Harmony Gardens.

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 necessar yto ensure the health, safety, and welfare of residents in your care. STATE CORRECTIO ONRDERS 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 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 . . ." In accordance with Minn. Stat. § 144G3. 1 Subd .4, MDH may asses sfines based on the level and scope of the violations; however, no immediate fines are assesse dfor this survey of your facility. 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: An equal opportunity employer . Letter ID: IS7N REVISE 0D9/13/2021 Harmony Gardens Novembe r18, 2025 Page 2 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 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 CLN PRINTED: 11/18/2025 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 _____________________________ 39485 11/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1440 COUNTY ROAD C EAST HARMONY GARDENS 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. SL39485016-0 PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On November 3, 2025, through November 4, 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 108 residents; 72 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 T3B411 If continuation sheet 1 of 8 PRINTED: 11/18/2025 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 _____________________________ 39485 11/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1440 COUNTY ROAD C EAST HARMONY GARDENS 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) 0 480 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, STATE FORM 6899 T3B411 If continuation sheet 2 of 8 PRINTED: 11/18/2025 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 _____________________________ 39485 11/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1440 COUNTY ROAD C EAST HARMONY GARDENS 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) 0 480 Continued From page 2 0 480 existing floor, wall, and ceiling finishes are allowed provided the facility keeps them clean and in good condition; (6) notwithstanding Minnesota Rules, part 4626.

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), a facility unlicensed personnel, physically abused the resident when the AP slapped the resident’s face. Investigative Findings and Conclusion: The Minnesota Department of Health determined abuse was inconclusive. Due to conflicting accounts of the incident, it could not be determined whether physical abuse did or did not occur. The resident reported the AP slapped her face and the AP denied the allegation. There was no physical evidence the AP slapped the resident, no witnesses to the alleged incident, and no camera in the resident’s room. The investigator conducted interviews with facility staff members, including administrative and nursing staff. The investigation included review of the resident records, facility internal investigation, facility incident report, personnel file, staff schedules, law enforcement report, and related facility policy and procedures. Also, the investigator observed staff interaction with the resident and staff interactions with other residents. The resident resided in an assisted living memory care unit. The resident’s diagnoses included amyotrophic lateral sclerosis (ALS, nervous system disease), and anxiety. The resident required hands on assistance of one staff with transfers. The resident was alert, oriented, and made her needs known. The resident was easily overwhelmed, became fearful, which led to crying spells. The resident at times had acute anxiety and crying spells that made the resident unable to do things or communicate effectively. The resident also received contracted hospice services. The resident’s record indicated the resident was admitted to a specialized area of the facility from a different floor the night of the alleged incident. The facility internal investigation indicated the first full day in the new living area; the resident told a contracted staff that the AP slapped the resident’s face. During the facility investigation, the resident stated during the overnight shift she asked the male overnight unlicensed personnel (AP) to assist her out of bed into her recliner. The resident stated the AP had grabbed her to help her up, the resident said she pushed the AP’s hand out of the way, and the AP responded by slapping the resident’s face. The resident stated the AP may have slapped her right cheek however she did not remember. The resident stated the incident occurred around 2:00 a.m. and the AP did not come back to the room after the incident. When leadership asked if this occurred intentionally, the resident said, “well yeah” and began crying. The resident stated the AP wanted her to shut up and had asked her “What do you need? Why are you crying?” when the AP came into the room. Leadership did not see noticeable redness, bruising, or swelling. During the facility investigation, the AP stated the resident had yelled and pushed his hand while he attempted to assist the resident out of bed. The AP stated the resident hit him in the face, and later in the shift the resident apologized. The AP stated he told the resident he was there to care for her, and she did not have to hit him. The resident became very emotional and was crying during shift. The resident had a history of crying. The AP stated when he tried to assist the resident in the past, the resident had not allowed him in the resident’s room, and stated the resident did not like the AP. During the facility investigation, the morning unlicensed personnel, stated when she arrived to shift at 6:00 a.m., the resident was ready to get out of bed. The resident was in a pleasant mood, and did not have any signs of bruising or redness. Throughout shift the resident did not report anything occurred with the AP, and the resident did not have any complaints of pain, swelling, redness, or bruising. During the facility investigation, multiple unlicensed personnel reported the resident had a history of striking out at staff. One unlicensed personnel stated the resident had a history of not wanting the AP to assist her during the overnight shift when the resident lived on a different floor of the facility. During the facility investigation, other residents were interviewed. None reported any concerns with the AP’s care or interactions with the AP during the overnight shift. The resident’s record indicated a licensed nurse assessed the resident’s skin due to the reported incident. There was no bruising, swelling on the resident’s cheek area, or reddened marks. The resident denied any physical pain. The facility reviewed camera footage from a hallway outside the resident’s room. The footage showed the AP entered the resident’s room a total of four times; at 10:55 p.m., for a minute or less. at 12:18 a.m. until 12:21 a.m., at 12:25 a.m. until 12:31 a.m., and at 3:57 a.m. until 4:02 a.m. The facility was unable to determine what occurred in the resident’s apartment behind closed doors. The facility contacted law enforcement to report the incident. The resident chose not to meet with law enforcement. The law enforcement report indicated the facility contacted law enforcement and reported the incident. During an interview, a contracted unlicensed personnel stated the resident reported to her that the facility male overnight unlicensed personnel (AP), had slapped the resident’s face when the resident requested to be transferred from her bed to her recliner. The resident said she “shooed” the AP’s hands away and the AP then slapped the resident’s face. The contracted staff stated there were no noticeable marks visible on the resident’s face. The resident was visually upset and crying. During an interview, a nurse stated the resident required staff assistance with transfers and was alert and oriented. The nurse stated after the resident reported the incident, a licensed nurse assessed the resident’s skin. The nurse stated the resident did not have red marks, no injuries, or complaints of pain. The nurse stated the resident had prior and ongoing extreme crying episodes that the resident could not control due to ALS disease. During an interview, leadership stated when she spoke to the resident the resident said it was the male unlicensed personnel working overnights that slapped her. Leadership stated the AP was the only male overnight unlicensed personnel working and was viewed on the facility hallway cameras entering and exiting the resident’s room. Leadership stated the AP denied the allegation. The alleged incident occurred on the first night the resident moved to a specialized area at the facility and the AP worked in the specialized area. Leadership stated the resident had requested assistance from the AP with a transfer. Leadership stated there were no physical signs of injury and there was no video evidence of the incident from the resident’s room. During an interview, the AP stated he went into the resident’s room to assist the resident to get up out of bed. The resident was crying, which was not abnormal for the resident. The AP stated the resident declined the AP’s assistance and help. The AP denied slapping the resident’s face. 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.

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): Facility staff neglected the resident when they did not toilet the resident as indicated on the service plan and the resident fell and sustained a right hip fracture and head injury. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. Although the resident fell and sustained a hip fracture, the resident was independent with mobility and fell during an independent transfer to the bathroom. Following the fall, staff assisted the resident off of the floor and attempted to contact the facility nurse. When a change in condition was later observed, the resident was transferred to the hospital for further evaluation. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigation included review of the resident’s record, facility internal investigation documentation, facility incident reports, personnel files, staff schedules, and related facility policies and procedures. Also, the investigator observed the facility, the resident’s room, and staff to resident interactions. The resident resided in an assisted living memory care unit with a diagnosis of dementia. The resident’s service plan included reassurance checks, medication management, and toileting assistance. The resident’s assessment indicated the resident was cognitively impaired and had a history of falls. The assessment further indicated the resident was independent with mobility and noted that the resident independently wandered throughout the unit with a four-wheeled walker and required reminders and standby assistance with toileting. The resident’s medical record indicated the resident was found on the floor in her bathroom at the end of an evening shift. Staff attempted to contact the on-call nurse; the nurse did not answer, and staff left a message about the fall. Staff assisted the resident off the floor and noted that the resident complained of knee pain but was able to walk back to bed with assistance. The on-call nurse spoke with facility staff later that night and documented on the fall. The nurse directed staff to increase safety checks and updated the resident’s family about the fall. The on-call nurse documented again around 5:30 a.m. that night shift staff completed safety checks and obtained vital signs. The nurse documented that the resident reported mild hip pain, had no change in gait with ambulation, and staff administered Tylenol for pain. Later that morning, the resident refused to get out of bed and complained of excruciating right hip pain. A facility nurse assessed the resident, contacted nurse management and the resident’s family, and transported the resident to the hospital for further evaluation. The resident was diagnosed with a right hip fracture and urinary tract infection (UTI). During an interview, the on-call nurse stated staff initially reported that the resident was found on floor, sustained no injuries, and had no complaints of pain. The on-call nurse instructed staff to continue safety checks, report any change in condition, and for the facility nurse to follow-up with the resident the next day. During an interview, nursing staff stated when unlicensed staff reported the resident refused to get out of bed due to leg pain, they completed an assessment and found the resident was unable to move her right leg. Nursing management and the resident’s family were notified, and the resident was sent to the hospital for further evaluation. 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, due to cognitive impairment. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Attempts to contact were not successful. Action taken by facility: The facility completed an investigation into the fall and completed staff education regarding incident reporting and on-call nurse protocol following the incident. 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: 07/26/2024 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 _____________________________ 39485 05/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1440 COUNTY ROAD C EAST HARMONY GARDENS 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 On May 23, 2024, the Minnesota Department of Health initiated an investigation of complaint #HL394859223C/#HL394851640M. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 Q0MK11 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. The Department of Health documents state correction orders using federal software. Tag numbers are assigned to Minnesota state statutes for Home Care Providers. 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. An equal opportunity employer. Letter ID: 9GJX Revise d04/20/2023 Harmony Gardens October 18, 2023 Page 2 DOCUMENTATION OF ACTION TO COMPLY Per Minn. Stat. § 144G.30, Subd. 5(c), the licensee must document actions taken to comply with the correction orders within the time period outlined on the state form; however, plans of correction are not required to be submitted for approval. The correction order documentation should include the following: Identify how the area(s) of noncompliance was corrected related to the resident(s)/employee(s) identified in the correction order. Identify how the area(s) of noncompliance was corrected for all of the provider’s residents/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 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 the Department of Health within 15 calendar days of the correction order receipt date. A state correction order under Minn. Stat. § 144G.91, Subd. 8, Free from Maltreatment is associated with a maltreatment determination by the Office of Health Facility Complaints. If maltreatment is substantiated, you will receive a separate letter with the reconsideration process under Minn. Stat. § 626.557. Please email reconsideration requests to: Health.HRD.Appeals@state.mn.us. Please attach this letter as part of your reconsideration request. Please clearly indicate which tag(s) you are contesting and submit information supporting your position(s). Please address your cover letter for reconsideration requests to: Reconsideration Unit 85 East Seventh Place St. Paul, MN 55164-0970 Harmony Gardens October 18, 2023 Page 3 You are encouraged to retain this document for your records. It is your responsibility to share the information contained in the letter and/or state form with your organization’s Governing Body. If you have any questions, please contact me. Sincerely, Jess Schoenecker, Supervisor State Evaluation Team Email: jess.schoenecker@state.mn.us Telephone: 651-201-3789 Fax: 1-866-890-9290 JMD PRINTED: 10/18/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 39485 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1440 COUNTY ROAD C EAST HARMONY GARDENS 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****** 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 License In accordance with Minnesota Statutes, section Providers. The assigned tag number 144G.08 to 144G.95, these correction orders are appears in the far left column entitled "ID issued pursuant to a survey. Prefix Tag." The state Statute number and the corresponding text of the state Statute Determination of whether violations are corrected out of compliance is listed in the requires compliance with all requirements "Summary Statement of Deficiencies" provided at the Statute number indicated below. column. This column also includes the When Minnesota Statute contains several items, findings which are in violation of the state failure to comply with any of the items will be requirement after the statement, "This considered lack of compliance. Minnesota requirement is not met as evidenced by." Following the surveyors' INITIAL COMMENTS: findings is the Time Period for Correction. SL39485015-0 PLEASE DISREGARD THE HEADING OF On September 25, 2023, through September 28, THE FOURTH COLUMN WHICH 2023, the Minnesota Department of Health STATES,"PROVIDER'S PLAN OF conducted a survey at the above provider, and CORRECTION." THIS APPLIES TO the following correction orders are issued. At the FEDERAL DEFICIENCIES ONLY. THIS time of the survey, there were 71 active residents; WILL APPEAR ON EACH PAGE. 26 receiving services under the Assisted Living with Dementia 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 subd. 1, 2, and 3. 01610 144G.70 Subd. 2 (a-b) Initial reviews, 01610 SS=E assessments, and monitoring (a) Residents who are not receiving any assisted LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 7QL911 If continuation sheet 1 of 6 PRINTED: 10/18/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 39485 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1440 COUNTY ROAD C EAST HARMONY GARDENS 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) 01610 Continued From page 1 01610 living services shall not be required to undergo an initial nursing assessment. (b) An assisted living facility shall conduct a nursing assessment by a registered nurse of the physical and cognitive needs of the prospective resident and propose a temporary service plan prior to the date on which a prospective resident executes a contract with a facility or the date on which a prospective resident moves in, whichever is earlier. If necessitated by either the geographic distance between the prospective resident and the facility, or urgent or unexpected circumstances, the assessment may be conducted using telecommunication methods based on practice standards that meet the resident's needs and reflect person-centered planning and care delivery. This MN Requirement is not met as evidenced by: Based on interview and record review, the licensee failed to ensure a registered nurse (RN) completed a comprehensive nursing assessment for two of three residents (R2, R4). This practice resulted in a level two violation (a violation that did not harm a resident's health or safety but had the potential to have harmed a resident's health or safety) and was issued at a pattern scope (when more than a limited number of residents are affected, more than a limited number of staff are involved, or the situation has occurred repeatedly; but is not found to be pervasive). The findings include: R2 was admitted on April 12, 2023. R2's Progress Notes for [R2] dated July 18, 2023, STATE FORM 6899 7QL911 If continuation sheet 2 of 6 PRINTED: 10/18/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 39485 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1440 COUNTY ROAD C EAST HARMONY GARDENS 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) 01610 Continued From page 2 01610 at 10:38 a.m.