Harrison Bay Senior Living.

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 . . ." IMPOSITION OF FINES In accordance with Minn. Stat. § 144G.31, Subd. 4, fines and enforcement actions may be imposed based on the level and scope of the violations and may be imposed immediately with no opportunity to correct the violation first as follows: Level 1: no fines or enforcement. Level 2: a fine of $500 per violation, in addition to any enforcement mechanism authorized in § 144G.20 for widespread violations; Level 3: a fine of $3,000 per violation per incident, in addition to any enforcement mechanism authorized in § 144G.20. Level 4: a fine of $5,000 per incident, in addition to any enforcement mechanism authorized in An equal opportunity employer. Letter ID: IS7N REVISED 09/13/2021 Harrison Bay Senior Living April 21, 2025 Page 2 § 144G.20. Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, the following fines are assessed pursuant to this survey: 0775 - 144g.45 Subd. 2. (a) - Fire Protection And Physical Environment - $500.00 Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, t he total amount you are assessed is $500.00. You will be invoiced approximately 30 days after receipt of this notice, subject to appeal. 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 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 REQUESTING A HEARING Alternatively, in accordance with Minn. Stat. § 144G.31, Subd. 5(d), an assisted living provider that has been assessed a fine under this subdivision has a right to a reconsideration or a hearing under this section and chapter 14. Pursuant to Minn. Stat. § 144G.20, Subd. 14 and Subd. 18, a request for a hearing must be in writing and received by the Department of Health within 15 business days of the correction order receipt date. The request must contain a brief and plain statement describing each matter or issue contested and any new information you believe constitutes a defense or mitigating factor. Harrison Bay Senior Living April 21, 2025 Page 3 To submit a hearing request, please visit: https://forms.web.health.state.mn.us/form/HRDAppealsForm To appeal fines via reconsideration, please follow the procedure outlined above. P lease note that you may request a reconsideration o r a hearing, but not both. If you wish to contest tags without fines in a reconsideration and tags with the fines at a hearing, please submit two separate appeals forms at the website listed above. The MDH Health Regulation Division (HRD) values your feedback about your experience during the survey and/or investigation process. Please fill out this anonymous provider feedback questionnaire at your 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 JMD PRINTED: 04/21/2025 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 _____________________________ 34150 03/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1861 COMMERCE BOULEVARD HARRISON BAY SENIOR LIVING MOUND, MN 55364 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 SL34150016-0 Time Period for Correction. On March 3, 2025, through March 6, 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 71 residents; 64 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. 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 WUXD11 If continuation sheet 1 of 13 PRINTED: 04/21/2025 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 _____________________________ 34150 03/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1861 COMMERCE BOULEVARD HARRISON BAY SENIOR LIVING MOUND, MN 55364 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) 0 480 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.

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 she was found with a palm-sized blister on her left lower back, along with smaller open blisters on the sides of the larger blister, caused by a heating pad. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. The resident used her own heating pad without the facility's knowledge. She fell asleep with it on, which caused a burn on her lower back. An unlicensed caregiver noticed the blister and reported it to the triage nurse. The resident was sent to the emergency room for evaluation and returned the same day. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and the resident’s family member. The investigation included review of the resident’s records, incident reports, staff schedules, policies, and procedures. The resident resided in an assisted living facility. The resident’s diagnoses chronic back pain and dementia. The resident’s service plan included assistance of one person with bathing, dressing, housekeeping, medication administration and escorting. The progress notes indicated one morning an unlicensed caregiver administered pain medication to the resident and observed a large red area on her lower back, along with burn marks and skin blisters. The resident told the unlicensed caregiver that she had left the heating pad on for too long. The unlicensed caregiver reported it to the triage nurse and the resident was sent to the emergency room for evaluation. The hospital record indicated the resident presented to the emergency department with a burn on the left side of her lower back. The record indicated a history of chronic back pain for which the resident used a heating pad for relief. She fell asleep with the heating pad on, resulting in the burn. The resident was diagnosed with a second-degree burn and was discharged back to the facility in stable condition. After the resident returned to the facility, the medical provider’s orders indicated the resident’s wound mupirocin cream (an antibacterial) and barrier cream as needed only. The home health care notes indicated the resident did not have any active wounds a month after the incident. During an interview, the resident stated she did not have any concern with her care. She left the heating pad on for too long and fell asleep while it was on. It was the accident. She said the heating pad belonged to her and she no longer uses it. The resident stated the nurse took a good care of the wound and it had healed. During an interview, a family member stated that the heating pad belonged to the resident and that he had no concerns about the care she received. During an interview, a manager stated she was unaware the resident was using her own heating pad, as the facility did not allow heating pads in the building. After the incident, the heating pad was removed, and the wound was assessed and treated by medical staff at the hospital. After returning from the hospital, the resident was referred to skilled home nursing visit to provide wound care. The care plan was updated, and the facility educated staff on the prohibition of heating pad use. 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: Yes. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Not Applicable. he Action taken by facility: The heating pad was removed, and the wound was assessed and treated by medical staff at the hospital. The resident was referred to skilled home nursing visit, and appropriate follow-up care was arranged. The care plan was updated, and staff were educated on the prohibition of heating pad use. 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: 01/13/2025 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 _____________________________ 34150 01/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1861 COMMERCE BOULEVARD HARRISON BAY SENIOR LIVING MOUND, MN 55364 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 January 8, 2025, the Minnesota Department of Health initiated an investigation of complaints #HL341507342M/HL341502481C . No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 1LQE11 If continuation sheet 1 of 1

Finding: Not Substantiated Nature of the 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 the facility failed to order the resident’s pain medications and did not properly maintain her nerve stimulator for pain relief. Additionally, the facility failed to check on the resident at night which led to yeast infections. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. While there was an occasion when a medication ran out, this was due to difficulty with insurance coverage and the facility worked to resolve this issue. There was an occasion when the resident’s nerve stimulator was not properly charged, and the facility put new interventions in place to prevent recurrence of this issue. While the resident did develop a yeast infection, the resident received treatment for this and the facility provided nighttime cares for incontinence. The investigator conducted interviews with facility staff members, including administrative staff and unlicensed staff. The investigator contacted the resident's family member. The investigation An equal opportunity employer. included review of resident's records. The investigation included an onsite visit, observations, and interactions between residents and facility staff. The resident resided in an assisted living unit. The resident’s diagnoses include osteoarthritis and weakness. The resident’s service plan included assistance with all activities of daily living which included toileting and incontinence cares assist three times a day and medication administration. The resident’s assessment indicated she was one person assist with transfers. Based on the progress notes, the nerve stimulator was charged twice a week by nursing. According to the medication administration record (MAR), the resident missed one dose of her clotrimazole, but the facility restocked it the next day. A few months later, the resident ran out of Lidocaine patches, and the family had to provide them because insurance did not cover for it. However, the resident did not miss any lidocaine treatments as it was ordered to be applied 12 hours on and 12 hours off. The medication administration records indicated the resident received a prescription to receive treatment for a yeast infection for approximately six months. The MAR indicated the resident’s pain medication regimen was adjusted over several months. The order for oxycodone ½ five milligram (mg) tablet every four hours as needed was changed to twice daily scheduled and twice daily as needed. A review of the MAR did not identify an occasion in which the scheduled medication was not given multiple times in a row. During an interview, family member #1 stated staff members were responsive to the resident's needs, assisting her to the bathroom whenever she called, and changing her pad around 3 and 5 in the morning. The resident also had the opportunity to enjoy a jacuzzi bath downstairs once a week, and even twice a week if desired. The family member confirmed the staff administered pain medication to the resident as prescribed, every four hours apart. However, he mentioned having short-term memory loss and could not recall if the staff ever forgot to charge the resident's nerve stimulator. Overall, he expressed satisfaction with the care provided. In another interview, family member #2 stated everything had improved. The resident had a history of a broken back and in continuous pain. In the past, there was an incident where the facility ran out of oxycodone, leaving the resident without pain medication for several days. However, family member #2 stated could not recall when this occurred. Additionally, the family member mentioned the staff was supposed to change the resident at night, but they did not do it, resulting in a painful rash. During an interview, the unlicensed staff member explained the care tasks performed for the resident, including toileting care, changing briefs, clothes, and providing perineal care as needed. She confirmed regular checks on the resident due to her medication schedule, with brief changes occurring every 2 hours or as needed. She stated she knew of the resident’s nerve stimulator, but the nurses made sure it was charged. In an interview, a member of the management team acknowledged the incident with the Lidocaine patch, attributing it to insurance not covering the medication so the family was informed and got a supply. He did not recall an incident involving a shortage of oxycodone but confirmed the nurses monitored and charged the nerve stimulator twice a week. He stated the caregivers checked on the resident three times during a night for incontinence. 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, attempt was unsuccessful. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Not Applicable. Action taken by facility: The facility is collaborating with the family to address any concerns they had. In response to the incidents happened in the past, the facility staff have updated the resident's care plan to include regular charging of the nerve stimulator twice a week, and the resident will also be checked three times during the night to ensure she remains dry and comfortable. Action taken by the Minnesota Department of Health: No further action taken at this time. cc: The Office of Ombudsman for Long Term Care The Office of Ombudsman for Mental Health and Developmental Disabilities PRINTED: 08/07/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ C B. WING _____________________________ 34150 07/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1861 COMMERCE BOULEVARD HARRISON BAY SENIOR LIVING MOUND, MN 55364 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 July 19, 2023, the Minnesota Department of Health initiated an investigation of complaints #HL341505943M/HL341501142C. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 QG1F11 If continuation sheet 1 of 1