Oak Park 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 Allegations: The alleged perpetrator (AP) neglected the resident when she found the resident deceased on the floor and did not report a potential fall and possible new injuries. Additionally, the AP called 911 and cardiopulmonary resuscitation was initiated by first responders, however the resident’s advanced directives included do not resuscitate (DNR). Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was inconclusive. The AP found the resident deceased but did not clearly communicate if she witnessed the resident fall or if she found the resident on the floor. It was true CPR was initiated by first responders, however when paramedics arrived the advanced directive was clarified and CPR discontinued. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigation included review of the resident record, death record, facility internal investigation, facility fall incident reports, personnel files, staff schedules, the 911 audio call, law enforcement reports, and related facility policy and procedures. Also, the investigator observed facility activities and interviewed staff and residents in the memory care units. The resident resided in an assisted living memory care unit with a diagnosis of Alzheimer’s disease. The resident’s assessment indicated the resident was at risk for falls. Previously, she had been independent with mobility and used a walker but, after a fall with an injury and a decline in mobility, had been enrolled in hospice. The resident’s code status was DNR. The resident’s signed Physician’s Order for Life Sustaining Treatment (POLST) indicated DNR if the resident was found with no pulse and no respirations. A concern arose on the night the resident passed away when the AP, an unlicensed caregiver working the night shift, reported the resident had died to the on-call nurse and the resident’s family. However, other details were not clearly communicated such as the resident was found on the floor, passed away with potentially new injuries, 911 had been called, and CPR initiated but then discontinued when the POLST was reviewed. A 911 audio call indicated the AP called 911 and told dispatch that the resident was on the floor, and she did not think the resident was breathing. The dispatcher asked the AP “are we going to do CPR?” and the AP responded, “I think so, yes.” The dispatcher instructed the AP to roll the resident on her back and then walked the AP through the steps of CPR over the phone. The facility’s internal investigation included a written statement given by another unlicensed caregiver who was working the same night shift with the AP but on a different unit. This document indicated the AP came to his unit to ask for help because the AP had been reaching out to the “float” unlicensed caregiver [who rotated between the memory care and the regular assisted living unit] but was getting no response. The AP told the caregiver she had called 911. The caregiver went with the AP back to the memory care unit where the resident was lying on the floor. Police reports indicated first responders utilized an Automated External Defibrillator (AED) and started CPR because the AP stated there was not an active DNR order in place. When the ambulance crew arrived, POLST was found and reviewed so CPR was discontinued. During an interview, the float unlicensed caregiver stated the AP asked for her help. When the float went down to the memory care unit, the AP had already called 911. The float stated it was clear the resident was on hospice. During an interview, the on-call nurse stated she received multiple phone calls from the facility regarding the resident’s death. The first call was from the float unlicensed caregiver, who told her the resident had passed away and, without any further details, the nurse did not realize the other details. Later, the AP called her saying she could not reach the family. The AP called again asking where to find hospice contact information. The on-call nurse stated they did not discuss any further details such as the resident was on the floor, injuries, nor CPR. Not knowing any of this, the nurse sent a group text to the memory care phones indicating the resident was presentable in case family came to view her before the resident was taken from the facility. The nurse stated she did not hear anything more until morning when she saw that a family member had texted hours earlier that she wanted to be called right away. During interview, a nurse manager stated all residents have a book in their apartment that contains the medication record along with POLST information. The resident’s book in place however the AP apparently did not utilize it initially. The nurse stated unlicensed caregiver receive training on who to call when a fall or death occurs. While the AP did not follow these steps, she did seek help from other caregivers. During interviews, family member(s) stated they received news of the resident’s death, went to the facility and were met by a police officer at the resident’s door. The resident was still lying on the floor, partially clothed, and had to be covered up by family. The AP could not explain what happened when questioned and left the unit and could not be reached again. The family waited for four hours to hear from the facility to return their calls. The family stated they had questions about the apparent injuries the resident had and how she came to be on the floor. The on-call hospice nurse did make a visit in the aftermath of the resident’s death. The death records indicated the manner of death was natural and the cause of death was related to late onset Alzheimer’s Disease. 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. (4) an individual makes an error in the provision of therapeutic conduct to a vulnerable adult which does not result in injury or harm which reasonably requires medical or mental health care; or (5) an individual makes an error in the provision of therapeutic conduct to a vulnerable adult that results in injury or harm, which reasonably requires the care of a physician, and: (i) the necessary care is provided in a timely fashion as dictated by the condition of the vulnerable adult; (ii) if after receiving care, the health status of the vulnerable adult can be reasonably expected, as determined by the attending physician, to be restored to the vulnerable adult's preexisting condition; (iii) the error is not part of a pattern of errors by the individual; (iv) if in a facility, the error is immediately reported as required under section 626.557, and recorded internally in the facility; (v) if in a facility, the facility identifies and takes corrective action and implements measures designed to reduce the risk of further occurrence of this error and similar errors; and (vi) if in a facility, the actions required under items (iv) and (v) are sufficiently documented for review and evaluation by the facility and any applicable licensing, certification, and ombudsman agency. Vulnerable Adult interviewed: No, the resident was deceased. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: No, the AP declined an interview with the investigator. Action taken by facility: The facility reviewed the procedures for resident falls, deaths, and hospice with all caregivers, which was completed on each unit and with one-to-ones. The facility added communication to identify which residents were on hospice.

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: The alleged perpetrator (AP) abused the resident when she scratched and left marks on the resident’s hands after she tried to reset the resident’s call pendant away from him prior to completing cares. The AP also shook her fist at the resident. Investigative Findings and Conclusion: The Minnesota Department of Health determined whether abuse occurred was inconclusive. The resident did have visible marks on her skin which likely occurred when the AP and the resident hands grappled over the AP’s name tag and the call pendant. However, the investigation did not identify evidence to show this incident met the definition of abuse or a potential error in therapeutic conduct on behalf of the AP. The accounts of the two people present, while generally the same, included inconsistencies which led to a determination of inconclusive. The investigator conducted interviews with facility staff members, including nursing staff and unlicensed staff. The investigation included a 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 resident and staff interactions and general activities during a recent visit to the facility. The resident resided in an assisted living memory care unit. The resident’s diagnoses included traumatic brain injury-induced dementia and heart failure. The resident’s service plan included assistance with medications, and all activities of daily living; bathing, personal hygiene, catheter care, laundry, meals, housekeeping, behavior interventions and every two-hour safety checks. The resident’s assessment indicated he used a walker for mobility and had moderate memory impairment with behaviors associated to his dementia diagnosis. Review of a concern indicated that the AP tried to take the call pendant out of the resident’s hands by pulling it, which caused scratches and bruising to the resident’s hands and the metal clamp on the pendant to bend. The concern also indicated the AP shook her fist back at the resident and stated “do you see my fist” after he shook his fist at her. Review of photos taken the day of the incident show scratches and broken skin on both the residents hands as well as a bent metal clamp on the call pendant. Review of the AP’s written statement indicated that night she gave the resident his medications and then tried to change his urinary bag when the resident became verbally aggressive, started name calling and grabbed the AP’s name tag when she tried turning off the pendant. Review of the pendant call activity log indicated the resident pressed the call pendant at 19:51 and it was cleared by the AP at 20:07, after a total of 16 minutes and 32 seconds. During interview with the investigator, the AP stated she attempted to change the resident’s urinary bag, when he became upset and grabbed her name tag. She said while the resident had held her name tag, she held his hand in an effort to stop the badge reel on the name tag from coming loose and hitting her or the resident. The AP stated that she wanted to turn the call pendant off because the nurse would call assuming the call pendant had been going off for so long. The AP admitted she tried to reset the pendant while the resident had it in his hand. She stated that when she bent down to turn it off, the resident went into defense mode and thought she was trying to take his call pendant and that is when it escalated. She stated she grabbed his arms at the wrist and told the resident to let go of her name tag. During an interview, another caregiver stated she did not witness the incident but did hear commotion from the resident’s room when she passed by the room at one point. The AP told the caregiver that the resident grabbed her name tag and would not let go and that she had to grab the resident’s hands to get him off of her. After the incident the caregiver stated she looked at the resident’s hands and noted they were bleeding, so she advised the AP to call the nurse and report what had occurred. During an interview, a nurse manager stated that staff are expected to answer resident calls within five minutes, and an alert will go out to management if a pendant call has not been answered after 15 minutes. If there is a case where the pendant cannot be reset in person, staff are to call, and management can reset it remotely. The nurse stated that this resident requests staff to complete cares before they reset his pendant, so the thought was that the AP tried to reset the pendant first, and a struggle ensued. The AP told the nurse it was the name tag the resident grabbed, and she tried to get him to let go. The resident stated the struggle was over the pendant that she tried to take and reset. The nurse stated whether it was the pendant or name tag, the AP used poor judgement and should have stopped and called the nurse with the issue. During interview, a family member stated that it was concerning that there is pressure put on staff to reset the call pendant within so many minutes. The family member said clearing the pendant with a dementia resident should not end in a physical altercation. He believed the pendant’s metal clasp (which was bent and damaged) likely cut the skin on the resident’s hands during the struggle. In conclusion, the Minnesota Department of Health determined abuse 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. Abuse: Minnesota Statutes section 626.5572, subdivision 2. "Abuse" means: (a) An act against a vulnerable adult that constitutes a violation of, an attempt to violate, or aiding and abetting a violation of: (1) assault in the first through fifth degrees as defined in sections 609.221 to 609.224; (2) the use of drugs to injure or facilitate crime as defined in section 609.235; (3) the solicitation, inducement, and promotion of prostitution as defined in section 609.322; and (4) criminal sexual conduct in the first through fifth degrees as defined in sections 609.342 to 609.3451. A violation includes any action that meets the elements of the crime, regardless of whether there is a criminal proceeding or conviction. (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; or (3) use of any aversive or deprivation procedure, unreasonable confinement, or involuntary seclusion, including the forced separation of the vulnerable adult from other persons against the will of the vulnerable adult or the legal representative of the vulnerable adult unless authorized under applicable licensing requirements or Minnesota Rules, chapter 9544. Vulnerable Adult interviewed: Yes. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Yes. Action taken by facility: The AP was removed from the schedule during an internal investigation. The AP no longer works at the facility. A review of vulnerable adult training and expectations was reviewed with all staff after the incident. Action taken by the Minnesota Department of Health: No action at this time. cc: The Office of Ombudsman for Long Term Care The Office of Ombudsman for Mental Health and Developmental Disabilities PRINTED: 02/ 24/ 2026 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 Oak Park Senior Living July 18, 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, Renee Anderson, Supervisor State Evaluation Team Email: Renee.L.Anderson@state.mn.us Telephone: 651-201-5871 Fax: 1 -866-890-9290 JMD PRINTED: 07/18/2025 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 _____________________________ 28227 05/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 13936 LOWER 59TH STREET NORTH OAK PARK SENIOR LIVING OAK PARK HEIGHTS, MN 55082 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 In accordance with Minnesota Statutes, section Minnesota Department of Health is 144G.08 to 144G.95, these correction orders are documenting the State Licensing issued pursuant to a survey. Correction Orders using federal software. Tag numbers have been assigned to Determination of whether violations are corrected Minnesota State Statutes for Assisted requires compliance with all requirements Living License Providers. The assigned provided at the Statute number indicated below. tag number appears in the far left column When Minnesota Statute contains several items, entitled "ID Prefix Tag." The state Statute failure to comply with any of the items will be number and the corresponding text of the considered lack of compliance. state Statute out of compliance is listed in the "Summary Statement of Deficiencies" INITIAL COMMENTS: column. This column also includes the SL #28227016-0 findings which are in violation of the state requirement after the statement, "This On May 12, 2025, through May 15, 2025, the Minnesota requirement is not met as survey at the above provider, and the following findings is the Time Period for Correction. correction orders are issued. At the time of the survey, there were 134 residents, 96 of whom PLEASE DISREGARD THE HEADING OF were receiving services under the provider's THE FOURTH COLUMN WHICH Assisted Living Facility with Dementia Care STATES,"PROVIDER'S PLAN OF license. CORRECTION." THIS APPLIES TO FEDERAL DEFICIENCIES ONLY. THIS 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 pursuant to 144G.31 Subd. 1, 2 and 3. 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 LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 X4CE11 If continuation sheet 1 of 12 PRINTED: 07/18/2025 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 _____________________________ 28227 05/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 13936 LOWER 59TH STREET NORTH OAK PARK SENIOR LIVING OAK PARK HEIGHTS, MN 55082 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 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 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 STATE FORM 6899 X4CE11 If continuation sheet 2 of 12 PRINTED: 07/18/2025 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 _____________________________ 28227 05/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 13936 LOWER 59TH STREET NORTH OAK PARK SENIOR LIVING OAK PARK HEIGHTS, MN 55082 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 2 0 480 4626.

CORRECTION ORDERS The enclosed State Form documents the state correction orders. The 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 and enforcement actions 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 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. An equal opportunity employer. Letter ID: IS7N REVISED 09/13/2021 Oak Park Senior Living August 10, 2023 Page 2 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 the MDH within 15 calendar days of the correction order receipt date. A state correction order under Minn. Stat. § 144G.91, Subd. 8, Free from Maltreatment is associated with a maltreatment determination by the Office of Health Facility Complaints. If maltreatment is substantiated, you will receive a separate letter with the reconsideration process under Minn. Stat. § 626.557. Please email reconsideration requests to: Health.HRD.Appeals@state.mn.us. Please attach this letter as part of your reconsideration request. Please clearly indicate which tag(s) you are contesting and submit information supporting your position(s). Please address your cover letter for reconsideration requests to: Reconsideration Unit 85 East Seventh Place St. Paul, MN 55164-0970 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, Jonathan Hill, Supervisor State Evaluation Team Email: jonathan.hill@state.mn.us Telephone: 651-201-3993 Fax: 6 51-281-9796 JMD PRINTED: 08/10/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 28227 08/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 13936 LOWER 59TH STREET NORTH OAK PARK SENIOR LIVING OAK PARK HEIGHTS, MN 55082 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 Licensing ASSISTED LIVING PROVIDER LICENSING Correction Orders using federal software. CORRECTION ORDER(S) Tag numbers have been assigned to Minnesota State Statutes for Assisted In accordance with Minnesota Statutes, section Living with Dementia Care license 144G.08 to 144G.95, these correction orders are providers. The assigned tag number issued pursuant to a survey. appears in the far left column entitled "ID Prefix Tag." The state Statute number and Determination of whether violations are corrected the corresponding text of the state Statute requires compliance with all requirements out of compliance is listed in the provided at the Statute number indicated below. "Summary Statement of Deficiencies" When Minnesota Statute contains several items, column. This column also includes the failure to comply with any of the items will be findings which are in violation of the state considered lack of compliance. requirement after the statement, "This Minnesota requirement is not met as INITIAL COMMENTS: evidenced by." Following the surveyors' SL28227015-0 findings is the Time Period for Correction. On July 31, 2023, through August 4, 2023, the PLEASE DISREGARD THE HEADING OF survey at the above provider, and the following STATES,"PROVIDER'S PLAN OF correction orders are issued. At the time of the CORRECTION." THIS APPLIES TO survey there were 79 residents, all of whom FEDERAL DEFICIENCIES ONLY. THIS received services under the provider's Assisted WILL APPEAR ON EACH PAGE. Living with Dementia Care facility 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 pursuant to 144G.31 Subd. 1, 2 and 3. 0 480 144G.41 Subd 1 (13) (i) (B) Minimum 0 480 SS=F requirements (13) offer to provide or make available at least the following services to residents: LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 ENEO11 If continuation sheet 1 of 7 PRINTED: 08/10/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 28227 08/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 13936 LOWER 59TH STREET NORTH OAK PARK SENIOR LIVING OAK PARK HEIGHTS, MN 55082 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 (B) food must be prepared and served according to the Minnesota Food Code, Minnesota Rules, chapter 4626; and This MN Requirement is not met as evidenced by: Based on observation, interview and record review, the licensee failed to ensure food was prepared and served according to the Minnesota Food Code. 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 the residents). The findings include: Please refer to the included document titled, Food and Beverage Establishment Inspection Report dated August 2, 2023, for the specific Minnesota Food Code deficiencies. TIME PERIOD FOR CORRECTION: Twenty-one (21) days 0 510 144G.41 Subd. 3 Infection control program 0 510 SS=D (a) All assisted living facilities must establish and maintain an infection control program that complies with accepted health care, medical, and nursing standards for infection control. (b)The facility's infection control program must be consistent with current guidelines from the national Centers for Disease Control and STATE FORM 6899 ENEO11 If continuation sheet 2 of 7 PRINTED: 08/10/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 28227 08/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 13936 LOWER 59TH STREET NORTH OAK PARK SENIOR LIVING OAK PARK HEIGHTS, MN 55082 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) 0 510 Continued From page 2 0 510 Prevention (CDC) for infection prevention and control in long-term care facilities and, as applicable, for infection prevention and control in assisted living facilities. (c) The facility must maintain written evidence of compliance with this subdivision. This MN Requirement is not met as evidenced by: Based on observation, interview, and record review, the licensee failed to establish and maintain an effective infection control program to comply with accepted health care, medical, and nursing standards for infection control.