Caring Hearts Senior Community.

findings which are in violation of the state items, failure to comply with any of the items will requirement after the statement, "This be considered lack of compliance. Minnesota requirement is not met as evidenced by." Following the surveyors' INITIAL COMMENTS: findings is the Time Period for Correction. #HL265337129C PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH STATES,"PROVIDER'S PLAN OF On April 10, 2024, the Minnesota Department of CORRECTION." THIS APPLIES TO Health conducted a complaint investigation at the FEDERAL DEFICIENCIES ONLY. THIS above provider, and the following correction WILL APPEAR ON EACH PAGE. orders are issued. At the time of the complaint investigation, there were 14 residents receiving THERE IS NO REQUIREMENT TO services under the provider's Assisted Living with SUBMIT A PLAN OF CORRECTION FOR Dementia Care license. VIOLATIONS OF MINNESOTA STATE STATUTES. The following correction orders are issued for #HL265337129C, tag identification 0250, 1060, The letter in the left column is used for 1070. tracking purposes and reflects the scope and level issued pursuant to 144G.31 subd. 1, 2, and 3. 0 250 144G.20 Subdivision 1 Conditions 0 250 SS=F (a) The commissioner may refuse to grant a provisional license, refuse to grant a license as a LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 WKIR11 If continuation sheet 1 of 16 PRINTED: 05/13/2024 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 _____________________________ 26533 04/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4451 EAST WOODMAN STREET SENIOR CLASS COMMUNITY LLC PEQUOT LAKES, MN 56472 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) 0 250 Continued From page 1 0 250 result of a change in ownership, refuse to renew a license, suspend or revoke a license, or impose a conditional license if the owner, controlling individual, or employee of an assisted living facility: (1) is in violation of, or during the term of the license has violated, any of the requirements in this chapter or adopted rules; (2) permits, aids, or abets the commission of any illegal act in the provision of assisted living services; (3) performs any act detrimental to the health, safety, and welfare of a resident; (4) obtains the license by fraud or misrepresentation; (5) knowingly makes a false statement of a material fact in the application for a license or in any other record or report required by this chapter; (6) denies representatives of the department access to any part of the facility's books, records, files, or employees; (7) interferes with or impedes a representative of the department in contacting the facility's residents; (8) interferes with or impedes ombudsman access according to section 256.9742, subdivision 4, or interferes with or impedes access by the Office of Ombudsman for Mental Health and Developmental Disabilities according to section 245.94, subdivision 1; (9) interferes with or impedes a representative of the department in the enforcement of this chapter or fails to fully cooperate with an inspection, survey, or investigation by the department; (10) destroys or makes unavailable any records or other evidence relating to the assisted living facility's compliance with this chapter; (11) refuses to initiate a background study under STATE FORM 6899 WKIR11 If continuation sheet 2 of 16 PRINTED: 05/13/2024 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 _____________________________ 26533 04/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4451 EAST WOODMAN STREET SENIOR CLASS COMMUNITY LLC PEQUOT LAKES, MN 56472 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) 0 250 Continued From page 2 0 250 section 144.057 or 245A.04; (12) fails to timely pay any fines assessed by the commissioner; (13) violates any local, city, or township ordinance relating to housing or assisted living services; (14) has repeated incidents of personnel performing services beyond their competency level; or (15) has operated beyond the scope of the assisted living facility's license category. (b) A violation by a contractor providing the assisted living services of the facility is a violation by the facility. This MN Requirement is not met as evidenced by: Based on interview and record review, the licensee failed to fully cooperate with an inspection, survey, or investigation by the department. This had the potential to affect all residents, staff, and visitors. This practice resulted in a level two violation (a violation that did not harm a resident's health or safety but had the potential to have harmed a resident's health or safety, but was not likely to cause serious injury, impairment, or death), and is issued at a widespread scope (when problems are pervasive or represent a systemic failure that has affected or has the potential to affect a large portion or all of the residents). The findings include: On April 10, 2024, at 10:30 a.m., the investigator called the facility to initate a complaint investigation. The investigator identified herself to the staff member answering the phone and advised a complaint investigation was being initiated and asked to speak with the licensed STATE FORM 6899 WKIR11 If continuation sheet 3 of 16 PRINTED: 05/13/2024 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 _____________________________ 26533 04/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4451 EAST WOODMAN STREET SENIOR CLASS COMMUNITY LLC PEQUOT LAKES, MN 56472 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) 0 250 Continued From page 3 0 250 assisted living director or clinical nurse supervisor. The staff member stated she would transfer the call to chief executive officer (CEO)-A and wrote down a call back number for the investigator in case the call got disconnected. CEO-A answered the call and the investigator provided information on what the complaint investigation was about. The investigator told CEO-A an email would be sent in a few minutes with a list of documents to be sent today that needed to be reviewed. CEO-A confirmed her email address. On April 10, 2024, at 10:37 a.m., the investigator sent CEO-A an email requesting records for R1, some policies, and general information. The email included "Please have all information sent by end of day today, April 10th, by 4:30 p.m. Please let me know if you have any questions. Thank you!" On April 10, 2024, at 4:55 p.m., the investigator emailed CEO-A again writing, "I haven't heard anything back from you or received any information so just wanted to confirm you were not submitting any information for the investigation." On April 11, 2024, at 5:49 a.m., CEO-A replied with some of the requested documentation. The investigator wrote back advising CEO-A that the documents provided were submitted after the time they were requested by. No further information was provided. TIME PERIOD FOR CORRECTION: Twenty-one (21) days STATE FORM 6899 WKIR11 If continuation sheet 4 of 16 PRINTED: 05/13/2024 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 _____________________________ 26533 04/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4451 EAST WOODMAN STREET SENIOR CLASS COMMUNITY LLC PEQUOT LAKES, MN 56472 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) 01060 Continued From page 4 01060 01060 144G.52 Subd.