Dellwood Gardens.

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 for widespread violations; Level 3: a fine of $3,000 per violation per incident, in addition to any enforcement mechanism authorized in § 144G.20. Level 4: a fine of $5,000 per incident, in addition to any enforcement mechanism authorized in § 144G.20. An equal opportunity employer. Letter ID: IS7N REVISED 09/13/2021 Dellwood Gardens June 5, 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 - 1290 - 144g.60 Subdivision 1 - Background Studies Required - $3,000.00 St - 0 - 2310 - 144g.91 Subd. 4 (a) - Appropriate Care And Services - $3,000.00 Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, t he total amount you are assessed is $6,000.00. 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 Dellwood Gardens June 5, 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, Renee Anderson, Supervisor State Evaluation Team Email: Renee.L.Anderson@state.mn.us Telephone: 651-201-5871 Fax: 1-866-890-9290 AH PRINTED: 06/05/2025 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 _____________________________ 29953 04/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 753 EAST 7TH STREET DELLWOOD GARDENS SAINT PAUL, MN 55106 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 Licensing ASSISTED LIVING PROVIDER LICENSING Correction Orders using federal software. CORRECTION ORDER(S) Tag numbers have been assigned to Minnesota State Statutes for Assisted In accordance with Minnesota Statutes, section Living License Providers. The assigned 144G.08 to 144G.95, these correction orders are tag number appears in the far left column issued pursuant to a survey. entitled "ID Prefix Tag." The state Statute number and the corresponding text of the Determination of whether violations are corrected state Statute out of compliance is listed in requires compliance with all requirements the "Summary Statement of Deficiencies" provided at the Statute number indicated below. column. This column also includes the When Minnesota Statute contains several items, findings which are in violation of the state failure to comply with any of the items will be requirement after the statement, "This 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 #29953016-0 PLEASE DISREGARD THE HEADING OF On April 21, 2025, through April 24, 2025, 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 87 residents, all of whom were WILL APPEAR ON EACH PAGE. receiving services under the provider's Assisted Living Facility with Dementia Care license. THERE IS NO REQUIREMENT TO SUBMIT A PLAN OF CORRECTION FOR An immediate correction order was identified on VIOLATIONS OF MINNESOTA STATE April 23, 2025, issued for SL29953016-0, tag STATUTES. The letter in the left column is identification 2310. used for tracking purposes and reflects the scope and level pursuant to 144G.31 An immediate correction order was identified on Subd. 1, 2 and 3. April 24, 2025, issued for SL29953016-0, tag identification 1290. During the course of the survey, the licensee took action to mitigate the imminent risk of the above deficiencies. Noncompliance remained and the scope and level remain unchanged. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 PJO211 If continuation sheet 1 of 32 PRINTED: 06/05/2025 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 _____________________________ 29953 04/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 753 EAST 7TH STREET DELLWOOD GARDENS SAINT PAUL, MN 55106 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 144G.41 Subdivision 1 Subd. 1a (a-b) Minimum 0 480 SS=F requirements; required food services (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: 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 a resident when they failed to provide medical care to the resident. The resident had a wound on her leg which became infected. The resident died from the infection. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. The resident had chronic (long term) wounds to her legs and the facility coordinated care with an agency who entered the facility to provide daily wound care to the resident. The facility increased services for the resident to address her declining health. Although the resident died from sepsis (severe infection), the facility coordinated care with the resident’s health care providers and sent her to the hospital when her health condition changed. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted the wound care agency. The investigation included review of the resident’s records, wound care records, and physician An equal opportunity employer. reports. Also, the investigator toured the facility and observed staff administer mediations and treatments to residents. The resident resided in an assisted living facility. The resident’s diagnoses included venous stasis ulcers (leg wounds caused by poor circulation), chronic obstruction pulmonary disease (COPD), anemia, lymphedema (leg swelling), and heart failure. The resident’s service plan included assistance with safety checks, bathing, escorting to meals, and transfers. The resident’s nursing assessment indicated she was alert and orientated. The resident was able to communicate her needs and administered her own medications. The resident required continuous oxygen. She slept in a chair as opposed to a bed because of past trauma. She dressed and groomed herself independently. The resident’s nurse practitioner (NP) notes indicated the resident had wounds to both her legs because of poor circulation. There was drainage from the wounds and the surrounding tissue. Slough (non-viable tissue) was present in the wounds. The resident received an antibiotic medication for infection of her wounds one month prior to her hospitalization. The resident’s wounds appeared to have less drainage while she received the antibiotic medication, but her wounds did not heal. The resident required further specialized treatment from a wound care clinic. NP notes indicated the resident did not want to go outside of the facility for medical appointments. Additionally, the resident had poor function of her lungs and heart. The NP requested the resident attend appointments with a pulmonologist (lung specialist), and cardiologist (heart specialist). The resident did not want to attend those appointments regardless of the health risks. The NP continued to monitor the resident’s lab work and chronic health diagnoses. Progress notes indicated the day before the facility sent the resident to the hospital, a wound care nurse and a facility nurse spoke to her regarding her wounds. The wound care nurse told the resident she needed to elevate her legs, or her wounds would not heal. The facility nurse added services for staff to assist her with elevating her legs, and showering. The resident was agreeable, as she refused assistance for these tasks in the past. The following day, the facility nurse went to check on the resident. The resident had low blood pressure and an elevated pulse. The nurse was not able to obtain the resident’s oxygen saturation level. The nurse also noticed the resident’s wounds had a foul odor. The nurse told the resident she thought she should go to the hospital, however the resident said she was not going to go. The nurse convinced her to go to the hospital and coordinated care to get her there. Wound care documentation indicated wound care nurses provided wound care to the resident twice during the week, prior to her hospitalization. The documentation indicated the wounds showed no signs or symptoms of infection. The wound care nurses spoke to the resident about allowing staff to assist her with showers and elevating her legs. Wound care documentation indicated the resident received wound care the day before the facility sent her to the hospital. Documentation from the visit indicated the resident did not have a fever. Her skin color, and skin temperature were withing normal limits. The resident was alert, orientated, and able to communicate her needs. The wound care nurse and facility nurse educated the resident on the importance of personal hygiene and allowing staff to assist her with showering. Documentation further indicated the resident had an appointment with a wound care specialty clinic the following month. During an interview, a wound care nurse said the wound care agency provided wound care daily to the resident. The wound care nurse said they tried to provide care three times weekly, however had to increase their services and treat the resident daily because there was so much drainage from the resident’s leg wounds. During an interview, a facility nurse said the day before the resident went to the hospital, she appeared at her baseline health status. The resident denied feeling sick. The facility nurse said she observed the resident’s wounds together with the wound care nurse the day before she went to the hospital. The facility nurse said the wound care nurse told her the resident’s wounds were not any better, but not any worse. The facility nurse said the following day, she saw the resident and thought she looked sick. The resident’s blood pressure was lower, and she had an elevated pulse. The facility nurse sent the resident to the hospital; however, the resident did not believe she was sick. Medical records indicated the resident died at the hospital seven days later from sepsis (infection). 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. Deceased. Family/Responsible Party interviewed: No. Attempted but did not respond. Alleged Perpetrator interviewed: Not Applicable. The Action taken by facility: The facility coordinated care with the wound care agency, and the resident’s medical providers. The facility increased services to assist with the residents changing health status. 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: 06/03/2024 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 _____________________________ 29953 04/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 753 EAST 7TH STREET DELLWOOD GARDENS SAINT PAUL, MN 55106 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 complaint investigation. state Statute number and the corresponding text of the state Statute out Determination of whether a violation is 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.