All Saints 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 All Saints Senior Living December 11, 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 HHH PRINTED: 12/11/2024 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 _____________________________ 29576 11/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1880 INDEPENDENCE DRIVE ALL SAINTS SENIOR LIVING SHAKOPEE, MN 55379 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 SL29576016-0 Time Period for Correction. On November 4, 2024, through November 6, 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 90 residents; CORRECTION." THIS APPLIES TO 79 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 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 L7D411 If continuation sheet 1 of 8 PRINTED: 12/11/2024 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 _____________________________ 29576 11/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1880 INDEPENDENCE DRIVE ALL SAINTS SENIOR LIVING SHAKOPEE, MN 55379 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 November 4, 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. 0 780 144G.45 Subd. 2 (a) (1) Fire protection and 0 780 SS=E physical environment (a) Each assisted living facility must comply with the State Fire Code in Minnesota Rules, chapter STATE FORM 6899 L7D411 If continuation sheet 2 of 8 PRINTED: 12/11/2024 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.

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: The alleged perpetrator (AP) emotionally abused the resident when she yelled “damn it” after the resident fainted during a mechanical transfer and slipped in the lift. Investigative Findings and Conclusion: The Minnesota Department of Health determined abuse was not substantiated. The AP used improper language one time when the resident fainted midway through a mechanical lift transfer from the bathroom using a standing mechanical lift. The AP then made sure the resident was safe and went to get help. In addition, neglect was not substantiated. Although, the AP transferred the resident without a second staff member using a mechanical lift, it was a one-time occurrence, the resident was provided medical treatment, returned to baseline health status, and the AP received retraining. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted the resident’s family member. An equal opportunity employer. The investigation included review of resident records, in room camera footage, policies and procedures and personnel records. Also, the investigator observed staff members using the standing mechanical lift to transfer residents and observed the resident receive hospice cares. The resident resided in an assisted living facility. She lived on a unit, which housed residents needing more 1:1 cares and mechanical lift transfers. The resident’s diagnoses included Parkinson’s, diabetes, congestive heart failure, benign vertigo (dizziness) and weakness. The resident’s service plan included assistance with toileting and transfers with a standing mechanical lift with two staff. The resident’s assessment indicated she could make her needs known. One day, the AP helped the resident transfer from the toilet using the standing mechanical lift. Room camera footage showed the AP backing the lift out of the bathroom by herself. The resident stood facing the AP and grasping the two standing mechanical lift handles which were positioned overhead and slightly behind her head. A safety sling encircled the resident’s chest. About midway through the bathroom doorway, the resident went limp; her head dropped forward, and she let go of the lift handlebars but remained upright. The AP yelled hang on and the resident’s name. The AP yelled, hang on to the bar “damn it!” The AP checked the resident’s hands and said her name twice as she pushed the standing lift back into the bathroom. The AP was not on camera once she moved the lift into the bathroom, but said to the resident, “You passed out, I’m going to get help.” Progress notes indicated staff notified the nurse of the incident and the nurse assessed the resident. Several hours later, the resident complained of arm and shoulder pain and asked to go to the hospital. The nurse called 911 and the resident went to the hospital by ambulance and was admitted for treatment of a closed collar bone fracture. Review of the resident’s hospital records indicated the resident told hospital staff she “passed out” in the bathroom when she stood up but did not hit her head. Scans showed she had a mildly displaced left mid clavicle (collarbone) fracture. During an interview, the AP said she had transferred the resident many times with the standing mechanical lift and never had the resident faint. The AP said she and a second staff member were getting ready to transfer the resident off the toilet, but the resident said she needed a little more time. The second staff member left to answer a resident call light and said she would be right back. About 30 seconds later, the resident said she was done and wanted to get off the toilet right away. The AP said the resident repeated she wanted to get off the toilet even though the AP told her they needed to wait for the second staff person to return and help. The AP said she started the standing lift transfer on her own expecting the second staff person to be right back. The AP said the resident just fainted without any warning. The AP said she was shocked, scared and yelled for help. As she moved the resident back into the bathroom, the resident regained consciousness, was able to hang onto the handles and sit on the toilet while the AP went for help. The AP said she did not see the in-room camera footage of the incident and she was not aware she yelled “damn it” until the internal investigation. She told management she did not swear at the resident, it was just from fear. The AP said she was suspended a few days during the investigation then retrained on using the standing mechanical lift, which she knew always required two people. The AP said it was poor judgement on her part using the lift by herself. The second staff member who worked that shift said she did not remember much about the incident. During an interview, nursing management said an internal investigation was done. The AP was suspended pending the investigation outcome and then retrained on proper use of the standing mechanical lift. She was given a written warning for her language during the incident. Management said the resident was reassessed and switched to a full mechanical lift for transfers instead of the standing mechanical lift due to leg weakness. During an interview, the family member said they were notified of the incident. The family member said the resident fainted on the toilet once before but did not think the standing mechanical lift was involved. He said he felt there was no intentional harm of the resident by staff members and no concern about the AP swearing when the resident fainted. The family member said the AP was the resident’s favorite staff member. The resident was not available for an interview. In conclusion, the Minnesota Department of Health determined abuse and neglect were 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. 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: (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. 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 (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: Attempted, not available to interview. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Yes.