Deer Crest 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 . . ." 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: An equal opportunity employer. Letter ID: IS7N REVISED 09/13/2021 Deer Crest Senior Living January 27, 2025 Page 2 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 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, Jodi Johnson, Supervisor State Evaluation Team Email: jodi.johnson@state.mn.us Telephone: 507-344-2730 Fax: 1 -866-890-9290 JMD PRINTED: 01/27/2025 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 _____________________________ 30636 12/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 470 HEWITT BOULEVARD DEER CREST SENIOR LIVING RED WING, MN 55066 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 SL30636016-0 Time Period for Correction. On December 9, 2024, through December 11, PLEASE DISREGARD THE HEADING OF 2024, the Minnesota Department of Health THE FOURTH COLUMN WHICH conducted a full survey at the above provider. At STATES,"PROVIDER'S PLAN OF the time of the survey, there were 77 residents; CORRECTION." THIS APPLIES TO 58 receiving services under the Assisted Living FEDERAL DEFICIENCIES ONLY. THIS Facility with 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 FVKV11 If continuation sheet 1 of 19 PRINTED: 01/27/2025 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 _____________________________ 30636 12/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 470 HEWITT BOULEVARD DEER CREST SENIOR LIVING RED WING, MN 55066 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 4626.0033, 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 STATE FORM 6899 FVKV11 If continuation sheet 2 of 19 PRINTED: 01/27/2025 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 _____________________________ 30636 12/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 470 HEWITT BOULEVARD DEER CREST SENIOR LIVING RED WING, MN 55066 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 allowed provided the facility keeps them clean and in good condition; (6) 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, an unlicensed caregiver, financially exploited the resident when opioid medications were missing from the resident’s supply. Investigative Findings and Conclusion: The Minnesota Department of Health determined financial exploitation was inconclusive. The investigation indicated tape was present on the narcotic medication card and a different medication was taped in spaces on the narcotic card, however, it was inconclusive that the alleged perpetrator was the specific person who diverted the narcotic medication. The length of time the tape was reportedly on the back of the narcotic card increased the number of individuals who may have switched out the narcotics. 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), facility internal investigation, facility incident reports, personnel files, staff schedules, law enforcement report, and related facility policy and procedures. Also, the investigator observed staff to resident interactions and narcotic count in facility. The resident resided in an assisted living memory care unit. The resident’s diagnoses included Alzheimer’s disease and a fractured left radius (bone in wrist area). The resident’s assessment indicated the resident had both short- and long-term memory impairment and required the assistance of one unlicensed caregiver for transfers from bed to wheelchair. The resident’s service plan included assistance with transfers, assistance with placing to a brace and sling to her left arm, and medication administration. The resident was experiencing pain in her left arm after a fall with fracture; the pain was managed with narcotic medications administered by unlicensed caregivers. The facility internal investigation indicated a concern was reported to facility nurse #1 regarding tape which was found on the back of the resident’s narcotic medication card. Nurse #1 later discovered the medications taped in the narcotic card spaces were not the prescribed narcotic medication but had been switched out for a different medication raising the concern someone had taken the resident’s narcotics. Upon reviewing the security video, the managers found that the alleged perpetrator had suspicious behavior viewed on the video. However, the only video footage was dated on the day the staff member(s) reported the tape on the narcotic card to the facility nurses. The internal investigation included notes from interviews. Those interview notes indicated staff members accounts said the tape had been present for up to 4 days on the narcotic medication card before it was brought to the attention of managers and nursing staff. During investigative interviews, multiple unlicensed caregivers reported they noticed tape on the narcotic medication card several days before it was reported to the nursing staff but did not report the incident because the narcotic count was correct. During an interview, the alleged perpetrator stated she reported the tape on the narcotic medication card to a nurse [a nurse other than nurse #1] who verified the narcotic count was correct. The alleged perpetrator stated she did view the security video footage dated the same day the incident was reported to the facility nurses. She stated she did place tape on the medication card to reinforce the tape that was already present. She also stated she did not take the narcotic medication. In conclusion, the Minnesota Department of Health determined financial exploitation 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. Financial exploitation: Minnesota Statutes, section 626.5572, subdivision 9 (a) In breach of a fiduciary obligation recognized elsewhere in law, including pertinent regulations, contractual obligations, documented consent by a competent person, or the obligations of a responsible party under section 144.6501, a person: (1) engages in unauthorized expenditure of funds entrusted to the actor by the vulnerable adult which results or is likely to result in detriment to the vulnerable adult; or (2) fails to use the financial resources of the vulnerable adult to provide food, clothing, shelter, health care, therapeutic conduct or supervision for the vulnerable adult, and the failure results or is likely to result in detriment to the vulnerable adult. (b) In the absence of legal authority, a person: (1) willfully uses, withholds, or disposes of funds or property of a vulnerable adult; (2) obtains for the actor or another the performance of services by a third person for the wrongful profit or advantage of the actor or another to the detriment of the vulnerable adult; (3) acquires possession or control of, or an interest in, funds or property of a vulnerable adult through the use of undue influence, harassment, duress, deception, or fraud; or (4) forces, compels, coerces, or entices a vulnerable adult against the vulnerable adult's will to perform services for the profit or advantage of another. Vulnerable Adult interviewed: No, cognitively impaired Family/Responsible Party interviewed: Yes Alleged Perpetrator interviewed: Yes Action taken by facility: The facility completed an internal investigation and alleged perpetrator is no longer employed at facility. The facility reviewed its procedure for medication storage and provided education for unlicensed caregivers to report irregularities such as this right away. 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: 11/13/2024 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 _____________________________ 30636 10/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 470 HEWITT BOULEVARD DEER CREST SENIOR LIVING RED WING, MN 55066 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 October 15, 2024, the Minnesota Department of Health initiated an investigation of complaint #HL306367544C/#HL306365426M. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 ACD711 If continuation sheet 1 of 1

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 the AP yelled at the resident and slapped the resident on the face during toileting care. Investigative Findings and Conclusion: The Minnesota Department of Health determined abuse was inconclusive. The AP denied that she slapped the resident. Although the argument were overheard, no one witnessed the AP slap the resident. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted law enforcement for the police report. The investigation included a review of policies and procedures, employee personnel files and training records. Several resident medical records were reviewed, including the resident’s record. An equal opportunity employer. The resident resided in an assisted living memory care unit. The resident’s diagnoses included dementia and history of traumatic brain injury. The resident’s service plan indicated the resident was wheelchair bound and required assistance with personal cares and toileting assistance. The resident’s assessment indicated she was oriented to person, place and time with intermittent confusion. Review of the incident investigation summary indicated the AP (an unlicensed staff person) was assisting the resident in the bathroom. Another staff member arrived on the unit, saw the resident’s call light was on and heard yelling coming from the resident’s bathroom. The staff member entered the resident’s room, told the AP to leave and finished providing the resident’s cares. At that time, the resident told the staff member the AP had slapped her on her right cheek. Later, the staff member informed facility administrators of the incident and the head nurse made a visit to the facility to interview the resident and staff. The nurse woke the resident who was already asleep in her bed on her right side and noted the resident’s cheek was reddened. The head nurse also interviewed the AP, who stated the resident continued to press the call button even after the AP was in the resident’s bathroom. The AP also stated the resident had grabbed her clothing during the incident. The AP denied she slapped the resident. Later in the evening, the resident requested assistance and the AP provided assistance again, this time without incident. The resident’s cheek was not reddened or had any injuries the following day. Review of the police report indicated police interviewed all involved in the incident. No charges were filed. During an interview with the investigator, the staff member stated she overheard an argument between the resident and the AP but did not witness the AP slap the resident. The resident was interviewed and stated the AP slapped her on the cheek. The resident recalled the events in the same manner as the night the head nurse interviewed her. During interview with the investigator, the AP stated the resident wanted to go to bed right after supper. The AP stated she was the only staff member in the unit and had to complete supper duties first so she told the resident she would help her as soon as she was able. When she assisted the resident, the resident got aggressive and grabbed the AP’s clothing. The AP called for additional help. The AP stated she did not hit the resident. A family member was also interviewed and stated the resident told them about the incident after it happened. 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. Vulnerable Adult interviewed: Yes. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Yes. Action taken by facility: The facility investigated the incident and provided additional training on reporting abuse. The AP was no longer employed by the facility. 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: 07/07/2023 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 _____________________________ 30636 06/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 470 HEWITT BOULEVARD DEER CREST SENIOR LIVING RED WING, MN 55066 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 June 7, 2023, the Minnesota Department of Health initiated an investigation of complaint #HL306365156C/#HL306363105M. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 6BYO11 If continuation sheet 1 of 1