Cerenity Residence On Humboldt.

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): An alleged perpetrator (AP), an agency staff member, neglected a resident when they failed to respond to the resident’s pendant call for assistance to the bathroom. The resident fell after she attempted to walk herself to the bathroom. The resident was transported to the emergency department. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. There was not a preponderance of evidence to suggest maltreatment occurred. The AP was responding to another resident emergency at the time the resident fell. Although the resident was evaluated at the emergency department, she returned to the facility a few hours later at her baseline health status. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator interviewed the resident. The investigation included review of the resident’s facility record including her call pendant report and fall incident report, internal investigation, hospital record, facility incident reports, AP employee file, staff schedules, and related facility policy and procedures. Also, the investigator observed resident interactions with staff while onsite at the facility. The resident resided in an assisted living facility. The resident’s diagnoses included but were not limited to unsteadiness on feet and repeated falls. The resident’s services included assistance with activities of daily living, medications, meals, housekeeping, laundry and toileting assistance every three hours. The resident’s assessment indicated the resident had moderate cognitive impairment but was able to make her needs known, was independent with the use of her call light, used a manual wheelchair and walker for mobility and required a gait belt for transfers. Staff responded to the resident’s call light and found the resident on the floor. The resident was unable to report how she fell but assumed she was trying to go to the bathroom since her walker was next to her. Staff contacted 911 and had the resident transported to the emergency department for further evaluation. Hospital records indicated the resident reported to hospital staff she fell while walking to the bathroom. The resident was diagnosed with a closed head injury and returned to the facility a few hours later at her normal baseline status. Facility leadership initiated an internal investigation into the fall and found the resident’s call pendant was on for one hour prior to staff finding her on the floor. Staff interviewed during the investigation reported they were responding to another resident emergency at the time of the fall and answered the call light as soon as they could. The AP stated she rushed to the resident’s apartment after she saw the resident’s call pendant alert and immediately called the on-call nurse who advised her to call 911. The AP stated she remained with the resident until she was transported to the emergency department. The AP stated the resident got up to use the bathroom by herself and pushed her call pendant because she noticed her wheelchair was not in her room. The AP reported she had taken the resident’s wheelchair out of her room to assist with the resident emergency in the common area because the storage unit wheelchair was not in proper working order. Review of the facility staff schedule at the time of the incident indicated the AP was the only staff member scheduled to work and provide cares and medications for almost 30 residents. During interview with facility leadership, leadership acknowledged the AP should not have removed the resident’s wheelchair from her room, but the AP did not know where to find extra wheelchairs, so she used the resident’s wheelchair to respond to another resident emergency. Following the incident, all staff were educated about where to find extra medical equipment, including wheelchairs. When interviewed, the resident stated she felt guilty asking for assistance because staff felt overloaded every time she called. The resident also stated she loved living at the facility and had no concerns with the care provided by staff. When interviewed, the AP stated when she was alerted to the resident fall in the common area she looked around for a wheelchair and found one in a storage room, but it was unusable but recalled the resident had a wheelchair, so she borrowed the resident’s wheelchair. The AP stated the resident told her she tried to use her walker to go to the bathroom after the AP did not respond when she pressed her call pendant. The AP indicated as soon as she was able, she responded to the resident’s call light and found her on the floor and stayed with her until the ambulance arrived. The AP stated as an agency staff person she picked up a lot of shifts at the facility and stated it was “overwhelming” at times, answering call lights, administering medications, and insulin. 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: Yes. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Yes. The Action taken by facility: The facility educated staff following the incident. The facility received leadership approval for an additional shift from 5:00 p.m. until 9:00 p.m. to assist with resident cares in the assisted living facility. Action taken by the Minnesota Department of Health: The facility was found to be in noncompliance. To view a copy of the Statement of Deficiencies and/or correction orders, please visit: https://www.health.state.mn.us/facilities/regulation/directory/provcompselect.html If you are viewing this report on the MDH website, please see the attached Statement of Deficiencies. You may also call 651-201-4200 to receive a copy via mail or email cc: The Office of Ombudsman for Long Term Care The Office of Ombudsman for Mental Health and Developmental Disabilities PRINTED: 04/ 17/ 2026 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 _____________________________ 30462 01/ 08/ 2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 514 HUMBOLDT AVENUE CERENITY RESIDENCE ON HUMBOLDT SAINT PAUL, MN 55107 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 January 8, 2026, the Minnesota Department Assisted Living Provider 144G. of Health conducted a complaint investigation of #HL304622423C/ #HL304629042M. No correction Minnesota Department of Health is orders are issued. documenting the State Correction Orders using federal software. Tag numbers have been 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 is listed in the "Summary Statement of Deficiencies" column. This column also includes the findings which are in violation of the state requirement after the statement, "This Minnesota requirement is not met as evidenced by." Following the evaluators' findings is the Time Period for Correction. PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH STATES, "PROVIDER' S PLAN OF CORRECTION. " THIS APPLIES TO FEDERAL DEFICIENCIES ONLY. THIS 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.

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): A facility staff member/alleged perpetrator (AP) neglected the resident when the plan of care was not followed, and the resident fell and sustained a hip fracture. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. Although the resident fell and was hospitalized, there was not a preponderance of evidence to support the fall was caused by the failure of facility staff to provide necessary care or services. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff and unlicensed staff. The investigator interviewed the resident’s family member. The investigation included review of the resident record, the resident’s hospital record, facility internal investigation, personnel files, staff schedules, and related facility policy and procedures. Also, the investigator observed direct staff care during her onsite investigation. The resident resided in an assisted living memory care unit. The resident’s diagnoses included but were not limited to dementia and unsteadiness on feet. The resident’s admission assessment indicated the resident was alert and oriented to self only. The assessment identified the resident was independent with toileting and the resident was able to toilet self without issue. The assessment further indicated the resident required stand by assistance with dressing and grooming due to balance issues. The assessment included under the mobility section the resident was SBA (stand by assist) or assist of one staff to meals and activities up to three times or more per day; use of assistive device (wheelchair, walker, etc). The mobility section included the use of a walker for ambulation; staff are to remind resident to use when they see him without. The resident’s admission service plan indicated the resident required standby assistance to meals or activities up to three or more times per day. The day the fall occurred, the resident was seen by staff walking to his room. The resident did not have his walker. A short time after he returned to his room, the resident called for help. The resident was found on the floor. The incident report indicated the resident slipped and fell on spilled coffee in his bathroom after returning from breakfast. Staff contacted 911 and the resident was sent to the hospital for further evaluation. The resident’s hospital record indicated the resident was diagnosed with a closed fracture of the right hip bone (femur). Facility administration investigated the fall. The staff member/alleged perpetrator(AP) was assisting another resident when she saw the resident walk past her without his walker. The AP provided conflicting reports on if she reminded the resident to use his walker prior to the fall. The resident was already inside his apartment when he fell. The AP immediately responded to the resident’s cry for help and staff called 911. Following nursing staff’s evaluation of the incident all memory care service plans were reviewed for accuracy in mobility status and staff were educated on resident safety, fall prevention, durable medical equipment, and reporting resident changes in condition. When interviewed, the AP stated she was with another resident in the dining area getting their insulin and medications ready to bring the other resident back to their apartment. The AP stated she saw the resident without his walker and reminded the resident he needed to use it. The AP stated shortly after she heard the resident yell for help, she immediately ran to his apartment where she found the resident on the floor. The AP stated she called the nurse and took the resident’s vitals. When interviewed, a staff member stated the AP told her the resident refused to use his walker. The staff member stated the resident was easy to direct but sometimes the resident did not want to use his walker even when you redirected him. The staff member stated the incident would not have happened if they had another staff member working. When interviewed, a facility nurse stated the resident was a high fall risk demonstrated by his shuffling gait and stiff way he walked. The nurse stated the resident was forgetful and needed a lot of reminders to use his walker, but the resident usually complied when asked. The nurse stated she was unsure what the resident’s initial service plan indicated, stating it was difficult for her to understand and read it. When interviewed, the resident’s family member stated the resident was outgoing and enjoyed going to the dining area, stating he never liked to stay in his apartment. The family member stated it was staff’s responsibility to ensure the resident had his walker and used it. When interviewed, facility leadership stated the facility met the minimum staffing levels but following the incident the facility added a morning float shift from 6:30 a.m. to 1:00 p.m., to work between the memory care unit and the assisted living side. 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 to interview due to the resident’s cognition. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Yes. The Action taken by facility: The facility re-educated staff on the importance of reminding and assisting residents who require the use of durable medical equipment (DME) for walking and transfers, and all resident’s service plans in memory care were reviewed and updated on mobility status. In addition, a float shift was added to the morning shift to assist residents in the memory care unit and assisted living. 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: 04/ 17/ 2026 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 _____________________________ 30462 12/ 30/ 2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 514 HUMBOLDT AVENUE CERENITY RESIDENCE ON HUMBOLDT SAINT PAUL, MN 55107 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 December 30, 2025, the Minnesota Assisted Living Provider 144G. Department of Health initiated an investigation of complaint #HL304627185C/ #HL304627423M. No Minnesota Department of Health is correction orders are issued. documenting the State Correction Orders using federal software. Tag numbers have been 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 is listed in the "Summary Statement of Deficiencies" column. This column also includes the findings which are in violation of the state requirement after the statement, "This Minnesota requirement is not met as evidenced by." Following the evaluators' findings is the Time Period for Correction. PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH STATES, "PROVIDER' S PLAN OF CORRECTION. " THIS APPLIES TO FEDERAL DEFICIENCIES ONLY. THIS 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.

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 . . ." IMPOSITION OF FINES In accordance with Minn. Stat. § 144G.31, Subd. 4, fines and enforcement actions may be imposed based on the level and scope of the violations and may be imposed immediately with no opportunity to correct the violation first as follows: Level 1: no fines or enforcement; Level 2: a fine of $500 per violation, in addition to any enforcement mechanism authorized in § 144G.20; Level 3: a fine of $1,000 per incident, in addition to any enforcement mechanism authorized in § 144G.20; Level 4: a fine of $3,000 per incident, in addition to any enforcement mechanism authorized in § 144G.20; Level 5: a fine of $5,000 per violation, in addition to any enforcement mechanism authorized in § 144G.20. An equal opportunity employer. Letter ID: IS7N REVISED 09/13/2021 Cerenity Residence on Humboldt September 15, 2025 Page 2 Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, the following fines are assessed pursuant to this survey: St - 0 - 0775 - 144g.45 Subd. 2. (a) - Fire Protection And Physical Environment - $500.00 St - 0 - 1290 - 144g.60 Subdivision 1 - Background Studies Required - $1,000.00 Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, t he total amount you are assessed is $1,500.00. You will be invoiced approximately 30 days after receipt of this notice, subject to appeal. 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. 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 REQUESTING A HEARING Alternatively, in accordance with Minn. Stat. § 144G.31, Subd. 5(d), an assisted living provider that has been assessed a fine under this subdivision has a right to a reconsideration or a hearing under this section and chapter 14. Pursuant to Minn. Stat. § 144G.20, Subd. 14 and Subd. 18, a request for a hearing must be in writing and received by the Department of Health within 15 business days of the correction order receipt date. The request must contain a brief and plain statement describing each matter or issue contested and any new information you believe constitutes a defense or mitigating factor. To submit a hearing request, please visit: https://forms.web.health.state.mn.us/form/HRDAppealsForm Cerenity Residence on Humboldt September 15, 2025 Page 3 To appeal fines via reconsideration, please follow the procedure outlined above. P lease note that you may request a reconsideration o r a hearing, but not both. If you wish to contest tags without fines in a reconsideration and tags with the fines at a hearing, please submit two separate appeals forms at the website listed above. 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, Casey DeVries, Supervisor State Evaluation Team Email: Casey.DeVries@state.mn.us Telephone: 651-201-5917 Fax: 1-866-890-9290 AH PRINTED: 09/15/2025 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 _____________________________ 30462 07/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 514 HUMBOLDT AVENUE CERENITY RESIDENCE ON HUMBOLDT SAINT PAUL, MN 55107 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. SL30462016-0 PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On July 28, 2025, through July 30, 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 71 residents; 71 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 An immediate correction order was identified on STATUTES. July 28, 2025, issued for SL30462016-0, tag identification 1290. THE LETTER IN THE LEFT COLUMN IS USED FOR TRACKING PURPOSES AND During the survey, the licensee took action to REFLECTS THE SCOPE AND LEVEL mitigate the immediate risk. However, ISSUED PURSUANT TO 144G.31 noncompliance remained, and the scope and SUBDIVISION 1-3. level remain unchanged. 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 EFEV11 If continuation sheet 1 of 27 PRINTED: 09/15/2025 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 _____________________________ 30462 07/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 514 HUMBOLDT AVENUE CERENITY RESIDENCE ON HUMBOLDT SAINT PAUL, MN 55107 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.

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), contracted staff, abused a resident when the AP had an altercation with the resident. The resident sustained a right rib fracture. Investigative Findings and Conclusion: The Minnesota Department of Health determined abuse was inconclusive. Although there was an altercation between the AP and the resident, the resident and the AP provided conflicting information regarding the cause of the resident’s injury. There were no witnesses to the altercation and when later interviewed by a security guard of the facility, the resident did not mention being injured by the AP. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted a staffing agency regarding the AP. The investigation included review of employee and resident files, and facility policies and An equal opportunity employer. procedures. Also, the investigator observed unlicensed personnel (ULP) perform resident cares and several residents during their daily activities. The resident resided in an assisted living facility. The resident’s diagnoses included major depression, dysphagia (difficulty swallowing), and restless leg syndrome. The resident’s service plan included assistance with medication management and behavior management. The resident had impaired judgement, decreased safety awareness, was very hard of hearing, and at risk for falls. The resident had a history of exhibiting verbal aggression and throwing objects at staff when frustrated. The resident often reacted out of anger and admitted that in the moment of anger, the resident was unable to realize the consequences of his actions. A facility report indicated late one evening the resident came out of his room and saw the AP in the hallway that the resident did not recognize. The resident was concerned because he did not know what the AP was up to, and that the AP did not belong in the facility. The resident approached the AP, followed the AP down the hall, and repeatedly asked the AP to identify himself however, the AP continued to ignore the resident. The resident became agitated and aggressive with the AP, throwing two pop cans and hitting the AP in an attempt to get the AP out of the facility. After being hit by the cans, the resident stated there was a verbal altercation between the resident and AP when the resident pushed his stomach against the AP. The AP responded by shoving/pushing the resident into a wall with an attached railing, four to five times and the AP walked away. The facility report indicated when interviewed the AP stated late one evening, the AP heard the resident yelling accusing the AP of trespassing and being homeless. The AP attempted to explain to the resident that he was an employee however, the resident continued yelling at the AP. The AP offered to get the security guard for the resident however, the resident threw a pop can and bag of chips at the AP. The AP indicated the resident pushed his stomach into the AP. The AP indicated the resident swung his arms many times towards the AP, missing the AP causing the AP to fall against a wall. The AP left and brought a security guard to talk with the resident. The security guard report included a conversation with the resident and AP approximately 20 minutes after the altercation. The report indicated the resident said he contacted the AP with his stomach but made no mention of being shoved or pushed into a wall by the AP. The following morning, the resident complained to staff of right-side rib pain and stated the AP had pushed the resident into a wall the previous evening. Staff arranged for an evaluation of the resident at a local hospital. Following the hospital evaluation, the resident returned to the facility the same day with a diagnoses of a right rib fracture and a prescription for pain medication. During an interview, a facility director stated the AP had been working on a regular basis at the facility from a staffing agency. The director stated following the incident, staff conducted additional resident interviews and they had no concerns with the care provided by the AP. During an interview, the AP stated he was standing in the hallway charting when the resident came out of his room and approached him. The resident asked the AP if he was a drug dealer or doing drugs and he responded by saying his name and that he worked there. The AP tried to walk away, and the resident threw a pop can at him. The resident approached the AP and tried to grab him and tore his shirt pocket as the AP stepped back. The resident continued to swing at the AP and swung so hard he lost his footing and fell back against the doorframe and to the floor. The AP stated he walked away, and the resident followed him, so he went down the stairwell and asked the security guard for assistance. The AP stated during the altercation, he repeatedly told the resident he worked at the facility. The AP stated at no point did he put his hands on the resident. During an interview, the resident stated that night following the altercation with the AP and when on his way to his room, the AP returned with the security guard who defused the situation. The security guard identified the AP as a worker and pointed out to the resident, the AP was wearing a badge, a scrub top, a fanny pack, and holding a computer. 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: No, resident stated he was self-directed. Alleged Perpetrator interviewed: Yes. Action taken by facility: The facility conducted an internal investigation. The security guard filled out incident report. The AP was removed from the schedule. The facility communicated with the staffing agency. Staff were reeducated during change of shift meetings. 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: 05/08/2024 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 _____________________________ 30462 12/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 514 HUMBOLDT AVENUE CERENITY RESIDENCE ON HUMBOLDT SAINT PAUL, MN 55107 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 December 20, 2023, the Minnesota Department of Health initiated an investigation of complaint #HL304626935C/#HL304629285M.