The Alton.

STATE LICENSING COMPLIANCE REPORT Report #: HL258295642C Date Concluded: October 16, 2025 Name, Address, and County of Facility Investigated: The Alton 1306 Alton Street St. Paul, MN 55116 Ramsey County Facility Type: Assisted Living Facility with Evaluator’s Name: Willette Shafer, RN Dementia Care (ALFDC) Special Investigator The Minnesota Department of Health conducted a complaint investigation to determine compliance with state laws and rules governing the provision of care under Minnesota Statutes, Chapter 144G. The purpose of this complaint investigation was to review if facility policies and practices comply with applicable laws and rules. No maltreatment under Minnesota Statutes, Chapter 626 was alleged. To view a copy of the correction orders, if any, please visit: https://www.health.state.mn.us/facilities/regulation/directory/provcompselect.html, or call MDH website, please see the attached state form. PRINTED: 10/23/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ C B. WING _____________________________ 25829 10/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1306 ALTON STREET THE ALTON SAINT PAUL, MN 55116 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE PREFIX PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 000 Initial Comments 0 000 On October 15, 2025, the Minnesota Department of Health initiated an investigation of complaint #HL258295642C. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 MW7511 If continuation sheet 1 of 1

correction orders and document the actions taken to comply in the agency's records. The Department reserves the right to return to the agency 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. In accordance with Minn. Stat. § 144A.474, Subd. 11, state licensing orders issued pursuant to the last survey, completed on March 7, 2024, found not corrected at the time of the June 4, 2024, follow-up survey and/or subject to penalty assessment are as follows: 0660 - Tuberculosis Prevention And Control - 144g.42 Subd. 9 - $500.00 The details of the violations noted at the time of this follow-up survey completed on June 4, 2024 (listed above), are on the attached State Form. Brackets around the ID Prefix Tag in the left hand column, e.g., {2 ----} will identify the uncorrected tags. The total amount you are assessed is $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. § 144A.474, Subd. 8(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. IMPOSITION OF FINES: Level 1: no fines or enforcement. Level 2: a fine of $500 per violation, in addition to any enforcement mechanism authorized in § 144A.475 for widespread violations; Level 3: a fine of $3,000 per violation per incident, in addition to any enforcement mechanism authorized in § 144A.475. An equal opportunity employer. Letter ID: NQMR_Revised 04/23/2023 The Alton June 27, 2024 Page 2 Level 4: a fine of $5,000 per incident, in addition to any enforcement mechanism authorized in § 144A.475. CORRECTION ORDER RECONSIDERATION PROCESS In accordance with Minn. Stat. § 144A.474, Subd. 12, you may challenge the correction order 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 Department of Health within 15 business days of the correction order receipt date. A state licensing order under Minn. Stat. § 144A.44 Subd. 1(14), 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. 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. § 144A.474, Subd. 11 (g), a home care 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. § 144A.475, subd 4 and Subd. 7, a request for a hearing must be in writing and received by MDH within 15 calendar 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. 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. We urge you to review these orders carefully. If you have questions, please contact Renee Anderson at You are encouraged to retain this document for your records. It is your responsibility to share the information contained in the letter and/or state form with your organization’s Governing Body. Sincerely, Renee L Anderson, Supervisor State Evaluation Team Email: Renee.L.Anderson@state.mn.us Telephone: 651-201-5871 Fax: 1-866-890-9290 AH PRINTED: 06/27/2024 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ R B. WING _____________________________ 25829 06/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1306 ALTON STREET THE ALTON SAINT PAUL, MN 55116 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****** ASSISTED LIVING PROVIDER LICENSING CORRECTION ORDER In accordance with Minnesota Statutes, section 144G.08 to 144G.95, this correction order(s) has been issued pursuant to a survey. Determination of whether a violation has been corrected requires compliance with all requirements provided at the Statute number indicated below. When Minnesota Statute contains several items, failure to comply with any of the items will be considered lack of compliance. INITIAL COMMENTS: Project # SL25829016-1 On June 3, 2024, through June 5, 2024, the follow up survey with the above provider to follow-up on orders issued pursuant to a survey completed on March 7, 2024. At the time of the survey, there were 41 active residents; all of whom were receiving services under the Assisted Living with Dementia Care license. As a result of the revisit, the following orders were reissued. {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 7R5O12 If continuation sheet 1 of 14 PRINTED: 06/27/2024 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ R B. WING _____________________________ 25829 06/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1306 ALTON STREET THE ALTON SAINT PAUL, MN 55116 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: No further action required. {0 510} 144G.41 Subd. 3 Infection control program {0 510} SS=D (a) All assisted living facilities must establish and maintain an infection control program that complies with accepted health care, medical, and nursing standards for infection control. (b)The facility's infection control program must be consistent with current guidelines from the national Centers for Disease Control and Prevention (CDC) for infection prevention and control in long-term care facilities and, as applicable, for infection prevention and control in assisted living facilities. (c) The facility must maintain written evidence of compliance with this subdivision. This MN Requirement is not met as evidenced by: No further action required. {0 550} 144G.41 Subd. 7 Resident grievances; reporting {0 550} SS=F maltreatment All facilities must post in a conspicuous place information about the facilities' grievance procedure, and the name, telephone number, and email contact information for the individuals who are responsible for handling resident grievances. The notice must also have the contact information for the Office of Ombudsman for Long-Term Care and the Office of Ombudsman for Mental Health and Developmental Disabilities and must have information for reporting suspected maltreatment to the Minnesota Adult Abuse Reporting Center. The notice must also STATE FORM 6899 7R5O12 If continuation sheet 2 of 14 PRINTED: 06/27/2024 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ R B. WING _____________________________ 25829 06/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1306 ALTON STREET THE ALTON SAINT PAUL, MN 55116 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) {0 550} Continued From page 2 {0 550} state that if an individual has a complaint about the facility or person providing services, the individual may contact the Office of Health Facility Complaints at the Minnesota Department of Health.

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) physically abused the resident by placing their hands on the resident’s face in a way to force the resident to take medication. Investigative Findings and Conclusion: The Minnesota Department of Health determined abuse was inconclusive. The investigation found there was insufficient evidence to determine if abuse occurred. The AP denied the allegations, and the resident could not be interviewed due to her cognitive impairment. Video footage of the day of the allegation was not available for the investigation and per facility review, there was obstructed view of the resident and AP’s faces. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, the alleged perpetrator, and unlicensed staff. The investigator contacted a family An equal opportunity employer. member. The investigation included review of the resident’s medical record, personnel files, facility incident reports, facility policy and procedures and the facility’s internal investigation. Also, the investigator observed medication administration, and staff interactions with the resident. The resident resided in an assisted living memory care unit. The resident’s diagnoses included Alzheimer’s disease, diabetes, anxiety disorder and mood disorders. The resident’s service plan included assistance with medication administration, dressing, grooming, transfers, and walking. The resident’s assessment indicated the use of wheelchair and wheeled walker, cognitive impairment, and noted resistance to cares at times. The facility’s internal investigation indicated an allegation was received the AP forcefully gave the resident medications when she refused. There was a lack of evidence in facility video footage due to camera angle pointing toward the resident with the AP standing in front of the resident’s face. The resident’s medical record included a physician order around the time of the allegation for the resident to receive her medications crushed due to refusals and difficulty swallowing her pills. The AP’s personnel file indicated she had received appropriate vulnerable adult abuse and neglect training, and had not received previous disciplines, complaints or concerns. During investigative interviews, multiple staff members stated the resident often refuses cares including toileting and medication administration. During an interview with the manager, the manager stated the allegation about the AP came to a surprise to him. The manager stated it appeared in the video, the AP stood over the resident who was on the couch, put medications in the resident’s hand and the resident threw her medications. The medications were picked up and readministered. During an interview, the AP stated she did not place her hands on the resident’s face and when offering the medication to the resident. The resident opened her mouth and took the medication. The AP did not recall the resident spitting out the medication. The resident was not able to complete an interview due to her cognitive impairment. During an interview, the family member stated she was not aware of the alleged incident. She stated the resident can be resistive to cares and difficult to care for. She did not have any concerns with the cares the resident receives or her safety. 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: (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; Stop here if it is not a restraints issue or sexual abuse. (d) The act of forcing, compelling, coercing, or enticing a vulnerable adult against the vulnerable adult's will to perform services for the advantage of another. Vulnerable Adult interviewed: No, due to cognitive impairment. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Yes. the Action taken by facility: The facility completed an internal investigation and the AP no longer works for the 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: 09/13/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ C B. WING _____________________________ 25829 07/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1306 ALTON STREET THE ALTON MEMORY CARE SAINT PAUL, MN 55116 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 CORRECTION using federal software. Tag numbers have ORDER 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 complaint investigation. Prefix Tag." The state Statute number and the corresponding text of the state Statute Determination of whether a violation is 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 a 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. #HL258298376C/#H258294903M PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On July 18th, 2023, the Minnesota Department of STATES,"PROVIDER'S PLAN OF Health conducted a complaint investigation at the CORRECTION." THIS APPLIES TO above provider, and the following correction FEDERAL DEFICIENCIES ONLY. THIS orders are issued. At the time of the complaint WILL APPEAR ON EACH PAGE. investigation, there were 97 residents receiving services under the provider's Assisted Living with THERE IS NO REQUIREMENT TO Dementia Care license. SUBMIT A PLAN OF CORRECTION FOR VIOLATIONS OF MINNESOTA STATE The following correction orders are issued for STATUTES. #HL258298376C/#H258294903M, tag identification 0510, 1750 The letter in the left column is used for tracking purposes and reflects the scope and level issued pursuant to 144G.31 subd. 1, 2, and 3. 0 510 144G.41 Subd. 3 Infection control program 0 510 SS=D (a) All assisted living facilities must establish and maintain an infection control program that LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 65FO11 If continuation sheet 1 of 5 PRINTED: 09/13/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ C B. WING _____________________________ 25829 07/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1306 ALTON STREET THE ALTON MEMORY CARE SAINT PAUL, MN 55116 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) 0 510 Continued From page 1 0 510 complies with accepted health care, medical, and nursing standards for infection control.

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 . . ." Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, no immediate fines are assessed. 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 An equal opportunity employer. Letter ID: IS7N REVISED 09/13/2021 The Alton Memory Care May 23, 2023 Page 2 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, Jonathan Hill, Supervisor State Evaluation Team Email: jonathan.hill@state.mn.us Telephone: 651‐201‐3993 Fax: 651‐281‐9796 PMB PRINTED: 05/23/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ 25829 B. WING _____________________________ 05/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1306 ALTON STREET THE ALTON MEMORY CARE SAINT PAUL, MN 55116 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE 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 with Dementia Care license 144G.08 to 144G.95, these correction orders are providers. The assigned tag number issued pursuant to a survey. appears in the far left column entitled "ID Prefix Tag." The state Statute number and Determination of whether violations are corrected the corresponding text of the state Statute requires compliance with all requirements out of compliance is listed in the provided at the Statute number indicated below. "Summary Statement of Deficiencies" When Minnesota Statute contains several items, column. This column also includes the failure to comply with any of the items will be findings which are in violation of the state considered lack of compliance. requirement after the statement, "This Minnesota requirement is not met as INITIAL COMMENTS: evidenced by." Following the surveyors' SL25829015-0 findings is the Time Period for Correction. On May 15, 2023, through May 17, 2023, the PLEASE DISREGARD THE HEADING OF survey at the above provider, and the following STATES,"PROVIDER'S PLAN OF correction orders are issued. At the time of the CORRECTION." THIS APPLIES TO survey, there were 47 active residents; all of FEDERAL DEFICIENCIES ONLY. THIS whom received services under the Assisted Living WILL APPEAR ON EACH PAGE. with Dementia Care license. 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 subd. 1, 2, and 3. 0 470 144G.41 Subdivision 1 Minimum requirements 0 470 SS=F (11) develop and implement a staffing plan for LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 Q2TE11 If continuation sheet 1 of 11 PRINTED: 05/23/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ 25829 B. WING _____________________________ 05/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1306 ALTON STREET THE ALTON MEMORY CARE SAINT PAUL, MN 55116 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 0 470 Continued From page 1 0 470 determining its staffing level that: (i) includes an evaluation, to be conducted at least twice a year, of the appropriateness of staffing levels in the facility; (ii) ensures sufficient staffing at all times to meet the scheduled and reasonably foreseeable unscheduled needs of each resident as required by the residents' assessments and service plans on a 24-hour per day basis; and (iii) ensures that the facility can respond promptly and effectively to individual resident emergencies and to emergency, life safety, and disaster situations affecting staff or residents in the facility; (12) ensure that one or more persons are available 24 hours per day, seven days per week, who are responsible for responding to the requests of residents for assistance with health or safety needs. Such persons must be: (i) awake; (ii) located in the same building, in an attached building, or on a contiguous campus with the facility in order to respond within a reasonable amount of time; (iii) capable of communicating with residents; (iv) capable of providing or summoning the appropriate assistance; and (v) capable of following directions; This MN Requirement is not met as evidenced by: Based on observation, interview, and record review, the licensee failed to post a 24-hour daily staffing schedule with the required information. This had the potential to affect all residents, staff, 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) and was issued at a STATE FORM 6899 Q2TE11 If continuation sheet 2 of 11 PRINTED: 05/23/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ 25829 B. WING _____________________________ 05/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1306 ALTON STREET THE ALTON MEMORY CARE SAINT PAUL, MN 55116 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 0 470 Continued From page 2 0 470 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: On May 15, 2023, at 10:30 a.m., during the entrance conference, licensed assisted living director (LALD)-A stated the regular staffing included eight unlicensed personnel (ULP) on both the day (approximately 7:00 a.m.-3:00 p.m.) and evening (approximately 3:00 p.m.-11:00 p.m.