The Waters On Mayowood.

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 The Waters On Mayowood December 5, 2024 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: 12/05/2024 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 31474 10/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 827 MAYOWOOD ROAD SW THE WATERS ON MAYOWOOD ROCHESTER, MN 55902 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 SL31474016-0 Time Period for Correction. On October 21, 2024, through October 24, 2024, PLEASE DISREGARD THE HEADING OF the Minnesota Department of Health conducted a THE FOURTH COLUMN WHICH full survey at the above provider. At the time of STATES,"PROVIDER'S PLAN OF the survey, there were 202 residents; 89 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 Subd 1 (13) (i) (B) Minimum 0 480 SS=F requirements LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 M2WA11 If continuation sheet 1 of 15 PRINTED: 12/05/2024 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 31474 10/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 827 MAYOWOOD ROAD SW THE WATERS ON MAYOWOOD ROCHESTER, MN 55902 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 (13) offer to provide or make available at least the following services to residents: (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 document titled, Food and Beverage Establishment Inspection Report (FBEIR) dated October 22, 2024, for the specific Minnesota Food Code violations. The Inspection Report was provided to the licensee within 24 hours of the inspection. TIME PERIOD FOR CORRECTION: Please refer to the FBEIR for any compliance dates. 0 970 144G.50 Subd. 5 Waivers of liability prohibited 0 970 SS=C The contract must not include a waiver of facility liability for the health and safety or personal property of a resident. The contract must not STATE FORM 6899 M2WA11 If continuation sheet 2 of 15 PRINTED: 12/05/2024 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 31474 10/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 827 MAYOWOOD ROAD SW THE WATERS ON MAYOWOOD ROCHESTER, MN 55902 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) 0 970 Continued From page 2 0 970 include any provision that the facility knows or should know to be deceptive, unlawful, or unenforceable under state or federal law, nor include any provision that requires or implies a lesser standard of care or responsibility than is required by law.

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 the facility did not respond to the resident's call light leading to the resident to call 911 for his own hospitalization. Additionally, the facility neglected the resident when the facility did not provide catheter cares and/or medication administration. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. Although the resident did call 911 on his own, the facility was following the resident’s plan of care and facility policy and procedures were being followed. 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, hospital records, pharmacy records, facility internal investigation, facility incident reports, staff schedules, and related facility policy and procedures. Also, the investigator toured the facility and observed interactions between staff and residents. The resident resided in an assisted living memory care unit. The resident’s diagnoses included Alzheimer’s dementia, benign prostatic hyperplasia (BPH) (enlargement of the prostate gland) and hypertension. The resident’s assessment indicated the resident needed the assistance of two facility staff members and a walker to ambulate, had short term memory impairment and occasionally needed redirection. The resident’s service plan included assistance with medication management, safety checks, and catheter care. One morning the resident was admitted to the hospital for a urinary tract infection and deep vein thrombosis (DVT). During the hospitalization, a concern arose that the resident had to call 911 himself because the facility did not answer his call light. Additionally, the resident’s blood pressure were found to be high, which raised the concern that the facility was not providing all his medications. The resident had a catheter, and a concern arose it had not been changed in a timely manner. Facility-provided call light logs for the morning the resident called 911 indicated the resident pressed the call for assistance two times. The call light log showed the first time the call light was pressed the facility staff answered the alert in two minutes, the second time the call light was activated, the alert was responded to in ten minutes. The resident’s Electronic Medication Administration Record (EMAR) indicated the resident’s medication for hypertension was given as ordered by the provider. A review of the resident’s EMAR indicated no doses for the ordered blood pressure medication were missed. The Palliative Care Homebound Program consult visit completed by the resident’s medical provider after his admission to the facility indicated a urology consult would be arranged by the medical provider for urology testing and monthly catheter changes. The Uniform Disclosure of Assisted Living Services and Amenities (UDALSA) indicated the facility was unable to change or manage a Foley catheter, however unlicensed caregivers could empty and change catheter bags. The resident’s medical record indicated the medical provider was notified of resident complaints regarding the catheter on three instances during the month the resident resided in the facility. During an interview, the nurse stated the resident’s provider managed the catheter as the facility would only empty and change the catheter bags. During an interview, the family member stated the facility did disclose on admission they could only empty and change catheter bags. However, she stated she was told the resident’s provider would come to the facility and change the catheter, but she was not sure if that happened. The family member reported the resident had pressed his pendent at midnight the day the resident went to the hospital and no facility staff responded. A review of the facility call log did not reveal an alarm was made for assistance from the resident at midnight, the pendent was activated two hours prior to midnight two times and the alarm was answered by facility staff within one minute each time. 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, unable due to cognitive impairment. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Not Applicable. Action taken by facility: Resident hospitalized and discharged to a needed higher level of care. 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: 05/ 29/ 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 _____________________________ 31474 05/ 01/ 2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 827 MAYOWOOD ROAD SW THE WATERS ON MAYOWOOD ROCHESTER, MN 55902 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 May 1, 2024, the Minnesota Department of Health initiated an investigation of complaint #HL314747882C/ #HL314749805M. No correction orders are issued. LABORATORY DIRECTOR' S OR PROVIDER/ SUPPLIER REPRESENTATIVE' S SIGNATURE TITLE (X6) DATE STATE FORM 6899 6PKV11 If continuation sheet 1 of 1

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 unlicensed personnel discovered resident deceased in his apartment. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. The facility documented the resident had a recent decline in health and the resident was scheduled to be admitted to hospice that day. 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’s facility record, and recent hospital stay medical provider notes. Also, the investigator toured the facility and observed staff to resident interactions. An equal opportunity employer. The resident resided in an assisted living specialty care secured unit. The resident’s diagnoses included heart failure, chronic kidney disease, and myocardial infarction (heart attack). The resident’s service plan included assistance with bathing, grooming, dressing, bed transfers, and oxygen management. The resident’s change in condition assessment completed less than two weeks prior to death indicated the resident was orientated to person, place, and time, and could use his call pendent. This same assessment indicated he did not require safety checks/comfort checks. The resident’s progress notes indicated the resident had been requiring more assistance and was scheduled to meet with hospice the day he passed away. The same documents indicated the resident was recently hospitalized and started on oxygen via nasal cannula related to changes in breathing. The facility updated the resident’s medical provider frequently. During investigative interviews, multiple unlicensed staff members stated resident was able to communicate his needs. The staff members stated the resident had a decline in health but was still able to use his call light and ask for assistance and make his needs known. When unlicensed caregivers entered his room that morning to provide cares, the resident was lying in bed with his call pendant where he always kept it, with bed covers over him, oxygen still in place, but he was unresponsive. The unlicensed caregivers notified the facility nurse to provide an update appropriately. During an interview, the facility nurse stated the resident was generally independent and active during his daily routine. During the last month prior to his death, he required more assistance related to cardiac (heart) issues. The resident was listed as a do not resuscitate and do not intubate. During an interview, a family member stated the resident’s heart was only working at 20% and was scheduled to be admitted to hospice that day. The family member stated there had been three recent hospital stays and the resident decided he did not want to return to the hospital and chose to enroll in hospice. 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: deceased Family/Responsible Party interviewed: Yes Alleged Perpetrator interviewed: Not Applicable Action taken by facility: No action required. Action taken by the Minnesota Department of Health: No further action required. cc: The Office of Ombudsman for Long Term Care The Office of Ombudsman for Mental Health and Developmental Disabilities PRINTED: 12/21/2023 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 _____________________________ 31474 11/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 827 MAYOWOOD ROAD SW THE WATERS ON MAYOWOOD ROCHESTER, MN 55902 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 November 13, 2023, through November 14, 2023,, the Minnesota Department of Health initiated an investigation of complaint #HL314746602C/#HL314748971M. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 9XYY11 If continuation sheet 1 of 1