Boden Senior Lvg - Maplewood.

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 Statemen tof Deficiencies "column. This column also includes the findings that are in violation of the state statute after the statement, "This MN Requiremen tis not met as evidenced by . . ." IMPOSITION OF FINES In accordance with Minn. Stat. § 144G3. 1, Subd .4, fines and enforcement actions may be imposed based on the level and scope of the violations and may be imposed immediately with no opportunity to correct the violation first as follows: Leve l1: no fines or enforcement; Leve l2: a fine of $500 per violation, in addition to any enforcement mechanism authorized in § 144G2. 0; Leve l3: a fine of $1,000 per incident, in addition to any enforcement mechanism authorized in § 144G2. 0; Leve l4: a fine of $3,000 per incident, in addition to any enforcement mechanism authorized in § 144G2. 0; Leve l5: a fine of $5,000 per violation, in addition to any enforcement mechanism authorized in § 144G2. 0. An equal opportunity employer . Letter ID: IS7N REVISE 0D9/13/2021 Boden Senio rLiving - Maplewood October 13, 2025 Page 2 Therefore ,in accordance with Minn. Stat. §§ 144G0. 1 to 144G9. 999, the following fines are assessed pursuant to this survey: 0510 - 144g.41 Subd. 3 - Infection Control Program - $500.00 0775 - 144g.45 Subd. 2. (a) - Fire Protection And Physica lEnvironment - $1,000.00 Therefore ,in accordance with Minn. Stat. §§ 144G0. 1 to 144G9. 999, the total amount you are assesse dis $1,500.00. You will be invoiced approximately 30 days after receipt of this notice, subject . to appeal DOCUMENTATIO ONF ACTION TO COMPLY In accordance with Minn. Stat. § 144G3. 0, Subd .5(c), the licensee must docum ent 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: x Identify how the area(s) of noncompliance was corrected related to the resident(s)/ employees( ) identified in the correction order. x 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. x Identify what changes to your systems and practices were made to ensure compliance with the specific statute(s). CORRECTIO ONRDER RECONSIDERATI OPRNOCESS In accordance with Minn. Stat. § 144G3. 2, Subd .2, you may challenge the correction order(s) issued, including the level and scope ,and any fine assesse dthrough 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 REQUESTIN AG HEARING Alternatively ,in accordance with Minn. Stat. § 144G3. 1, Subd .5(d), an assisted living provider that has been assesse da fine under this subdivision has a right to a reconsideration or a hearing under this section and chapter 14. Pursuan tto Minn. Stat. § 144G2. 0, Subd .14 and Subd .18, a request for a hearing must be in writing and received by the Department of Health within 15 business days of the correction order receipt date. The request must contain a brief and plain statement describing each matter or issue contested and any new information you believe constitutes a defense or mitigating factor. To submit a hearing request, please visit: https:/ / forms.web.health.state.mn.us/form/ HRDAppealsForm Boden Senio rLiving - Maplewood October 13, 2025 Page 3 To appea lfines via reconside ration, please follow the pr ocedur e outlined above. Plea se note that you may request a reconsideration or a hearing, but not both. If you wish to contest tags without fines in a reconsideration and tags with the fines at a hearing, please submit two separate appeals forms at the website listed above. 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: https:/ / forms.office.com/g/ Bm5uQEpHV.a Your input is important to us and will enable MDH to improve its processe sand communication with providers . If you have any questions regarding the questionnaire ,please contact Susan Winkelmann at susanw. inkelmann@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 organizations’ Governing Body. If you have any questions ,please contact me. Sincerely, Casey DeVries ,Supervisor State Evaluation Team Email: caseyd. evries@state.mn.us Telephone :651-201-5917 Fax :1-866-890-9290 JMD PRINTED: 10/13/2025 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 _____________________________ 34426 09/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1700 BEAM AVENUE BODEN SENIOR LIVING - MAPLEWOOD MAPLEWOOD, MN 55109 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 *****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 Facilities. The In accordance with Minnesota Statutes, section assigned tag number appears in the 144G.08 to 144G.95, these correction orders are far-left column entitled "ID Prefix Tag." issued pursuant to a survey. The state Statute number and the corresponding text of the state Statute out Determination of whether violations are 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 Minnesota Statute contains several items, are in violation of the state requirement failure to comply with any of the items will be after the statement, "This Minnesota considered lack of compliance. requirement is not met as evidenced by." Following the evaluators' findings is the INITIAL COMMENTS: Time Period for Correction. SL34426016-0 PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On September 2, 2025, through September 3, STATES,"PROVIDER'S PLAN OF 2025, the Minnesota Department of Health CORRECTION." THIS APPLIES TO conducted a change of ownership (CHOW) FEDERAL DEFICIENCIES ONLY. THIS survey at the above provider. At the time of the WILL APPEAR ON EACH PAGE. survey, there were 43 residents; 42 receiving services under the Assisted Living Facility with THERE IS NO REQUIREMENT TO Dementia Care license. 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. 0 510 144G.41 Subd. 3 Infection control program 0 510 SS=F LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 BPC111 If continuation sheet 1 of 27 PRINTED: 10/13/2025 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 _____________________________ 34426 09/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1700 BEAM AVENUE BODEN SENIOR LIVING - MAPLEWOOD MAPLEWOOD, MN 55109 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) 0 510 Continued From page 1 0 510 (a) All assisted living facilities must establish and maintain an infection control program that complies with accepted health care, medical, and nursing standards for infection control. (b)The facility's infection control program must be consistent with current guidelines from the national Centers for Disease Control and Prevention (CDC) for infection prevention and control in long-term care facilities and, as applicable, for infection prevention and control in assisted living facilities.

Finding: Inconclusive 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 two residents (Resident #3 and Resident #4) when she sprayed water in Resident #3’s face in retaliation to the resident being uncooperative, and on another occasion, spit in a glass and offered it to Resident #4 to drink. Investigative Findings and Conclusion: The Minnesota Department of Health determined abuse was inconclusive. It is unable to be determined if the incidents occurred. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator also contacted the residents’ family. The investigation included review of resident medical records, employee training, facility documentation and policies and procedures. Also, the investigator toured the facility and observed staff to resident interactions. An equal opportunity employer. Resident #3 resided in the memory care unit. Resident #3’s diagnoses included traumatic brain injury, arthritis, and glaucoma. The resident’s service plan included assistance with medication management, bathing, housekeeping, laundry, meals, and safety checks. The resident’s assessment indicated signs of sundowning (behaviors including confusion, anxiety, aggression or ignoring directions, which appear later in the day). Resident #4 also resided in the memory care unit. Resident #4’s diagnoses included traumatic brain injury and dementia. The resident’s service plan included assistance with medication management, bathing, housekeeping, laundry, meals, and safety checks. A facility report indicated an unlicensed staff member/alleged perpetrator (AP) was witnessed spraying Resident #3 in the face during a shower. It was also reported that the AP spit in glass and offered it to Resident #4 to drink. During an interview, a nurse stated that on the day of the alleged incident, the AP reported she was bit by Resident #3 while providing care and showed the nurse a bite mark on the AP’s chest. Later that same day, another staff member reported to the nurse that she witnessed the AP spraying Resident #3 in the face with water during a shower. During an interview, the witness recalled passing by Resident #3’s room and heard Resident #3 yelling, “Stop it!” Upon entering the resident’s room, she witnessed the AP repeatedly using the handheld shower head to spray water directly into the face of the resident. The caregiver attempted to stop the AP, but the AP continued to spray water in the resident’s face. The caregiver asked the AP to leave, and she assumed care of the resident and completed the shower. During an interview with a staff member who witnessed the AP drinking from a glass while assisting residents, the staff member recalled telling the AP to stop drinking at the table but did not witness the AP spitting in a cup and offering it to Resident #4. During an interview with facility administration, they stated internal investigations were completed related to the allegations involving the AP and Resident #3 and Resident #4. Administration indicated the AP denied the allegations; however, following the investigations the AP was terminated. Resident #3 and Resident #4 were observed at the facility within the locked memory unit and were unable to be interviewed due to cognitive impairment. During an interview with a family member of Resident #3, they stated the facility informed them of the allegation concerning the bathing incident. The family stated the internal investigation led to the dismissal of the AP and they had no other concerns with the care provided by the facility. During a conversation with Resident #4’s family, they stated they were informed by the facility of the allegation concerning the drinking glass incident. The family stated that they understood it to be an isolated incident and had no concerns with the care provided at the facility. Attempts to contact the AP were unsuccessful. In conclusion, the Minnesota Department of Health determined abuse was inconclusive. Inconclusive: Minnesota Statutes, section 626.5572, Subdivision 11. "Inconclusive" means there is less than a preponderance of evidence to show that maltreatment did or did not occur. 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; Vulnerable Adult interviewed: No, due to cognitively impairment. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: No. Action taken by facility: The facility conducted internal investigations into the incidents and the AP was terminated. 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 Ramsey County Attorney Maplewood City Attorney Maplewood Police Department PRINTED: 03/27/2024 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 _____________________________ 34426 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1700 BEAM AVENUE ELK RIDGE ALZHEIMER'S SPECIAL MAPLEWOOD, MN 55109 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****** The Minnesota Department of Health (MDH) issued a determination ASSISTED LIVING PROVIDER CORRECTION maltreatment occurred, and an individual ORDER person was responsible for the maltreatment, in connection with incidents In accordance with Minnesota Statutes, section which occurred at the facility. Please refer 144G.08 to 144G.95, these correction orders are to the public maltreatment report for issued pursuant to a complaint investigation. details. Determination of whether a violation is corrected Minnesota Department of Health is requires compliance with all requirements documenting the State Correction Orders provided at the statute number indicated below. using federal software. Tag numbers have When a Minnesota Statute contains several been assigned to Minnesota State items, failure to comply with any of the items will Statutes for Assisted Living Facilities. The be considered lack of compliance. assigned tag number appears in the far left column entitled "ID Prefix Tag." The INITIAL COMMENTS: state Statute number and the corresponding text of the state Statute out #HL344266502C/#HL344268886M of compliance is listed in the "Summary #HL344265863C/#HL344268525M Statement of Deficiencies" column. This #HL344264226C/#HL344267626M column also includes the findings which #HL344265882C/#HL344268487M are in violation of the state requirement after the statement, "This Minnesota On January 18 and January 19, 2024, the requirement is not met as evidenced by." complaint investigation at the above provider, and Time Period for Correction. the following correction orders are issued. At the time of the complaint investigation, there were 41 PLEASE DISREGARD THE HEADING OF residents receiving services under the provider's THE FOURTH COLUMN WHICH Assisted Living with Dementia Care license. STATES,"PROVIDER'S PLAN OF CORRECTION." THIS APPLIES TO The following correction order is issued/orders FEDERAL DEFICIENCIES ONLY. THIS are issued for WILL APPEAR ON EACH PAGE. #HL344266502C/#HL344268886M, tag identification 0730. THERE IS NO REQUIREMENT TO SUBMIT A PLAN OF CORRECTION FOR The following correction order is issued/orders VIOLATIONS OF MINNESOTA STATE are issued for STATUTES.

Finding: Substantiated, facility 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 a resident when the AP restrained the resident’s arms which caused bruising and skin tears. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was substantiated. The facility was responsible for the maltreatment. The facility failed to provide interventions for staff to use with a combative resident, so staff resorted to restraining the resident’s arms when providing incontinence cares. The facility had several recommended interventions which they did not communicate with the staff via the service plan. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted family. The investigation included review of the resident records, photos of the resident’s injuries, the facility internal investigation, facility incident reports, personnel files, staff schedules, related facility policy and procedures. Also, the investigator observed staff interactions with residents. The resident lived in an assisted living with memory care. The resident’s diagnoses included traumatic brain injury, arthritis, and bilateral hearing loss. The resident’s service plan included assistance with bathing, redirection of behaviors, dressing/undressing, safety checks, fall prevention, toileting, and medication administration. Prior to admission, the resident’s family provided information about the resident’s history, likes, hobbies, and preferences, but the facility did not incorporate any of the information into the service plan for behavior interventions. The resident’s behavior assessments recommended several different interventions for staff, but the facility did not incorporate the information into the resident’s service plan. The resident’s service plan directed staff to “re-direct, monitor, and report” the residents’ behaviors. An incident report indicated one night the AP held down the resident’s arms while changing the resident’s incontinence brief because the resident was combative. The resident received bruises and two large skin tears on her arm as a result. The report indicated staff notified the on-call nurse. During an interview, the nurse stated staff often had difficulty redirecting the resident. The nurse stated the facility did not require staff read the new resident information about likes, hobbies, and preferences. The nurse stated the recommended interventions should be in the resident’s service plan. The nurse stated the AP and another staff each held down one of the resident’s arms while changing her, to keep themselves safe from the resident. The nurse stated she did not consider their actions a restraint. During investigative interviews, multiple staff members stated the facility did not provide interventions specific to the resident and reported they typically had to come up with interventions on their own. During an interview, the AP stated the resident was aggressive at night and staff had difficulty changing the resident’s incontinence brief because the resident would punch and kick at them. The AP stated the resident would not listen to her on the night of the incident. The AP stated her coworker held the resident’s arms down on the night of the incident, while the AP quickly changed and cleaned up the resident. The AP stated the facility gave no direction on how to deal with the resident, leaving it up to staff to figure it out. The AP stated it was common practice to hold down the resident’s arms/hands if the resident was hitting out. During an interview, the other staff working on the night of the incident stated she normally held the resident’s hands to prevent her from hitting. The staff stated on the night of the incident the resident was moving around a lot, trying to get loose from her hold. The staff stated she did not intentionally harm the resident, but the resident ended up with skin tears that were bleeding. During an interview, a family member stated the resident was very hard of hearing and got frustrated when she did not know what was going on. In conclusion, the Minnesota Department of Health determined neglect 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. 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 Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Yes. Action taken by facility: The facility changed the resident’s services to include assistance of two staff for toileting. The facility re-educated the AP and staff involved in the incident on recommended interventions for the resident. Action taken by the Minnesota Department of Health: The responsible party will be notified of their right to appeal the maltreatment finding. 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 Ramsey County Attorney Maplewood City Attorney Maplewood Police Department PRINTED: 03/07/2024 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 _____________________________ 34426 02/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1700 BEAM AVENUE ELK RIDGE ALZHEIMER'S SPECIAL MAPLEWOOD, MN 55109 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****** ASSISTED LIVING PROVIDER CORRECTION ORDER In accordance with Minnesota Statutes, section 144G.08 to 144G.95, these correction orders are issued pursuant to a complaint investigation. Determination of whether a violation is corrected requires compliance with all requirements provided at the statute number indicated below. When a Minnesota Statute contains several items, failure to comply with any of the items will be considered lack of compliance. INITIAL COMMENTS: #HL344269260C/ #HL344261683M On February 14, 2024, the Minnesota Department of Health conducted a complaint investigation at the above provider, and the following correction orders are issued. At the time of the complaint investigation, there were 45 residents receiving services under the provider's Assisted Living with Dementia Care license. The following correction orders are issued for #HL344269260C/#HL344261683M, tag identification 1290, 1640, 2360. 01290 144G.60 Subdivision 1 Background studies 01290 SS=I required (a) Employees, contractors, and regularly scheduled volunteers of the facility are subject to the background study required by section 144.057 and may be disqualified under chapter LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 WUGJ11 If continuation sheet 1 of 11 PRINTED: 03/07/2024 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 _____________________________ 34426 02/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1700 BEAM AVENUE ELK RIDGE ALZHEIMER'S SPECIAL MAPLEWOOD, MN 55109 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) 01290 Continued From page 1 01290 245C. Nothing in this subdivision shall be construed to prohibit the facility from requiring self-disclosure of criminal conviction information. (b) Data collected under this subdivision shall be classified as private data on individuals under section 13.02, subdivision 12. (c) Termination of an employee in good faith reliance on information or records obtained under this section regarding a confirmed conviction does not subject the assisted living facility to civil liability or liability for unemployment benefits.