Ecumen Lakeview Commons.

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 CORRECTIO NORDERS 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 . . ." IMPOSITION OF FINES In accordance with Minn. Stat. § 144G.31, 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: Level 1: no fines or enforcement; Level 2: a fine of $500 per violation, in addition to any enforcement mechanism authorized in § 144G.20; Level 3: a fine of $1,000 per incident, in addition to any enforcement mechanism authorized in § 144G.20; An equal opportunity employer. Letter ID: IS7N REVISE D09/13/2021 Ecumen Lakeview Commons January 5, 2026 Page 2 Level 4: a fine of $3,000 per incident, in addition to any enforcement mechanism authorized in § 144G.20; Level 5: a fine of $5,000 per violation, in addition to any enforcement mechanism authorized in § 144G.20. Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, the following fines are assessed pursuant to this survey: 0775 - 144g.45 Subd. 2. (a) - Fire Protection And Physical Environment - $500.00 0780 - 144g.45 Subd. 2 (a) (1) - Fire Protection And Physical Environment - $500.00 The refor e, in accor danc e wit h Minn. Sta t. §§ 144G.01 to 144G.999 9, the total amount you are assessed is $1,000.00. You will be invoiced approximately 30 days after receipt of this notice, subject to appeal . DOCUMENTATIO ONF ACTION TO COMPLY In accorda nce with Min n. Stat. § 144G.30, Sub d. 5(c), th e lic ens ee mus t docum ent ac tions taken t o 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 · 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). CORRECTIO NORDER RECONSIDERATIO PNROCESS 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 REQUESTIN GA HEARING Alternatively, in accordance with Minn. Stat. § 144G.31, Subd. 5(d), an assisted living provider that has been assessed a fine under this subdivision has a right to a reconsideration or a hearing under this section and chapter 14. Pursuant to Minn. Stat. § 144G.20, 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 Ecumen Lakeview Commons January 5, 2026 Page 3 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 To appe al fi nes via re cons iderat ion , pl ease follow the procedu r e outl ined abo ve. Plea se no te tha t you may re que st a rec onside rati on or a hearing, bu t not bot h. If you wish to cont est ta gs with out fine s 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 conv enien ce at thi s link: https: / / forms. office.com/ g/ Bm5uQEpHVa. Your inpu t is import ant 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, Renee Anderson, Supervisor State Evaluation Team Email: Renee. L.Anderson@state. mn.us Tel ephon e: 651-201- 5871 Fax: 1-866- 890- 9290 JMD PRINTED: 01/ 05/ 2026 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 _____________________________ 20114 12/ 05/ 2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1200 NORTH LAKEWOOD DRIVE ECUMEN LAKEVIEW COMMONS MAPLEWOOD, MN 55119 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 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. " The issued pursuant to a survey. 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. SL20114016- 0 PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On December 1, 2025, through December 5, STATES, "PROVIDER' S PLAN OF 2025, the Minnesota Department of Health CORRECTION. " THIS APPLIES TO conducted a full survey at the above provider and FEDERAL DEFICIENCIES ONLY. THIS the following correction orders are issued. At the WILL APPEAR ON EACH PAGE. time of the survey, there were 95 residents; 95 receiving services under the Assisted Living THERE IS NO REQUIREMENT TO Facility with 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. 0 480 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 ZK4J11 If continuation sheet 1 of 9 PRINTED: 01/ 05/ 2026 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.

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) neglected the resident when the AP failed to follow the resident’s care plan. After the AP left the resident in her wheelchair unsupervised in her apartment, the resident tried to get out of her chair and fell. The resident broke her hip and died a few days later. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was inconclusive. The resident was agitated trying to grab at people during dinner. AP-1 and AP-2 brought the resident to her room to help her calm down. Staff often brought the resident to her apartment to decease stimuli and was indicated as an intervention on the resident’s care plan. AP-1 and AP-2 were unaware the resident’s care plan changed three days prior to the incident and indicated the resident should remain in common areas. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted family member. The investigation included review of the resident’s records, family member’s documentation, death record, hospital records, facility internal investigation, facility incident reports, personnel files, staff schedules, and related facility policy and procedures. Also, the investigator toured the facility and observed staff providing cares to residents. The resident resided in an assisted living memory care unit. The resident’s diagnoses included Alzheimer’s disease. The resident received hospice care and was declining mentally and physically. The resident’s service plan included assistance with grooming, toileting, meals, assist of one to ambulate but staff should use a full body mechanical lift when tired. Hospice notes written one month prior to the incident indicated the resident continued to decline physically and mentally. The resident’s cognitive score declined on all assessments. She was more confused, easily agitated around other residents, and her hallucinations increased. She continued to have a steady decrease in weight, cheeks sunken, unable to ambulate and required a wheelchair. The resident had multiple falls since hospice admission and was more agitated during meals. The hospice plan of care updated one week prior to the incident indicated the resident used a wheelchair (Broda) for mobility and transferred with assist of one. The resident required assistance from one staff for meals and grooming. Staff should reapproach the resident when agitated. The resident’s behavior triggers included loud, busy environments, and fast movements. The resident’s care plan updated three days before the incident indicated the resident should remain in common areas in Broda chair while awake. The care plan also indicated the resident should be brought to her apartment when agitated as a family member reported “she will usually calm down when alone.” An email correspondence sent between the family member and a member of management indicated three days before the incident a staff member left the resident in her apartment unsupervised, and the resident slid out of her recliner. Management’s response to the family member indicated management would re-educate staff on the resident’s care plan and require a signed acknowledgement of understanding. A meeting note documented two days before the incident indicated the resident’s family member requested the resident remain in common areas in her Broda chair unless she was in bed. The facility agreed to accommodate the family’s request when the resident was calm but indicated when the resident was restless or over stimulated the resident would be brought to her apartment to calm down. The family member was aware the facility was unable to provide one to one staffing to prevent falls and the resident remained at risk for falls even in the common area. The resident’s progress notes indicated the care plan was updated two days before to include the resident should not be left alone in her apartment unless she was in bed. The resident should remain in the common area the resident was in bed, cares were being completed, or her family member was present. The internal investigation indicated AP-1 assisted the resident with dinner in the dining room. During dinner, the resident was agitated, grabbed at people, and appeared tired. AP-1 and AP-2 brought the resident to her apartment, completed cares, and assisted her into the recliner in her apartment to rest. AP-1 and AP-2 reported they thought the quieter, familiar environment would help the resident feel calmer. AP-1 and AP-2 left the resident’s door open, so she was easily observed. The resident was found shortly after AP-1 and AP-2 left on her apartment floor. While the resident was lifted off the floor with a full body lift, the resident’s family member arrived. The resident reported pain in her hip. A progress not written by hospice one day after the incident indicated the resident’s leg had a possible fracture. The provider was updated, and an order was written for an x-ray. The family member declined the x-ray and wanted to continue comfort cares. The resident’s progress notes indicated the facility reported concerns the family had with the resident’s pain management and the provider adjusted her medications several times during the end of her life. During an interview, a member of management said the resident’s service plan was recently updated to include keeping the resident in common areas in her Broda chair and the resident should not be left in her apartment unattended. She said staff received verbal education on the new intervention. She also said when changes are made to an electronic care plan the system highlighted the change and required staff to acknowledge understanding. During an interview, a member of management who was also a nurse said the resident was on hospice and rapidly declining. The resident had several falls including sitting herself on the floor while at the facility. Numerous interventions were implemented including increased supervision and increased assistance with transfers. The family member also placed a camera in the resident’s room to monitor the resident’s movement. The family member met with facility staff a couple days before the incident and discussed new interventions to keep the resident safe. The nurse said the family member was aware the resident became agitated and restless in loud environments and her apartment was safer for her during these times. She told the family the facility was unable to provide a staff member to always remain in the resident’s apartment with her. During an interview, AP-2 said AP-1 brought the resident to her apartment after dinner and they both assisted her with cares and put the resident in her recliner. AP-2 continued to assist the resident in her apartment, while she left to help another resident. She said she did not have time to look at the resident’s care plan before she started her shift, and nobody told her the resident’s care plan changed. She received a brief report from the outgoing staff before her shift, but the report failed to mention the resident was no longer able to sit in her recliner in her apartment. Before this incident, the resident often sat in the recliner in her apartment. After the resident fell, the nurse told AP-2 the care plan changed and showed her in the service plan. The notes area of the service delivery record indicated the resident should remain in common areas. The information was documented under a service scheduled later in the evening, after the incident (therefore the system alert did not provide the note prior to the incident). AP-2 was assigned to medication administration on the day of the incident and the new intervention was not visible on the medication administration record. AP-1 was assigned medication administration the day before the incident, so she was unaware of the change also. After the incident, management sent a message via text to AP-2 indicating the resident was unable to be left in her apartment unsupervised. During an interview, AP-1 said she never received any report on the resident before her shift started. After dinner, AP-1 and AP-2 assisted the resident to her recliner in her apartment. Shortly after moving the resident to her recliner, she found the resident on her apartment floor. AP-1 and AP-2 assisted the resident off the floor with a full body lift while her husband was present.

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 resident #1 and resident #2 when they failed to provide appropriate supervision for resident #1 and resident #2. As a result, resident #1 and resident #2 had an altercation that led to resident #1’s fall and a fractured pelvis. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. At the time of the altercation between resident #1 and resident #2, staff were providing the residents with appropriate supervision. The altercation between resident #1 and resident #2 was a sudden and unforeseen event between resident #1 and resident #2. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigation included review of resident #1 and resident #2 records, resident #1 hospital records, facility internal investigation, facility incident reports, staff schedules, and related facility policy and procedures. Also, the investigator observed staff and resident interactions. Resident #1 resided in an assisted living memory care unit. Resident #1’s diagnoses included dementia. Resident #1’s service plan included assistance with reassurance/redirection, dining escorts, and safety checks three times a day. The resident was independent with transfers and required standby assistance with a walker when walking outside of her apartment. The resident’s assessment indicated the resident had cognitive impairment and was not able to report abuse. Resident #2 resident in an assisted living memory care unit for approximately four days. Resident #2’s diagnoses included Alzheimer’s disease and Lewy body dementia. Resident 2’s service plan included assistance with safety checks three times a day and assistance with being redirected to her apartment when agitated or irritable. Staff were to monitor the resident for signs of irritation or agitation which included when resident #2 twiddled her fingers or had agitated facial expressions. The resident was independent with transfers and walking, had cognitive impairment, and was not able to report abuse. A seven minute and 13 second video with no sound was reviewed from the facility’s camera pointing toward the end of hallway with the lower portion of resident #1’s apartment door in the forefront of the video. When the video began both residents were in the common area, resident #1 standing next to resident #2 who was sitting in a glider chair. A staff member stood in front of both residents having a conversation. After approximately 15 seconds, the staff member left the hallway and walked out of site. About 30 seconds into the video, resident #1 sat down in a glider chair next to resident #2. Resident #1 and resident #2 appeared to be having a pleasant conversation for approximately three to four minutes. Next, resident #1 stood up from the glider chair and walked down the hallway out of sight. Approximately one minute later, resident #1 walked back towards resident #2. As resident #1 walked through the common area to her apartment door, resident #2 stood up from the glider chair and attempted to pick something up off the floor. Simultaneously, resident #1 walked around resident #2 to enter her apartment. Without warning, resident #2 suddenly followed behind resident #1 who was shutting the apartment door. The video showed resident #2 pushing on resident #1’s apartment door against resident #1 who was attempting to shut the door. Next, the video showed the door close with both resident #1 and resident #2 in resident #1’s apartment. Approximately one minute later, the video showed a facility staff member entering resident #1’s apartment. The staff member can be seen leading resident #2 out of resident #1’s apartment across the hall and to resident #2’s apartment that was out of the video view. The facility incident report indicated one evening resident #1 was screaming out for help. When a nurse entered resident #1’s apartment, resident #1 was on the floor, and both resident #1 and resident #2 were pulling on a kitchen apron. The nurse escorted resident #2 out of the apartment and into her own apartment. The incident report indicated resident #1 was transferred to the hospital for an evaluation. Hospital records indicated resident #1 sustained a right pelvic fracture and bruising to her right elbow. Resident #1 was hospitalized for three days and transferred to a higher level of care. During an interview, the nurse stated during a safety check for resident #2, screaming was heard from resident #1’s apartment. Upon entering the apartment, resident #2 was standing while holding onto one end of a kitchen apron and resident #1 was on the floor holding the other end of the kitchen apron. The nurse stated they intervened and escorted resident #2 back to her apartment. Resident #1 was checked on after resident #2 was in her apartment. The nurse stated they did not see how the incident started. During an interview, leadership stated resident #1 came out of her apartment and had talked with resident #2. At some point resident #1 returned to her apartment and resident #2 followed her as if “following a friend.” Leadership stated resident #1 and resident #2 did not have any altercation before the incident. Following the incident, resident #2 was escorted back to her room, and resident #2’s family member stayed with her for the evening. Three days after the incident, resident 2’s family member transferred resident #2 to a behavioral health unit. Leadership stated it was not clear what occurred between resident #1 and resident #2 after resident #1’s apartment door closed. During an interview, resident #1’s family member stated there had not been an incident like this before between resident #1 and resident #2. Resident #1 sustained bruises and a fractured pelvis after the incident with resident #2. Following the incident, resident #1 was hospitalized, transferred to a transitional care unit, and to a different memory care unit. 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 #1 no longer resided in the facility. An interview with resident #2 was attempted but could not be completed due to cognition. Family/Responsible Party interviewed: Yes. Both resident #1 and resident #2 family members were interviewed. Alleged Perpetrator interviewed: Not Applicable. the Action taken by facility: Following the incident, resident #2 was escorted to her apartment. Resident #1 was transported to a hospital. 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: 12/23/2024 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 _____________________________ 20114 12/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1200 NORTH LAKEWOOD DRIVE ECUMEN LAKEVIEW COMMONS MAPLEWOOD, MN 55119 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 December 2, 2024, the Minnesota Department of Health initiated an investigation of complaint #HL201149665C/#HL201146482M. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 0UZ811 If continuation sheet 1 of 1

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): Unknown facility staff neglected a resident when they provided hot coffee that scalded the resident’s mouth and lips. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was inconclusive. The resident was found with dark discoloration of her lips and tongue. Initially the facility registered nurse and hospice registered nurse thought the resident was burned with coffee. Following a facility investigation, it was determined the resident may have bled internally due to the resident’s diagnosis of thrombocytopenia (a condition that occurred when the platelet count in your blood is too low causing bleeding.) The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted the hospice medical director, the county medical examiners, the hospice nurse and family members. The investigation included An equal opportunity employer. review of facility medical records, hospice medical records, death certificate, pictures of the resident, facility internal investigation, facility schedules, and policies, and procedures. Also, the investigator made an onsite visit to the facility. The resident resided in an assisted living facility. The resident’s diagnoses included dementia and thrombocytopenia. The resident’s service plan included assistance with oral care, grooming, bed mobility, safety checks, meal tray delivery, setup, and assistance with eating. The resident was bedridden, did not transfer out of bed, and was under the care of hospice and facility staff. The resident required staff to anticipate her needs. The hospice notes from the day of incident indicated the “patient [resident] may have received too hot of coffee after telling staff to microwave it for three minutes and her entire mouth is burned.” The hospice notes indicated the resident was unable to rate her pain level, however, the note indicated the resident had moderate pain. The note indicated the “patient’ [resident’s] outer lips were burned as well as the inner mouth and tongue.” The hospice note indicated the resident’s lower lip was necrotic (death of cells or tissue through disease or injury) and the entire lip and mouth was bloody with the upper lip necrotic with scabs. The facility’s incident report indicated one morning the resident was found lying in bed with lip and tongue discoloration. The resident’s lips were dry, flaky, and purple/black in color. Facility staff had observed the resident picking on her mouth, lips, and tongue with bleeding. The facility investigation indicated the day of the incident the resident’s lips and mouth were purplish brown in color. The resident’s upper and lower lip appeared dry and flaky. The resident’s tongue had a nickel size blackish brown discoloration on the left side. The remainder of the resident’s mouth was red in color. The resident enjoyed coffee and according to the hospice nurse, had asked a nurse practitioner earlier in the week to heat coffee in the microwave for three minutes. The nurse practitioner did not heat the coffee as requested. The facility report indicated no coffee was observed at the resident’s bedside and no staff reported serving the resident coffee. The report indicated the hospice medical director and the resident’s primary care physician indicated the resident had scabbing from internal bleeding and the discoloration around the lips was dried blood. The resident was unable to report the cause of discoloration. The resident denied pain and was observed rubbing a washcloth against her lips without facial grimacing. Review of multiple pictures of the resident’s face revealed the upper and lower lips were dry, flaky, with a dark discoloration of the resident’s lips, mouth, and tongue. Portions of the upper lip not discolored was pale pink in color. There was no swelling, redness, or blisters to the resident mouth, lips, tongue, chin, neck, or chest. During an interview, the facility nurse stated the resident had started to shake more due to a decline in her health. The nurse stated, staff had not provided coffee for three or four days prior to the incident because of burning concerns. The nurse stated none of the staff reported heating or serving the resident hot coffee. The hospice nurse assumed facility staff gave the resident hot coffee because the resident had previously requested hot coffee. The nurse stated pictures were taken of the resident’s mouth and sent to the hospice medical director. The resident did not have any other markings outside of her mouth, nothing on her chest, or neck. The resident passed away less than 24 hours later. During an interview, unlicensed staff member (ULP), stated in the final days the resident was not eating or drinking. During an interview, the hospice nurse stated the morning of the incident, the resident appeared to have burns on her lips and inside of her mouth. Initially, the hospice nurse and facility nurse thought facility staff warmed up the resident’s coffee in a microwave and the resident drank it. The hospice nurse stated the hospice medical director, said the resident bled from her mouth. The hospice nurse stated the resident had no other areas on her body that looked burned. The resident passed away within 24 hours of the incident. During an interview, the hospice medical director stated the hospice nurse made a “speculation” because earlier the resident had asked the nurse practitioner for hot coffee. The hospice medical director stated the appearance of the resident’s mouth could be explained because the resident had thrombocytopenia and was prone to a gastrointestinal (GI) bleed. During an interview, the family member stated the resident needed assistances with eating because she was weak and shaky. The hospice nurse thought her mouth was burned because of coffee. The family member took pictures of the resident’s mouth. The death certificate indicated the resident’s cause death was from complications of oral scalding. Other significant conditions that contributed to the resident’s death was thrombocytopenia and dementia. During an interview, the county medical examiner stated the resident’s death was determined from a review of the resident’s medical records and pictures of the resident’s face. In conclusion, the Minnesota Department of Health determined neglect 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. 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 notified the hospice nurse and physicians. The resident’s diet was changed to liquids, ice cream and applesauce. Facility staff placed a do not use sign on the resident’s microwave. New physician orders for pain management and treatments for burns were obtained. The facility also completed an internal investigation. 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: 08/24/2023 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 _____________________________ 20114 08/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1200 NORTH LAKEWOOD DRIVE ECUMEN LAKEVIEW COMMONS MAPLEWOOD, MN 55119 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 August 14, 2023, the Minnesota Department of Health initiated an investigation of complaint #HL201145703M/#HL201149919C. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 4Y6F11 If continuation sheet 1 of 1