Lake Minnetonka Shores.

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 Lake Minnetonka Shores August 7, 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, Jess Schoenecker, Supervisor State Evaluation Team Email: Jess.Schoenecker@state.mn.us Telephone: 651-201-3789 Fax: 1-866-890-9290 AH PRINTED: 08/07/2025 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 _____________________________ 20219 06/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4559 SHORELINE DRIVE LAKE MINNETONKA SHORES SPRING PARK, MN 55384 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 Correction Orders ASSISTED LIVING PROVIDER LICENSING using federal software. Tag numbers have CORRECTION ORDER(S) been assigned to Minnesota State Statutes for Assisted Living Facilities. The In accordance with Minnesota Statutes, section assigned tag number appears in the 144G.08 to 144G.95, these correction orders are far-left column entitled "ID Prefix Tag." The issued pursuant to a survey. state Statute number and the corresponding text of the state Statute out Determination of whether violations are corrected of compliance is listed in the "Summary requires compliance with all requirements Statement of Deficiencies" column. This provided at the Statute number indicated below. column also includes the findings which When Minnesota Statute contains several items, are in violation of the state requirement failure to comply with any of the items will be after the statement, "This Minnesota considered lack of compliance. requirement is not met as evidenced by." Following the evaluators ' findings is the INITIAL COMMENTS: Time Period for Correction. SL20219016-0 PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On June 9, 2025, through June 11, 2025, the STATES,"PROVIDER'S PLAN OF survey at the above provider and the following FEDERAL DEFICIENCIES ONLY. THIS correction orders are issued. At the time of the WILL APPEAR ON EACH PAGE. survey, there were 64 residents; 64 receiving services under the Assisted Living Facility with THERE IS NO REQUIREMENT TO Dementia Care license. 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. 02040 144G.81 Subdivision 1 Fire protection and 02040 SS=F physical environment LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 CQ3C11 If continuation sheet 1 of 6 PRINTED: 08/07/2025 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 _____________________________ 20219 06/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4559 SHORELINE DRIVE LAKE MINNETONKA SHORES SPRING PARK, MN 55384 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) 02040 Continued From page 1 02040 An assisted living facility with dementia care must meet the requirements of section 144G.45 and the following additional requirements: (1) an assessment of safety risks must be performed on and around the property. The safety risks identified by the facility on the assessment must be mitigated to protect the residents from harm. The mitigation efforts must be documented in the facility's records; and (2) the facility shall be protected throughout by an approved supervised automatic sprinkler system by August 1, 2029. This MN Requirement is not met as evidenced by: Based on record review and interview, the licensee failed to provide hazard vulnerability assessment or safety risk assessment of the physical environment on and around the property for the facility. This deficient practice had the ability to affect all staff, residents, 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 was issued at a widespread scope (when problems are pervasive or represent a systemic failure that has affected or has potential to affect a large portion or all of the residents). Findings include: A record review and interview were conducted on June 10, 2025, at 12:43 p.m. with regional engineering manager (RM)-F on the hazard vulnerability assessment for the physical STATE FORM 6899 CQ3C11 If continuation sheet 2 of 6 PRINTED: 08/07/2025 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 _____________________________ 20219 06/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4559 SHORELINE DRIVE LAKE MINNETONKA SHORES SPRING PARK, MN 55384 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) 02040 Continued From page 2 02040 environment of the facility. Record review indicated that the licensee had not performed a hazard vulnerability assessment with mitigation factors on and around the property. During interview, RM-F stated he understood the requirements of this policy. TIME PERIOD FOR CORRECTION: Twenty-one (21) days 02170 144G.84 SERVICES FOR RESIDENTS WITH 02170 SS=F DEMENTIA (b) Each resident must be evaluated for activities according to the licensing rules of the facility.

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 resident was financially exploited by drug diversion when the alleged perpetrator (AP) tampered with and diverted 6 narcotic hydrocodone-acetaminophen tablets (Norco) for her own use and replaced them with another non-controlled medication. Investigative Findings and Conclusion: The Minnesota Department of Health determined financial exploitation by drug diversion by the AP was inconclusive. The resident’s Norco was tampered with and diverted in a time frame of 6 days, during that time at least 12 other staff had access to the medication. As a result, it could not be determined if the AP or another staff tampered with and diverted the resident’s Norco. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted law enforcement and the resident’s family. The investigation included review of the resident record(s), pharmacy records, facility internal investigation, facility surveillance videos, photographs, facility incident reports, personnel files, staff schedules, law enforcement report, and related facility policy and procedures. Also, the investigator observed resident’s and staff in the facility, and the facilities process to monitor and prevent the diversion of controlled drugs. The resident resided in an assisted living facility with diagnoses including osteoarthritis, degenerative joint disease, and acute pain left knee. The resident’s 90-day assessment indicated the resident received medication management and administration services from the facility. The assessment indicated the resident had intermittent pain in her left humorous and back, and chronic pain due to lupus and Lyme’s disease. The assessment indicated the resident utilized controlled drug narcotic pain medication Norco 7.5/325 milligrams (mg) twice daily. The resident assessment indicated interventions in place to prevent diversion included a double locked med cupboard, witnessed administration of all controlled drugs, and medication counting by unlicensed personnel (ULP) staff and/ or nursing staff. A facility occurrence report indicated the residents bubble pack in room [16] containing controlled drug hydrocodone-acetaminophen (Norco) had 6 pills that were removed and replaced with hydroxychloroquine tablets (a similar looking tablet). The report indicated the resident’s bubble pack appeared to be tampered with. The facility investigation included photographs of the cards which showed the back of the resident’s Norco bubble pack, with 6 tablets punched out and replaced with hydroxychloroquine, then taped over with scotch tape and paper tape. The facility investigation indicated leadership staff reviewed video surveillance footage which showed the AP had removed a handful of bubble pack medication cards from the resident in room [20]. The investigation indicated this was suspicious behavior because of the number of times the AP entered the resident’s room, and a ULP should not remove any cards from a resident room unless they were empty. The facility investigation indicated a nurse verified the residents Norco was intact and the count was correct on August 30 and indicated the diversion occurred sometime between August 30 and September 3. A police report indicated the resident’s Norco tablets appeared to have been opened and a piece of tape placed on the back to reseal it. The pills were identified on Drugs.com as 200 mg of Hydroxychloroquine, a noncontrolled drug. The report indicated the AP had unusual behavior and facility leadership suspected the AP took hydroxychloroquine pills from the resident in room [20], then tampered with and diverted 6 Norco tablets from the resident in [16]. The police report indicated the diversion could have occurred over a time span of 6 days. The report indicated the AP agreed to a voluntary DNA sample. The report indicated there was not enough probable cause to charge the AP, and the case was closed. A review of the AP’s personnel files indicated the AP was employed by the facility for 7 years with no pattern or conduct concerns for potential diversion. A review of the resident’s medication administration record (MAR), and controlled drug witness report indicated the AP had administered the controlled drug as prescribed 3 times during the time frame when the diversion occurred. The AP administrations were all witnessed by another staff indicating no concerns of diversion occurred during the AP’s administration times documented. The resident MAR and controlled drug report indicated another ULP staff not the AP had 2 documented administrations to the resident that were not witnessed or verified by another staff. The resident’s MAR, controlled drug witness report, and facility schedules indicated at least 12 other employees from August 30 to September 3, also had access to the resident’s Norco during the time frame when the diversion occurred. As a result, there is no way to know who tampered with and diverted the resident’s Norco. During email communication facility leadership indicated a resident would have about 6 days of medications remaining in each bubble pack card when a refill occurred. Leadership indicated when the cards were empty staff should remove the empty cards from the resident’s med cupboard. Leadership indicated although the AP was observed removing a handful of cards from room [20], and the resident in [20] was prescribed hydroxychloroquine, the inscription on her hydroxychloroquine pills did not match the inscription of all the hydroxychloroquine pills found in [16]'s tampered Norco cards. Leadership indicated when the resident in [20]’s cards were reviewed no pills were unaccounted for, and there did not appear to be any medication discrepancies. As a result, there was no indication the hydroxychloroquine found in the resident in [16]’s Norco bubble pack were from the resident’s supply in [20]. In addition, facility leadership indicated the AP was never witnessed taking any cards out of room [16], and the tampering and diversion occurred within room [16] where there was no video evidence. A review of the facilities video surveillance showed the AP remove numerous (at least 6) bubble pack cards from room [20]. The video was observed at a slowed rate and zoomed which showed the cards removed by the AP appeared to be empty. The AP’s body language and conduct appeared appropriate, and the AP did not appear to attempt to conceal removal of the bubble pack cards from room [20]. A pharmacy delivery record for the resident in [20] indicated a refill of the resident’s medications was completed on August 28, which included 10 medications in 13 bubble pack cards (6 days prior to when the AP was observed on video surveillance remove at least 6 cards from the resident’s room in [20]). The MAR indicated the resident in [20] had 8 medications prescribed for administration on the AP’s shift. The resident’s medication refill and removal of bubble pack cards from room [20], aligns with when the resident’s refill and removal of empty cards would have likely occurred. When interviewed the AP denied any wrongdoing and stated she followed protocol and made sure the count and administration of the resident’s Norco was always witnessed by another staff. The AP stated she had not noted any concerns with the medication count or bubble pack cards with any of her counts or administrations. The AP stated she gave law enforcement her DNA and permission to search her personal property for the resident’s narcotics because she had done nothing wrong and had nothing to hide. The AP stated the only reason she would ever have removed cards from [20] was if they were empty and indicated that resident had many cards that were empty and needed removal at the same time during her shift. In conclusion, the Minnesota Department of Health determined financial exploitation by drug diversion by the AP 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.

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 resident was found deceased in a lake near the facility. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. Although the resident was found in the lake deceased, there was no evidence to support that maltreatment occurred. The facility worked closely with the resident’s care team and family to assist in the resident’s care needs. Facility policies and procedures and the resident plan of care were followed at the time the incident occurred. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, unlicensed staff, and the resident’s psychotherapist. The investigation included review of the resident’s medical records, hospital records, personnel files, camera footage, police reports, and facility policies and procedures. At the time of the onsite visit the An equal opportunity employer. investigator toured facility grounds, including the lake and boat landing area where the resident was found, and observed staff interaction with residents. The resident resided in an assisted living facility. The resident’s diagnoses included schizophrenia and urine incontinence. The resident’s service plan included assistance with medication management, reassurance checks, and shower assistance. The resident was independent with ambulation and able to independently navigate facility grounds. The resident’s assessment indicated the resident was cognitively intact with a history of hallucinations, paranoia, and suicide attempts. The resident’s assessment included suicide prevention interventions of twice daily reassurance checks, weekly psychotherapist visits, bimonthly psychiatric visits, and monthly intramuscular (IM) psychotropic medication injections. Interventions included on the assessment indicated the resident’s significant other would encourage participation in activities, all sharp objects would be removed from the resident’s apartment, and monthly care conferences with the resident’s family, significant other, case manager, and facility team members. Hospital records records indicated the resident was seen in the emergency room one week prior to her death with complaints of fatigue, tremors, and intermittent chest pain. The resident was diagnosed with a urinary tract infection and discharged back to the facility four days later. Upon the resident’s return to the facility, staff observed and documented the resident was notably fatigued and did not want to leave her apartment. Due to the onset of weakness and recent hospitalization, a physical therapy evaluation was ordered by the physician. The day of the scheduled physical therapy appointment, the resident was not in her room when the therapist arrived to begin the 11:00 a.m. appointment. At 10:50 a.m. the therapist reported to facility staff that the resident was not in her room. Staff immediately began a search for the resident. At 10:58 a.m. the resident’s pendant light activated and identified the resident’s approximate location as near the independent living garages located on the backside of the facility, near the lake. Staff immediately went to this location and continued their search for the resident. The facility grounds included several feet of lakeshore and multiple boat docks. Due to the proximity of the lake to the facility, staff was aware of the need to complete a thorough search of this area if a resident was reported missing. Search efforts continued but revealed no sign of the resident. Nearby neighborhood search efforts were also unsuccessful. As more staff became aware of the missing resident, search efforts and staff involvement expanded to include approximately 20 staff. At 11:45 a.m. during continued search efforts, a staff member observed a white shoe floating in the lake. Staff who interacted with the resident that day confirmed the resident was wearing white shoes. Emergency services was contacted and arrived at the facility within minutes with a search and dive team to aide in the search. At 12:52 p.m. the dive team located the resident deceased in the water. Following the resident’s death, the facility completed an internal investigation. The investigation identified the resident was observed several times the morning of her death. A nurse who encountered the resident at 10:00 a.m. that morning, described the resident as “in a good mood.” The resident contacted her psychotherapist for a scheduled appointment via phone at 10:15 a.m. that morning. At 10:45 a.m. the resident spoke with a family member who called to remind the resident of the 11:00 a.m. physical therapy appointment. The family member who spoke with the resident that morning indicated there was no sign of concern during their conversation. Facility camera footage displayed the resident outside of the facility doors closest to the lake at 10:58 a.m. The resident was observed in the entry area, and camera footage displayed the resident briskly walking out of the facility towards the lake. There was no camera footage available of the lake or boat dock area. The police report was reviewed which indicated police and other emergency services arrived at the facility within three minutes of receiving the report of a missing resident. There was no criminal investigation into the incident and the case was closed. The resident’s death record was reviewed and listed the cause of death as “accidental.” During investigative interviews, multiple staff members stated the resident was independent and struggled with mental health problems. One of the mental health episodes recalled by staff included an incident of self-harm. The resident was described as having a flat affect no or ( nearly no emotional expression) at baseline, but multiple staff reported the resident was always polite and nice. Multiple staff members reported that the resident spent most of her time with her significant other, who resided in the independent living facility located on the same facility grounds. Staff members recalled that days prior to the resident’s death, the resident returned from the hospital; the resident stayed in her apartment, was notably weak, and seemed “depressed”. Staff described the resident as “different” upon her return from the hospital and seemed self- conscious about new tremors she experienced. Multiple staff reported the resident was smiling, happy, and walking at a fast pace the day of her death, which was a noted change in behavior for the resident from the days prior. During an interview, the resident’s psychotherapist described the resident as alert, orientated, and cognitively intact. The psychotherapist explained that over the last couple months, the resident experienced some health issues that changed her affect, however, her participation in visits didn’t change despite these health issues. The day of the resident’s death, the psychotherapist attempted to hold a scheduled phone meeting with the resident. The resident requested to reschedule the meeting time, stating the timing “wasn’t good for her”. The psychotherapist was unable to ask to follow up questions because the resident was “rushed”. However, the psychotherapist was not concerned with the resident being rushed as this had happened in the past. The psychotherapist stated the entire team involved in the resident’s care worked hard to make sure the resident felt supported. During an interview, the resident’s family indicated the facility did a great job in caring for the resident. The family described the staff as “conscientious, caring and involved.” 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: Not Applicable the Family/Responsible Party interviewed: No, family declined a formal interview. Alleged Perpetrator interviewed: Not Applicable the Action taken by facility: The facility assessed and monitored the resident’s condition and mental health status. When the resident was reported missing, facility staff began an immediate search of facility grounds, nearby neighborhoods, and contacted 911.

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 Lake Minnetonka Shores August 31, 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, Jess Schoenecker, Supervisor State Evaluation Team Email: jess.schoenecker@state.mn.us Telephone: 651-201-3789 F ax: 6 51-281-9796 JMD PRINTED: 08/31/2023 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 _____________________________ 20219 08/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4559 SHORELINE DRIVE LAKE MINNETONKA SHORES SPRING PARK, MN 55384 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 Correction Orders ASSISTED LIVING PROVIDER LICENSING using federal software. Tag numbers have CORRECTION ORDER(S) been assigned to Minnesota State Statutes for Assisted Living License In accordance with Minnesota Statutes, section Providers. The assigned tag number 144G.08 to 144G.95, these correction orders are appears in the far-left column entitled "ID issued pursuant to a survey. Prefix Tag." The state Statute number and the corresponding text of the state Statute Determination of whether violations are corrected out of compliance is listed in the requires compliance with all requirements "Summary Statement of Deficiencies" provided at the Statute number indicated below. column. This column also includes the When the Minnesota Statute contains several 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. SL#20219015 PLEASE DISREGARD THE HEADING OF On August 1, 2023, through August 4, 2023, the THE FOURTH COLUMN WHICH survey at the above provider, and the following CORRECTION." THIS APPLIES TO correction orders are issued. At the time of the FEDERAL DEFICIENCIES ONLY. THIS survey, there were 62 active residents; 62 WILL APPEAR ON EACH PAGE. receiving services under the Assisted Living/Dementia Care license. THERE IS NO REQUIREMENT TO SUBMIT A PLAN OF CORRECTION FOR VIOLATIONS OF MINNESOTA STATE STATUTES. 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: (B) food must be prepared and served according to the Minnesota Food Code, Minnesota Rules, chapter 4626; and LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 SRTU11 If continuation sheet 1 of 8 PRINTED: 08/31/2023 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 _____________________________ 20219 08/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4559 SHORELINE DRIVE LAKE MINNETONKA SHORES SPRING PARK, MN 55384 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 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 1, 2023, for the specific Minnesota Food Code deficiencies. TIME PERIOD FOR CORRECTION: Twenty-one (21) days 0 800 144G.45 Subd. 2 (a) (4) Fire protection and 0 800 SS=D physical environment (4) keep the physical environment, including walls, floors, ceiling, all furnishings, grounds, systems, and equipment in a continuous state of good repair and operation with regard to the health, safety, comfort, and well-being of the residents in accordance with a maintenance and repair program. This MN Requirement is not met as evidenced STATE FORM 6899 SRTU11 If continuation sheet 2 of 8 PRINTED: 08/31/2023 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 _____________________________ 20219 08/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4559 SHORELINE DRIVE LAKE MINNETONKA SHORES SPRING PARK, MN 55384 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) 0 800 Continued From page 2 0 800 by: Based on observation and interview, the licensee failed to maintain the physical environment, including walls, floors, ceiling, all furnishings, grounds, systems, and equipment in a continuous state of good repair and operation with regard to the health, safety, comfort, and well-being of the residents. This deficient condition had the ability to affect a limited number of staff and residents.