Bel Rae 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 Bel Rae Senior Living June 12, 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. Bel Rae Senior Living June 12, 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, Casey DeVries, Supervisor State Evaluation Team Email: casey.devries@state.mn.us Telephone: 651-201-5917 Fax: 1 -866-890-9290 JMD PRINTED: 06/12/2025 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 _____________________________ 31586 04/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2330 MOUNDS VIEW BOULEVARD BEL RAE SENIOR LIVING MOUNDS VIEW, MN 55112 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 SL31586016-0 Time Period for Correction. On April 28, 2025, through April 30, 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 82 residents; 60 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 6TOS11 If continuation sheet 1 of 19 PRINTED: 06/12/2025 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 _____________________________ 31586 04/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2330 MOUNDS VIEW BOULEVARD BEL RAE SENIOR LIVING MOUNDS VIEW, MN 55112 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: 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) abused the resident when he wheeled the resident along a hallway too fast and crashed her into a wall. The resident was upset and cried but was not physically harmed. Investigative Findings and Conclusion: The Minnesota Department of Health determined abuse was inconclusive. There was unclear and conflicting evidence to what occurred when the AP transported the resident. The staff member working with the AP provided a written statement but failed to interview with the investigator. The written statement failed to identify if the staff member witnessed the incident or only heard interactions and received report from another resident. Management staff indicated the AP’s actions were inappropriate even if the resident was unharmed. The AP denied the allegations. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted the AP and the resident’s family member. The investigation included review of the resident record, facility internal investigation, facility incident reports, personnel files, staff schedules and related facility policy and procedures. Also, the investigator observed staff and family transport the resident in her wheelchair. There was no video of the incident. The resident resided in an assisted living memory care unit. The resident’s diagnoses included dementia, depression, generalized anxiety disorder. The resident’s service plan indicated she used a wheelchair and required assist of one staff for transfers with a gait belt if she used her wheeled walker. The resident required toileting assistance. She could make her needs known. The AP’s personnel file included an incident summary and staff statements. A written statement by a staff member who observed the incident, indicated the resident was sitting at the table and asked to use the bathroom. The AP took the resident, seated in her wheelchair, tipped the wheelchair back and was doing a “wheelie.” The resident was screaming and crying scared. When the resident got to her room she was crying and screaming “my arms please your [sic] hurting me.” “STOP” “please stop!” The AP then brought the resident back to the table. The resident was upset, crying at the table. The resident later asked again to use the bathroom. The AP took the resident and purposely ran her wheelchair into a wall. The resident started screaming “your [sic] hurting me please stop.” Another memory care resident called to the staff member for help. The staff member went to the resident’s room and the resident was “drenched” with bowel movement and urine running down her legs. The resident was “double padded” with two incontinent pads filled with urine. The staff member reported the incident to nursing. It was unclear by the written statement what the staff member witnessed versus what she heard and had reported to her by the other resident. The incident summary indicated a nurse and the director of nursing (DON) went looking for the AP after receiving the report, but the AP had left the building while on break and did not answer his phone. The nurses assessed the resident and attempted to interview her, but she was to too upset to talk and crying. The nurses interviewed the other resident who witnessed the incident. The other resident stated “he ran her into the wall on purpose” and she kept crying for help and to stop, but he would not. The AP left before the end of his shift without management permission. The DON called the AP, asked him to return to the facility to discuss the incident and the AP refused. The DON informed the AP he was suspended pending an investigation. Management contacted the AP for a written statement. The AP refused to interview nor provided a written statement. The AP sent management a text message denying the false accusation of harming the resident, but it did not include a description of the incident. A few days later the AP resigned from his position without providing a statement on the incident. The resident provided a brief statement to the nurse indicating she screamed and the AP told her to stop screaming. However, the resident was unable to state what happened. During an onsite visit, management staff was unclear where in the hallway the incident took place. The investigator did not observe any damage or repair evidence to the wall. During an interview, a manager said the resident could be dramatic. The AP told her on a phone call that he was having fun with the resident. He had no previous complaints about transporting residents. During an interview, the DON said the AP’s action was not ok even if the resident was not hurt. She said the resident could not articulate what happened very well. During an interview, the AP said he worked at the facility several months. He worked all over the building and often did double shifts. That day, around one o’clock he took the resident to the bathroom, then went on his break and left the building. The AP said he did not recall running her into a wall while taking her to the bathroom. About an hour after his shift ended, the AP said he got a call from a nurse at the facility, who said the resident complained to a family member about her cares, that a staff person “beat on her.” They asked him to come in the next day to give a statement and he agreed. The AP said he had no idea what was going on and would never run a resident into a wall or beat them. The AP said the resident was a nice person, but she yelled for help all the time when staff transported her in her wheelchair. Everyone knew that. The AP said if he bumped the resident during cares he apologized. He said it was shocking when he heard the abuse complaint. He went to the facility the next day to give a statement and sign paperwork, but no one met with him, so he returned his key fob and left. He said he could not work there any longer. During an interview, the resident’s family member said the nurse told her about the incident. The family member said she was happy with the cares at the facility and had no concerns. The resident never mentioned the incident and the family member did not think abuse occurred. Records reviewed indicated the AP completed and passed computer trainings on dementia, person-centered cares, fraud and abuse. In conclusion, the Minnesota Department of Health determined abuse 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: (b) Conduct which is not an accident or therapeutic conduct as defined in this section, which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to, the following: (1) hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult; (2) use of repeated or malicious oral, written, or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening; Vulnerable Adult interviewed: No, due to cognition. Statement collected by nurse after incident. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Yes. the Action taken by facility: The facility conducted an internal investigation and assessed the resident. The AP no longer works at the facility. 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: 08/02/2024 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.