Elder Homestead.

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 Elder Homestead February 19, 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, Jess Schoenecker, Supervisor State Evaluation Team Email: Jess.Schoenecker@state.mn.us Telephone: 651-201-3789 Fax: 1-866-890-9290 HHH PRINTED: 02/19/2025 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 _____________________________ 20104 01/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 11400 4TH STREET NORTH ELDER HOMESTEAD MINNETONKA, MN 55343 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 been assigned to Minnesota State Statutes for Assisted Living Facilities with In accordance with Minnesota Statutes, section Dementia Care. 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 evaluators ' INITIAL COMMENTS: findings is the Time Period for Correction. Project # SL20104016 PLEASE DISREGARD THE HEADING OF On January 6, 2025, through January 9, 2025, the THE FOURTH COLUMN WHICH survey at the above provider, and the following CORRECTION." THIS APPLIES TO correction orders are issued. At the time of the FEDERAL DEFICIENCIES ONLY. THIS survey, there were thirty-seven (37) residents WILL APPEAR ON EACH PAGE. receiving services under the provider's 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 SUBDIVISION 1-3. 0 780 144G.45 Subd. 2 (a) (1) Fire protection and 0 780 SS=F physical environment LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 36X411 If continuation sheet 1 of 15 PRINTED: 02/19/2025 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 _____________________________ 20104 01/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 11400 4TH STREET NORTH ELDER HOMESTEAD MINNETONKA, MN 55343 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) 0 780 Continued From page 1 0 780 for dwellings or sleeping units, as defined in the State Fire Code: (i) provide smoke alarms in each room used for sleeping purposes; (ii) provide smoke alarms outside each separate sleeping area in the immediate vicinity of bedrooms; (iii) provide smoke alarms on each story within a dwelling unit, including basements, but not including crawl spaces and unoccupied attics; (iv) where more than one smoke alarm is required within an individual dwelling unit or sleeping unit, interconnect all smoke alarms so that actuation of one alarm causes all alarms in the individual dwelling unit or sleeping unit to operate; and (v) ensure the power supply for existing smoke alarms complies with the State Fire Code, except that newly introduced smoke alarms in existing buildings may be battery operated; This MN Requirement is not met as evidenced by: Based on observation and interview, the licensee failed to comply with Minnesota State Fire Code and Minnesota Rule 7511. This had the potential to directly affect all residents, staff, and visitors. 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 widespread scope (when problems are pervasive or represent a systemic failure that has affected or has the potential to affect a large portion or all of the residents). STATE FORM 6899 36X411 If continuation sheet 2 of 15 PRINTED: 02/19/2025 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 _____________________________ 20104 01/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 11400 4TH STREET NORTH ELDER HOMESTEAD MINNETONKA, MN 55343 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) 0 780 Continued From page 2 0 780 Findings include: On January 7. 2025, from approximately 2:00 p.m. to 4:44 p.m., the surveyor toured the facility with licensed assisted living director (LALD)-D.

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 assess her after a noted change in condition and failed to provide adequate care and services to the resident resulting in her death. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. The facility assessed the resident after falls, communicated concerns to the resident’s provider and provided cares as the resident allowed. The resident often refused cares, medications, and emergency room evaluations as recommended. The investigator conducted interviews with facility staff members, including administrative staff and nursing staff. The investigator contacted law enforcement. The investigation included review of the resident records, death record, hospital records, facility internal investigations, facility incident reports, staff schedules, law enforcement report, related facility policy and procedures. Also, the investigator observed resident cares and interactions with staff while on site. The resident resided in an assisted living facility. The resident’s diagnoses included chronic kidney disease and osteoporosis with pathological fracture. The resident’s service plan included assistance with medication administration, meal delivery and bathing. The resident’s assessment indicated the resident was alert, oriented, and walked with use of a walker. The resident was her own decision maker and independent with most activities of daily living. The resident’s service plan indicated the resident admitted to the facility on a wellness plan that included nursing assessments as required, staff response to activated call lights, daily safety check, and monthly monitoring of vital signs. Other services were available to the resident as requested via an a la cart pay per service system. The residents progress notes indicated the resident had multiple falls while residing at the facility and increased weakness from poor appetite. The notes indicated the nurses updated the resident’s medical provider and family, along with a review of the incident. Facility leadership implemented interventions after each fall. The facility staff educated the resident on risks and benefits for being evaluated after a fall with hitting her head due to being on blood thinners, but the resident declined. The notes indicated the facility also carried out new orders such as medication changes, lab work and x-ray orders received by the medical provider. The notes also indicated the facility nurse attempted on multiple occasions to meet with the resident to discuss services she felt could be beneficial for the resident to receive, but the resident refused to discuss the options. A facility incident report indicated the resident had fall approximately one week prior to hospitalization. The resident hit the back of her head and had a cut with some bleeding. The resident also had low blood sugar. The report indicated the resident was non-compliant with interventions. The resident’s progress notes indicated the day before the resident admitted to the hospital, the resident had been vomiting and had critical lab results. The medical provider advised the resident to be evaluated in the emergency room. The resident declined to go to the emergency room. The following day, the resident’s progress notes indicated staff updated the nurse of the resident’s continued vomiting, refusals of medications, and refusal to get out of bed. Staff called 911 and the resident transferred to the hospital. The notes indicated the resident passed away at the hospital two days later. The resident’s hospital record indicated the resident likely passed away from mesenteric ischemia (a medical condition where blood flow to the intestines is significantly reduced or blocked, usually due to a narrowing or blockage in the mesenteric arteries) and sepsis (a life-threatening condition that occurs when the body's immune system has an extreme response to an infection or injury.) The notes indicated the resident had profound hypokalemia (a condition where there are low levels of potassium in the blood) and hyponatremia (a condition where there are low levels of sodium in the blood) that was the suspected result of the resident’s poor oral intake. A law enforcement report indicated the resident was estranged from her family and there was no power of attorney in place. The report indicated that once the resident ran out of funds, the facility assisted her to obtain a state waiver to pay for services such as bathing, laundry, medication administration, meals delivered to her door, and housekeeping. The report indicated law enforcement contacted the medical examiner who reviewed hospital notes and determined the resident’s injuries were due to self-neglect. The law enforcement officer indicated the medical examiner’s findings corroborated his findings at the facility. An autopsy was not performed. The resident’s death record indicated the resident died due to complications of a right hip fracture related to a presumed fall. During an interview, a registered nurse (RN) stated the resident was very independent and was estranged from her family. The RN stated she felt the resident declined and needed more assistance. The RN was able to have a county assessment arranged to help the resident receive funding for more services. The RN stated the resident slowly began to refuse the extra services. The RN stated the facility delivered the resident’s meal trays to her room and a housekeeper notified her of meal trays with the food left on them in the resident’s room. The RN stated the provider was notified of their concerns of the resident not eating, losing weight, and feeling dizzy. The RN stated the resident told her it was good for a person to skip meals to shrink their stomach, and the RN educated the resident on the importance of nutrition. The RN stated when the resident had critical lab values, her provider recommended she be evaluated in the emergency department and provided the resident the risks of not going in. The RN stated the resident declined to go, but she still called 911 in hopes the emergency medical staff could evaluate her and convince her to go in. However, the resident continued to refuse to go to the hospital with the emergency medical staff. The RN stated the resident would refuse to allow her to assess her skin and would deny injury after a fall, stating she was fine. During an interview, a family member stated he had a strained relationship with the resident. The family member stated the resident was non-compliant for receiving care. The family member stated there were previous investigations that resulted in a determination of self-neglect, and he would not put it past the resident to neglect herself to death. The family member stated he would not be surprised if the resident refused to go to the hospital. During an interview, the licensed assisted living director (LALD) stated the facility had concerns about the resident’s personal choices as she did not always make right choices regarding her health. The LALD stated once they had a county waiver approved for the resident, she received assistance with things like bathing, meal tray delivery, and medications. The LALD stated the waiver paid for the cost of the services and told the resident multiple times the services were covered as she knew the resident previously declined assistance due to the financial burden of paying for them in the a la cart pay for service system she previously used. The LALD stated as soon as they were aware of a fall the resident was assessed for injury and pain. The LALD stated the resident refused to be evaluated at the hospital a few times, including when her medical provider recommended it. The LALD stated the facility also had concerns about the resident drinking alcohol, as it was an issue for her. The LALD stated she saw the resident clearly intoxicated, walking unsteady and smelled alcohol on the resident which contributed to her falls. The LALD stated there were no bruises on the resident reported to her, and believed if there were bruises staff did not see them as the resident had been refusing assistance with bathing so they did not have the chance to see her skin. 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.