Lilac Homes Assisted Living.

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 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), t he 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: x Identify how the area(s) of noncompliance was corrected related to the resident(s)/ employee(s) 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). An equal opportunity employer . Letter ID: IS7N REVISE 0D9/13/2021 Lilac Homes Assisted Living October 17, 2025 Page 2 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, Benjamin J. Zwart, Supervisor State Engineering Service sSection Email: BenjaminZ. wart@state.mn.us Telephone :651-201-3715 Fax :1-866-890-9290 HHH PRINTED: 10/17/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ R B. WING _____________________________ 28989 07/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2615 PARKVIEW DRIVE LILAC HOMES ASSISTED LIVING MOORHEAD, MN 56560 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****** ASSISTED LIVING PROVIDER FOLLOW UP SURVEY WITH RE-ISSUE OF ORDERS INITIAL COMMENTS SL28989016-1 On July 18, 2025, the Minnesota Department of Health conducted a follow-up survey at the above provider to follow-up on orders issued pursuant to a survey completed on April 23, 2025. At the time of the survey, there were 22 residents; 22 receiving services under the Assisted Living Dementia Care License. As a result of the follow-up survey, the following orders were reissued. {0 480} 144G.41 Subdivision 1 Subd. 1a (a-b) Minimum {0 480} SS=F requirements; required food services (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 LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 CVEX12 If continuation sheet 1 of 11 PRINTED: 10/17/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ R B. WING _____________________________ 28989 07/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2615 PARKVIEW DRIVE LILAC HOMES ASSISTED LIVING MOORHEAD, MN 56560 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} 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, existing floor, wall, and ceiling finishes are allowed provided the facility keeps them clean and in good condition; (6) notwithstanding Minnesota Rules, part 4626.1375, shielded or shatter-resistant lightbulbs are not required, but if a light bulb breaks, the facility must discard all exposed food and fully clean all equipment, dishes, and surfaces to remove any glass particles; and (7) notwithstanding Minnesota Rules, part 4626.1390, toilet rooms are not required to be provided with a self-closing door. This MN Requirement is not met as evidenced by: Not reviewed during this survey. STATE FORM 6899 CVEX12 If continuation sheet 2 of 11 PRINTED: 10/17/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ R B. WING _____________________________ 28989 07/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2615 PARKVIEW DRIVE LILAC HOMES ASSISTED LIVING MOORHEAD, MN 56560 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) {0 485} 144G.41 Subdivision 1.a (a) Minimum {0 485} SS=C requirements; required food services (a) All assisted living facilities must offer to provide or make available at least three nutritious meals daily with snacks available seven days per week, according to the recommended dietary allowances in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables. The menus must be prepared at least one week in advance and made available to all residents. The facility must encourage residents' involvement in menu planning. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. The facility must not require a resident to include and pay for meals in the resident's contract. This MN Requirement is not met as evidenced by: Not reviewed during this survey. {0 775} 144G.45 Subd. 2.

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 resident was neglected when the facility failed to ensure she received appropriate treatment for a toe wound. The resident was hospitalized/treated for osteomyelitis (a severe bone infection) . Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. The resident had chronic recurring cellulitis infections of the toe. The resident’s toe cellulitis had been treated by multiple providers prior to having a wound debridement/culture which identified 2 strains of MRSA (bacteria) in the wound. The resident was hospitalized 7 days later with no signs of acute infection. The facility followed the residents plan of care and physician orders for care of the residents’ toe. Additional concerns which were not alleged maltreatment were reviewed including transfers, toileting, and medication administration. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted the resident’s family member. The investigation included review of the resident record(s), hospital records, facility incident reports, and related facility policy and procedures. Also, the investigator observed the resident’s toe wound and other resident’s and staff at the facility. The resident was admitted to the assisted living facility secure memory care unit approximately 4 years prior with diagnoses including Alzheimer’s Disease, dementia, peripheral vascular disease, and cellulitis of the second toe. A resident assessment dated December 20, indicated the resident had moderate cognitive impairment and was recently diagnosed with cellulitis of the second toe on her left foot on August 26. The assessment identified the wound was chronic/recurring in nature. At the time of the assessment the resident’s toe had a healing scab that was not red. The resident’s care plan identified the resident had a history of cellulitis infection of the left second toe. The resident’s medical record indicated she received treatment for chronic recurring cellulitis infections of the left second toe including one time in 2022, and five times in 2023. A hospice recertification evaluation form indicated the resident was seen for continuation of hospice services and indicated the resident required antibiotics to treat a recurring cellulitis infection of the resident’s left second toe. On August 26 an after-visit summary (AVS) indicated the resident was again seen for a cellulitis infection of the left second toe and given an antibiotic injection and prescribed oral antibiotics. The AVS included instructions for wound care/dressing changes. On September 16 (22 days later) a physician’s order included new orders for wound care/dressing changes. On October 30, a progress note indicated the resident was seen by the provider and indicated the toe appeared to be healed but wanted a band aide on it just in case. The resident record included documentation of weekly skin/wound monitoring and supervision of staff completing dressing changes to ensure competency with no concerns identified. The resident’s record indicated weekly wound monitoring was completed and indicated the toe wound was scabbed and healing with no signs or symptoms of infection noted. 5 days later a progress note indicated the nurse received a message from the resident’s family member that the resident’s left second toe was red and inflamed, with possible drainage noted. Nursing advised the family to bring the resident in for evaluation due to history of recurring infection in that toe. An emergency department (ED) AVS indicated the toe appeared like it could possibly be infected, and the resident was given an antibiotic injection, and was also prescribed oral antibiotics. The AVS indicated an X-ray was completed with no concerns for osteomyelitis at that time. On December 31, a provider contact communication form included orders for daily wound care/dressing changes of the left second toe wound. On January 8, the resident was seen to establish care with a new provider and included a review of the resident record which indicated the resident had history of a chronic ulcer with cellulitis infections of the left foot second toe, most recently treated in December. An assessment of the resident’s toe showed a deformity of the left second toe with a chronic open sore and clear drainage present. The resident was again prescribed oral antibiotics for 7 days. 2 days later a weekly skin/wound monitoring note indicated the toe wound previously diagnosed cellulitis was slightly swollen with a small open area in the middle of the wound and a small amount of slough and minimal drainage noted. The note indicated dressing changes were completed as ordered. Another weekly skin/wound monitoring indicated the toe was slightly swollen, with a slight open area in the middle of the wound, and no drainage noted. The note indicated dressing changes were completed as ordered. On January 22, a provider progress note indicated the resident was seen by podiatry for the toe wound. The note indicated the resident was diagnosed with osteomyelitis and prescribed oral antibiotics. The note indicated family reported the resident’s infection improved while on antibiotics but deteriorated once the medication was discontinued. On January 29, a podiatry progress note indicated the resident’s wound was debrided to remove tissue and bone. A wound culture following the procedure identified the resident had 2 strains of MRSA in the wound. The resident returned to the facility with orders to keep the bandage in place for 2 days, then provide daily bandage changes after that. The note indicated oral antibiotics were again prescribed to treat the infection. 2 days later a weekly skin/wound monitoring indicated the debride wound was about 0.8 centimeters (cm) x 0.8cm in size, with slough noted to about 1/4 of wound bed, and pink tissue was also noted. The wound had no drainage at time of dressing change, and no odor was noted. 5 days later another skin/wound assessment indicated the wound was smaller with minimal drainage, no signs of infection were noted. The residents Medication and Treatment Administration Record indicated antibiotics and wound care/dressing changes were provided as ordered. 7 days later a progress note at the time of admission to the hospital indicated although an Xray showed evidence of osteomyelitis the resident had no signs or symptoms of acute infection including redness, edema, purulence, or malodor. The note indicated the resident was admitted to the hospital for management of the infected wound. The hospital record included a radiology report which indicated an MRI was completed and confirmed second toe osteomyelitis and cellulitis infection with abnormal bone marrow edema. Another hospital progress note indicated infectious disease was consulted who documented the resident had been seen and treated for cellulitis several times prior to being referred to podiatry and diagnosed and subsequently hospitalized with osteomyelitis. The note indicated despite being given oral antibiotics the wound worsened until she was admitted with the non-healing wound. The note indicated the resident had a polymicrobial non healing wound that despite best efforts including adequate antibiotic treatment and wound care may not heal. The hospital record indicated the resident was admitted to the hospital for 11 days and received IV antibiotics and wound care, then was discharged back to the facility. When interviewed facility leadership and nursing staff stated the resident had chronic recurring infections of her left second toe since admission, with no concern of worsening infection prior to her admission to the hospital. Leadership and nursing staff interviewed indicated they had no concerns for neglect of the resident’s toe wound and indicated they followed providers orders for treatment of the chronic recurring wound. When interviewed an unlicensed personnel (ULP) stated the resident had a recurring sore on her toe that never really healed. The staff stated they followed providers orders and provided care to the resident according to her orders and plan of care. When interviewed another ULP stated the resident had a recurring infection of the toe since admission to the facility that would come and go but never completely healed. The ULP stated she was trained and evaluated on the resident’s dressing changes to ensure she was completing them correctly. The ULP stated the toe wound looked no different prior to the resident being hospitalized and indicated they would report any changes or concerns to the nurse immediately.