The Waters of Kingsley Shores.

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 Kingsley Shores Senior Living 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 JMD 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 _____________________________ 29470 11/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 16880 KLAMATH TRAIL KINGSLEY SHORES SENIOR LIVING 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 SL29470016-0 Time Period for Correction. On November 18, 2024, through November 20, PLEASE DISREGARD THE HEADING OF 2024, the Minnesota Department of Health THE FOURTH COLUMN WHICH conducted a full survey at the above provider for STATES,"PROVIDER'S PLAN OF a change of ownership. At the time of the survey, CORRECTION." THIS APPLIES TO there were 92 residents; 59 receiving services FEDERAL DEFICIENCIES ONLY. THIS under the Assisted Living Facility with Dementia WILL APPEAR ON EACH PAGE. 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 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 BVB211 If continuation sheet 1 of 46 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 _____________________________ 29470 11/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 16880 KLAMATH TRAIL KINGSLEY SHORES SENIOR LIVING 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 BVB211 If continuation sheet 2 of 46 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 _____________________________ 29470 11/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 16880 KLAMATH TRAIL KINGSLEY SHORES SENIOR LIVING 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.

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 alleged perpetrator (AP) neglected the resident when the AP observed signs of a stroke, failed to assess the resident and call emergency medical services for two hours. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. During the AP’s initial assessment, the resident was assessed to have equal strength, able to communicate but was tired and weak The AP planned to have the resident evaluated by the resident’s primary care provider (PCP) that morning. An hour later when the AP received report of further decline with observable symptoms, she directed a registered nurse (RN) to assess the resident. The facility staff called emergency medical services and the resident transported to the hospital. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator interviewed the resident’s primary care provider and family member. The investigation included review of the resident’s medical record, facility incident report, facility policies, death record, personnel files, and staff schedule. Also, the investigator toured the facility and observed medication administration, staff assistance during a meal, and morning cares. The resident resided in an assisted living memory care unit. The resident’s diagnoses included dementia, generalized weakness, atrial fibrillation, congestive heart failure, and hypertension. The resident’s service plan included assistance with bathing, dressing, grooming, and transferring to wheelchair. She was independent with eating. The resident’s progress note written by the AP at 8:35 a.m., indicated she assessed the strength and speech of the resident. The AP wrote she planned for the resident’s PCP to evaluate the resident when she arrived at 10:00 a.m. during rounds. At 9:32 a.m., the AP wrote the resident had further changes in condition. The RN noted the resident had right sided weakness, leaned toward her weak side, had difficulty swallowing, and slurred speech. Staff sent the resident to the hospital. During an interview, the unlicensed personnel (ULP) said he assisted the resident with morning cares. He observed the resident was weak, tired, and was not her usual self. He reported his concerns to the AP, who was a RN. He observed the AP assess the resident’s verbal communication, and strength but denied observing the AP assess vitals. The resident was brought to the dining room where the ULP attempted to feed the resident. The resident had difficulty swallowing and was unable to eat or drink. The resident was sent to the hospital. During an interview, the AP said after the ULP assisted the resident out of bed, he brought her to the AP’s office and reported a change in condition. The AP assessed the resident’s strength, and verbal communication. Her strength was equal, and she was able to communicate. The AP planned to have the PCP evaluate the resident when she arrived in the morning. The resident was brought to the dining room for breakfast. After a morning meeting, a second ULP reported concerns to the AP. The AP directed the RN to assess the resident while in the dining room. The RN assessed a decline in the resident’s health from the AP’s initial assessment. Staff called emergency medical services and the resident was transported to the hospital where she was diagnosed with a stroke. The AP stated she did not assess vitals during her initial assessment but stated the resident was in medical distress. During an interview, the resident’s PCP said treatment for a stroke include medications that dissolve a clot. These medications must be administered within the first few hours of signs and/or symptoms. Since the resident woke up exhibiting a change of condition, there was no way to know when symptoms began, therefore earlier intervention may not have changed the outcome. During an interview, the family member said the facility called, reported the resident had a change in condition and exhibited signs of a stroke. At the hospital, brain scans showed several areas of the brain impacted by a stroke. The resident was still able to communicate while in the emergency department and declined medication to treat the clots. The resident also declined surgery. She was transferred to the intensive care unit. The family member said the resident was alert and able to make medical decisions. While at the hospital she regained some strength, but she never regained ability to swallow, and she declined a feeding tube. The resident passed away while at the hospital. 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, deceased. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Yes. Action taken by facility: The facility nurses assessed the resident during a change in condition and sent the resident to the hospital. Action taken by the Minnesota Department of Health: The facility was found to be in noncompliance. 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 If you are viewing this report on the MDH website, please see the attached Statement of Deficiencies. You may also call 651-201-4200 to receive a copy via mail or email cc: The Office of Ombudsman for Long Term Care The Office of Ombudsman for Mental Health and Developmental Disabilities PRINTED: 07/18/2024 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 _____________________________ 29470 06/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 16880 KLAMATH TRAIL SILVERCREST PROPERTIES LLC 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 ******ATTENTION****** Minnesota Department of Health is documenting the State Correction Orders ASSISTED LIVING PROVIDER CORRECTION using federal software. Tag numbers have 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. #HL294709642C/ #HL29470184M PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On June 4, 2024, the Minnesota Department of STATES,"PROVIDER'S PLAN OF Health conducted a complaint investigation at the CORRECTION." THIS APPLIES TO above provider, and the following correction FEDERAL DEFICIENCIES ONLY. THIS orders are issued. At the time of the complaint WILL APPEAR ON EACH PAGE. investigation, there were 51 residents 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 The following correction order is issued for STATUTES. #HL294709642C/ #HL29470184M, tag identification 2320. THE LETTER IN THE LEFT COLUMN IS USED FOR TRACKING PURPOSES AND REFLECTS THE SCOPE AND LEVEL ISSUED PURSUANT TO 144G.