Minnehaha Senior Living.

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 facility neglected the resident when staff did not administer the residents Pulmicort nebulizer treatment for 12 days. The resident experienced increasing shortness of breath and coughing. requiring hospitalization. The resident’s oxygen saturation (O2 sat) in the hospital was 82% on room air and she was diagnosed with asthma exacerbation. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was inconclusive. The resident’s medication administration record (MAR) indicated she went 12 days without using her Pulmicort nebulizer. However, the resident stated she self-administered the nebulizer during that timeframe, although the facility had no documentation. The resident’s medication management plan changed frequently between self-administration of medications and treatments, and at other times staff would be assigned to do so. Staff were unclear as to whether the resident was evaluated to self-administer her Pulmicort nebulizer during this timeframe, or if staff were to administer the nebulizer. The resident said two days before she went to the hospital, her nebulizer solution got low, so she started using it once a day instead of twice a day as ordered. The resident was hospitalized for chronic obstructive pulmonary disease (COPD) exacerbation, received treatment at the hospital, and returned to the facility at baseline. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator notified family. The investigation included review of the resident records, hospital records, pharmacy records, the facility internal investigation, facility incident reports, personnel files, staff schedules, and related facility policy and procedures. Also, the investigator observed medication processes and staff providing cares to residents. The resident resided in an assisted living facility. The resident’s diagnoses included COPD and asthma. The resident’s services included assistance with activities of daily living, meals, housekeeping, laundry, and medication management. The resident’s assessment indicated the resident was approved to self-administer her nebulizer treatment. The facility’s internal investigation indicated after a delivery of the resident’s Pulmicort solution from the pharmacy, a staff member brought it to the resident’s apartment. The staff member left the medications on the resident’s table, as she thought the resident was still self-administering her own medications. That same night, an evening shift staff member documented “No Supply” for the resident’s evening dose of the Pulmicort nebulizer. A nurse said the resident was assessed to self-administer medications. A staff nurse said he completed weekly medication checks, but did not document them. The staff nurse ordered Pulmicort nebulizer solution from the pharmacy mid-month. Eight days later, the staff nurse noticed the resident still did not have Pulmicort nebulizer solution, so he entered another refill request via the electronic medication administration record (eMAR). The staff nurse suspected the resident was using the Pulmicort nebulizer on her own but was unable to locate it. Unknown to staff, the resident’s family member took the resident to the hospital for wheezing. The resident was admitted with a diagnosis of acute/chronic respiratory failure with hypoxia. The resident was admitted, treated, and returned to the facility two days later in stable condition. After returning to the facility, the resident stated she administered her own nebulizer treatments for about two weeks prior to her hospitalization. Two days before she went to the hospital, she noticed her supply of nebulizer solution was getting low and began to self-administer one nebulizer treatment per day, instead of two as ordered. The resident requested to continue to self-administer her nebulizer and inhaler treatments. The resident’s progress notes indicated the pharmacy delivered a 15-day supply of the Pulmicort nebulizer solution mid-month. Staff were unable to locate the supply of nebulizer solution in the resident’s apartment. Staff documented the resident had been “hiding” medications and was unwilling to give them to staff. After her hospitalization, staff discussed a new plan regarding medication management with the resident and her family member, who agreed. The resident’s MAR indicated the resident was prescribed Pulmicort suspension 0.5mg/2, one vial to be inhaled via nebulizer every 12 hours for asthma. For the first week of the month, staff documented the Pulmicort nebulizer as “self-administer.” Then, for eight days, staff documented administering the Pulmicort nebulizer to the resident. For the rest of the month, staff documented the Pulmicort as not administered due to “no supply.” The MAR did not indicate specifically whether R1 was self-administering the Pulmicort nebulizer or if staff were to administer it. The resident’s medication assessment indicated she was evaluated and competent to self-administer inhalers and nebulizer treatments. Staff and nursing were to monitor the nebulizer solution was refilled before running out. The resident’s hospital record indicated her chief complaints were chest pain, shortness of breath, and asthma. Diagnoses included acute on chronic respiratory failure with hypoxia, chest pain, shortness of breath, and moderate persistent asthma with acute exacerbation. Upon arrival to the hospital, the resident’s oxygen saturation (O2 sat) on room air was 95% (normal range is 95%-100%). After a nebulizer treatment and walking a short distance, the resident was still short of breath and became hypoxic (a condition in which the body is deprived of adequate oxygen supply at the tissue level) with O2 sats dropping to 82%. After receiving more nebulizer treatments, the resident was discharged after two days in stable condition. When interviewed, an administrator said the staff were unaware when the resident’s family took the resident to the hospital. After investigating, leadership determined the resident had been self-administering her Pulmicort nebulizer. Although staff had been requesting refills from the pharmacy via their electronic MAR (eMAR) system, a refill never arrived. Nursing was aware the resident was out of her Pulmicort nebulizer solution. There had been many discussions and disagreements with the resident and her family member about whether she could self-administer her medications. There were also times when the resident and family member disagreed with each other about the medication management plan as well. When interviewed, a nurse said at one point the resident was self-administering her nebulizer treatments. Due to concerns about the resident taking medications properly, occasionally medication administration would be re-assigned to staff. The resident, however, wanted to continue self-administering her medications and would occasionally hide medications from staff. The continued changes regarding the resident’s medication administration caused confusion for staff and the resident. The resident stated she was happy with the current plan for her to self-administer her inhaler and nebulizer treatments. 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: Yes. Family/Responsible Party interviewed: No, did not respond. Alleged Perpetrator interviewed: Not Applicable. the Action taken by facility: Services were added for nursing to check the resident’s apartment weekly to ensure medications were not low on supply. The process to clarify which medications were self-administer and staff-administer were clarified for staff members. Action taken by the Minnesota Department of Health: The facility was found to be in noncompliance. To view a copy of the Statement of Deficiencies and/or correction orders, please visit: https://www.health.state.mn.us/facilities/regulation/directory/provcompselect.html If you are viewing this report on the MDH website, please see the attached Statement of Deficiencies. You may also call 651-201-4200 to receive a copy via mail or email. cc: The Office of Ombudsman for Long Term Care The Office of Ombudsman for Mental Health and Developmental Disabilities PRINTED: 06/06/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ C B.

correction orders and document the actions taken to comply in the facility's records. The Department reserves the right to return to the facility at any time should the Department receive a complaint or deem it necessary to ensure the health, safety, and welfare of residents in your care. STATE CORRECTION ORDERS The enclosed State Form documents the state correction orders. MDH documents state licensing correction orders using federal software. Tag numbers are assigned to Minnesota state statutes for Assisted Living Facilities. The assigned tag number appears in the far left column entitled "ID Prefix Tag." The state statute number and the corresponding text of the state statute out of compliance are listed in the "Summary Statement of Deficiencies" column. This column also includes the findings that are in violation of the state statute after the statement, "This MN Requirement is not met as evidenced by . . ." In accordance with Minn. Stat. § 144G.31 Subd. 4, MDH may assess fines based on the level and scope of the violations; h owever, no immediate fines are assessed for this survey of your facility. DOCUMENTATION OF ACTION TO COMPLY In accordance with Minn. Stat. § 144G.30, Subd. 5(c), the licensee must document actions taken to comply with the correction orders within the time period outlined on the state form; however, plans of correction are not required to be submitted for approval. The correction order documentation should include the following: Identify how the area(s) of noncompliance was corrected related to the An equal opportunity employer. Letter ID: IS7N REVISED 09/13/2021 Minnehaha Senior Living April 14, 2025 Page 2 resident(s)/employee(s) identified in the correction order. Identify how the area(s) of noncompliance was corrected for all of the provider’s resident(s)/employees that may be affected by the noncompliance. Identify what changes to your systems and practices were made to ensure compliance with the specific statute(s). CORRECTION ORDER RECONSIDERATION PROCESS In accordance with Minn. Stat. § 144G.32, Subd. 2, you may challenge the correction order(s) issued, including the level and scope, and any fine assessed through the correction order reconsideration process. The request for reconsideration must be in writing and received by MDH within 15 calendar days of the correction order receipt date. To submit a reconsideration request, please visit: https://forms.web.health.state.mn.us/form/HRDAppealsForm The MDH Health Regulation Division (HRD) values your feedback about your experience during the survey and/or investigation process. Please fill out this anonymous provider feedback questionnaire at your convenience at this link: h ttps://forms.office.com/g/Bm5uQEpHVa. Your input is important to us and will enable MDH to improve its processes and communication with providers. If you have any questions regarding the questionnaire, please contact Susan Winkelmann at susan.winkelmann@state.mn.us or call 651-201-5952. You are encouraged to retain this document for your records. It is your responsibility to share the information contained in the letter and state form with your organization’s Governing Body. If you have any questions, please contact me. Sincerely, Casey DeVries, Supervisor State Evaluation Team Email: Casey.DeVries@state.mn.us Telephone: 651-201-5917 Fax: 1-866-890-9290 HHH PRINTED: 04/14/2025 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 _____________________________ 30780 03/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3733 23RD AVENUE SOUTH MINNEHAHA SENIOR LIVING MINNEAPOLIS, MN 55407 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 000 Initial Comments 0 000 ASSISTED LIVING PROVIDER LICENSING Minnesota Department of Health is CORRECTION ORDER(S) documenting the State Correction Orders using federal software. Tag numbers have In accordance with Minnesota Statutes, section been assigned to Minnesota State 144G.08 to 144G.95, these correction orders are Statutes for Assisted Living Facilities. The issued pursuant to a survey. assigned tag number appears in the far-left column entitled "ID Prefix Tag." The Determination of whether violations are corrected state Statute number and the requires compliance with all requirements corresponding text of the state Statute out provided at the Statute number indicated below. of compliance is listed in the "Summary When Minnesota Statute contains several items, Statement of Deficiencies" column. This failure to comply with any of the items will be column also includes the findings which considered lack of compliance. are in violation of the state requirement after the statement, "This Minnesota INITIAL COMMENTS: requirement is not met as evidenced by." Following the evaluators ' findings is the SL30780016-0 Time Period for Correction. On March 17, 2025, through March 18, 2025, the PLEASE DISREGARD THE HEADING OF survey at the above provider. At the time of the STATES,"PROVIDER'S PLAN OF survey, there were 79 residents; 77 receiving CORRECTION." THIS APPLIES TO services under the Assisted Living Facility with FEDERAL DEFICIENCIES ONLY. THIS Dementia Care license. WILL APPEAR ON EACH PAGE. THERE IS NO REQUIREMENT TO SUBMIT A PLAN OF CORRECTION FOR VIOLATIONS OF MINNESOTA STATE STATUTES. THE LETTER IN THE LEFT COLUMN IS USED FOR TRACKING PURPOSES AND REFLECTS THE SCOPE AND LEVEL ISSUED PURSUANT TO 144G.31 SUBDIVISION 1-3. 01620 144G.70 Subd. 2 (c-e) Initial reviews, 01620 SS=D assessments, and monitoring LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 7WGR11 If continuation sheet 1 of 10 PRINTED: 04/14/2025 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 _____________________________ 30780 03/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3733 23RD AVENUE SOUTH MINNEHAHA SENIOR LIVING MINNEAPOLIS, MN 55407 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) 01620 Continued From page 1 01620 (c) Resident reassessment and monitoring must be conducted no more than 14 calendar days after initiation of services. Ongoing resident reassessment and monitoring must be conducted as needed based on changes in the needs of the resident and cannot exceed 90 calendar days from the last date of the assessment. (d) For residents only receiving assisted living services specified in section 144G.08, subdivision 9, clauses (1) to (5), the facility shall complete an individualized initial review of the resident's needs and preferences. The initial review must be completed within 30 calendar days of the start of services. Resident monitoring and review must be conducted as needed based on changes in the needs of the resident and cannot exceed 90 calendar days from the date of the last review. (e) A facility must inform the prospective resident of the availability of and contact information for long-term care consultation services under section 256B.0911, 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. This MN Requirement is not met as evidenced by: Based on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) conducted a comprehensive assessment every 90 days for one of two residents (R2). 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, but was not likely to cause serious injury, impairment, or death), and was issued at an isolated scope (when one or a limited number of residents are affected or one or STATE FORM 6899 7WGR11 If continuation sheet 2 of 10 PRINTED: 04/14/2025 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 _____________________________ 30780 03/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3733 23RD AVENUE SOUTH MINNEHAHA SENIOR LIVING MINNEAPOLIS, MN 55407 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) 01620 Continued From page 2 01620 a limited number of staff are involved or the situation has occurred only occasionally). The findings include: R2 was admitted to the licensee on June 12, 2023.

Finding: Not Substantiated Nature of Investigation: The Minnesota Department of Health investigated an allegation of maltreatment, in accordance with the Minnesota Reporting of Maltreatment of Vulnerable Adults Act, Minn. Stat. 626.557, and to evaluate compliance with applicable licensing standards for the provider type. Initial Investigation Allegation(s): The facility neglected the resident when they failed to administer scheduled medications as ordered. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. The facility followed the care plan and nursing staff assessed and adjusted the care plan as needed. There was not a preponderance of evidence to support that the actions of the facility staff met the definition of neglect. The investigator conducted interviews with facility staff members, including nursing staff. The investigation included review of the resident record, personnel files, employee training files, and facility policy and procedures. The investigator also toured the facility and observed staff interaction with residents. The resident resided in an assisted living facility. The resident’s diagnoses included asthma, hypertension (high blood pressure) and diabetes. The resident’s service plan included assistance with all activities of daily living, routine safety checks, and medication administration. The resident’s assessment indicated the resident was on a 28-day auto-refill cycle from her pharmacy. Oral medications were to be administered by facility staff and staff were to assist the resident as needed to self-administer the scheduled inhaler and nebulizer treatments. A review of complaint documents and the resident’s medical records indicated the resident had a history of exacerbations of asthma and recently experienced shortness of breath which required hospitalization and treatment including several medication adjustments. During interviews, multiple staff members stated that since arriving at the facility, the resident has been involved with her own medication administration while working with the facility to try different approaches to administration to maintain independence safely. During a discussion with the resident, she was able to identify her medication and administration times. The resident stated that staff assisted her with medication administration and had no concerns with the care and medication management provided at the facility. During an interview, a family member stated that the resident has been able to administer medications with assistance, including nebulizers since her admission. Although recently they had been in contact with facility nursing staff concerning the resident’s ability to self-administer medication even after receiving verbal ques and reminders from staff members. The family had concerns with care provided at the facility. 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, Unable Family/Responsible Party interviewed: Yes Alleged Perpetrator interviewed: N/A Action taken by facility: The nursing staff continued to monitor the resident’s ability to self-administer medication, as well as offering continued training to staff on proper data entry into the electronic health record. 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: 03/13/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ C B. WING _____________________________ 30780 02/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3733 23RD AVENUE SOUTH MINNEHAHA SENIOR LIVING MINNEAPOLIS, MN 55407 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 February 3, 2025, the Minnesota Department of Health initiated an investigation of complaint #HL307809901C/#HL307806602M. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 SS4611 If continuation sheet 1 of 1