA agreed to send the resident to the hospital. During an interview, an unlicensed caregiver who regularly was assigned to provide care to the resident, stated the resident was at his baseline condition on the day before he was transferred to the hospital. The unlicensed caregiver reported the resident was cooperative during the day shift, however it was reported he could be less cooperative during the evening shifts. The unlicensed caregiver reported he had assisted the resident to shower the day before and he did not notice skin breakdown during the shower. On the day the resident was transferred to the hospital, the unlicensed caregiver stated during the start of shift report he was told the resident had nausea and vomiting the previous shift and was weaker and more lethargic than the day prior. The unlicensed caregiver went on to state when he first checked on the resident, the resident was not responding as usual and was making a moaning sound. He stated he immediately alerted the facility nurse, who notified the family and EMS was called. During an interview, a facility nurse reported when a resident has a urinary catheter, a home health care provider manages the urinary catheter because the assisted living facility does not provide skilled nursing services. The assisted living staff can only provide assistance for catheter care including cleansing, emptying and changing the catheter bag. When concerns or issues present with the resident’s urinary catheter, the facility nurse would notify the home health provider. 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. The resident was deceased Family/Responsible Party interviewed: Yes Alleged Perpetrator interviewed: Not Applicable the Action taken by facility: The facility nurse notified the home health provider and POA with concerns. EMS was called when the resident’s condition changed. 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: 11/12/2025 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 _____________________________ 33524 09/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 16258 KENYON AVENUE THE MOMENTS OF LAKEVILLE LAKEVILLE, MN 55044 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE PREFIX PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 000 Initial Comments 0 000 On September 10, 2025, the Minnesota Department of Health initiated an investigation of complaint #HL335249267C/#HL335244582M. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 IP5R11 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. The correction order documentation should include the following: An equal opportunity employer. Letter ID: IS7N REVISED 09/13/2021 The Moments of Lakeville December 31, 2024 Page 2 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: 507-344-2730 Fax: 1-866-890-9290 HHH PRINTED: 12/31/2024 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 _____________________________ 33524 11/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 16258 KENYON AVENUE THE MOMENTS OF LAKEVILLE LAKEVILLE, MN 55044 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 SL33524016-0 Time Period for Correction. On November 18, 2024, through November 21, PLEASE DISREGARD THE HEADING OF 2024, the Minnesota Department of Health THE FOURTH COLUMN WHICH conducted a full survey at the above provider. At STATES,"PROVIDER'S PLAN OF the time of the survey, there were 83 residents; CORRECTION." THIS APPLIES TO 83 receiving services under the Assisted Living FEDERAL DEFICIENCIES ONLY. THIS Facility with 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 VRQZ11 If continuation sheet 1 of 47 PRINTED: 12/31/2024 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 _____________________________ 33524 11/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 16258 KENYON AVENUE THE MOMENTS OF LAKEVILLE LAKEVILLE, MN 55044 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 VRQZ11 If continuation sheet 2 of 47 PRINTED: 12/31/2024 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 _____________________________ 33524 11/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 16258 KENYON AVENUE THE MOMENTS OF LAKEVILLE LAKEVILLE, MN 55044 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.