The Waters of Highland Park.

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 The Waters of Highland Park August 5, 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, Renee Anderson, Supervisor State Evaluation Team Email: Renee.L.Anderson@state.mn.us Telephone: 651-201-5871 Fax: 1-866-890-9290 AH PRINTED: 08/05/2025 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 _____________________________ 31949 06/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 678 SNELLING AVENUE SOUTH THE WATERS OF HIGHLAND PARK 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 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 #31949016-0 PLEASE DISREGARD THE HEADING OF On June 2, 2025, through June 5, 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 79 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 VIOLATIONS OF MINNESOTA STATE STATUTES. The letter in the left column is used for tracking purposes and reflects the scope and level pursuant to 144G.31 Subd. 1, 2 and 3. 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 LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 Z04411 If continuation sheet 1 of 24 PRINTED: 08/05/2025 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 _____________________________ 31949 06/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 678 SNELLING AVENUE SOUTH THE WATERS OF HIGHLAND PARK 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 4626. (b) For an assisted living facility with a licensed capacity of ten or fewer residents: (1) notwithstanding Minnesota Rules, part 4626.0033, item A, the facility may share a certified food protection manager (CFPM) with one other facility located within a 60-mile radius and under common management provided the CFPM is present at each facility frequently enough to effectively administer, manage, and supervise each facility's food service operation; (2) notwithstanding Minnesota Rules, part 4626.0545, item A, kick plates that are not removable or cannot be rotated open are allowed unless the facility has been issued repeated correction orders for violations of Minnesota Rules, part 4626.1565 or 4626.1570; (3) notwithstanding Minnesota Rules, part 4626.0685, item A, the facility is not required to provide integral drainboards, utensil racks, or tables large enough to accommodate soiled and clean items that may accumulate during hours of operation provided soiled items do not contaminate clean items, surfaces, or food, and clean equipment and dishes are air dried in a manner that prevents contamination before storage; (4) notwithstanding Minnesota Rules, part 4626.1070, item A, the facility is not required to install a dedicated handwashing sink in its existing kitchen provided it designates one well of a two-compartment sink for use only as a handwashing sink; (5) notwithstanding Minnesota Rules, parts 4626.1325, 4626.1335, and 4626.1360, item A, existing floor, wall, and ceiling finishes are allowed provided the facility keeps them clean and in good condition; (6) notwithstanding Minnesota Rules, part STATE FORM 6899 Z04411 If continuation sheet 2 of 24 PRINTED: 08/05/2025 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 _____________________________ 31949 06/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 678 SNELLING AVENUE SOUTH THE WATERS OF HIGHLAND PARK 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 2 0 480 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 facility neglected the resident when facility staff did not have the resident’s pressure relieving air mattress plugged in resulting in pressure sores on the resident’s heels. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was inconclusive. Due to conflicting accounts provided, there was not a preponderance of evidence to support the resident’s air mattress was unplugged and was the direct action that caused the resident’s pressure injuries to her heels. When the resident’s pressure injuries were identified, they were treated, additional interventions were implemented, and the resident passed away days later at the facility related to her dementia diagnosis. The resident resided in an assisted living memory care unit. The resident’s diagnoses included dementia with behavioral disturbance. The resident’s service plan included assistance with bathing, dressing, grooming, turning, and repositioning. The resident’s assessment indicated the resident had thin fragile skin. The resident was receiving hospice services and had a pressure relieving air mattress. Complaint documents alleged facility staff left the resident’s air mattress unplugged, and the resident was found with pressure ulcers on both heels. Medical records indicated once the resident’s pressure ulcers were identified, the injuries were reported to the hospice and facility nurse. Both nurses assessed the resident’s heels the day the injuries were found. A wound dressing was applied to the resident’s heels, heel protector boots were applied, and the provider was updated. During investigative interviews, facility staff reported they could not recall the resident’s mattress being unplugged prior to the resident obtaining the heel injury. During an interview, a hospice staff stated prior to the heel injury the resident’s air mattress was observed to be unplugged. A hospice staff member stated after the injuries were assessed the mattress was not unplugged again and was in working order. During an interview, a hospice nurse stated prior to the incident the resident had interventions in place to prevent skin breakdown including an alternating pressure mattress, turning, repositioning, and incontinent care every four hours. When the concern was reported, the heels were assessed, and the reported pressure ulcers were not open wounds but were identified as pressure injuries. The heels were covered with a dressing, wound care three times a week was implemented and pressure relieving boots were ordered and the resident continued to use the air mattress. The hospice nurse stated the resident had been ill weeks prior to the heel injuries and the resident continued to decline and passed away soon after. During an interview, the facility nurse stated when the injuries formed there was no documentation that staff ensured the mattress was plugged in; however, staff denied the mattress was unplugged. After the heel injuries were reported the facility followed the recommendations provided by hospice. Even though there was no indication the mattress was unplugged, the facility provided staff education to ensure mattresses are always plugged in when they are in use. During an interview, a family member stated he was aware of the resident’s heel injuries, and he had not seen the air mattress unplugged. In conclusion, the Minnesota Department of Health determined neglect 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. 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. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Not Applicable. the Action taken by facility: The facility collaborated with the hospice team and implemented interventions to prevent worsening of the heel injuries. 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: 05/21/2025 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 _____________________________ 31949 04/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 678 SNELLING AVENUE SOUTH THE WATERS OF HIGHLAND PARK 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 Facilities. The In accordance with Minnesota Statutes, section assigned tag number appears in the 44G.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. column also includes the findings which When a Minnesota Statute contains several are in violation of the state requirement items, failure to comply with any of the items will after the statement, "This Minnesota be considered lack of compliance. requirement is not met as evidenced by." Following the evaluators ' findings is the INITIAL COMMENTS: Time Period for Correction. #HL319496524C/#HL319498784M PLEASE DISREGARD THE HEADING OF On April 22, 2025, the Minnesota Department of THE FOURTH COLUMN WHICH Health conducted a complaint investigation at the STATES,"PROVIDER'S PLAN OF above provider, and the following correction CORRECTION." THIS APPLIES TO orders are issued. At the time of the complaint FEDERAL DEFICIENCIES ONLY. THIS investigation, there were 74 residents receiving WILL APPEAR ON EACH PAGE. services under the provider's Assisted Living with Dementia Care license. THERE IS NO REQUIREMENT TO The following correction order is issued/orders SUBMIT A PLAN OF CORRECTION FOR are issued for # VIOLATIONS OF MINNESOTA STATE #HL319496524C/#HL319498784M , tag STATUTES. identification 1940. 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. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 M1CB11 If continuation sheet 1 of 4 PRINTED: 05/21/2025 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 _____________________________ 31949 04/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 678 SNELLING AVENUE SOUTH THE WATERS OF HIGHLAND PARK 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) 01940 Continued From page 1 01940 01940 144G.72 Subd. 3 Individualized treatment or 01940 SS=D therapy managemen For each resident receiving management of ordered or prescribed treatments or therapy services, the assisted living facility must prepare and include in the service plan a written statement of the treatment or therapy services that will be provided to the resident.

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 alleged perpetrator (AP), a facility staff member neglected the resident when the AP administered incorrect medication to the resident. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. Although the medication error occurred, the error was an isolated incident. Upon discovery of the error, the AP immediately notified the facility nurses, emergency medical services, and the resident was sent to the hospital for evaluation. The resident returned to the facility the next day at her baseline health condition. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigation included review of the resident records, hospital records, facility incident reports, personnel files, staff schedules, and related facility policy and procedures. Also, the investigator observed medication administration by a facility staff member. The resident resided in an assisted living facility. The resident’s diagnoses included altered mental status and chronic kidney disease. The resident’s service plan included assistance with medication management. The resident’s assessment indicated the resident was independent with dressing and transferring. The resident’s assessment indicated the resident had mild cognitive impairment. An incident report indicated one evening the resident received the wrong medications. The resident received another resident’s medication that included atorvastatin (for high cholesterol) and donepezil (used for Alzheimer’s disease). The resident experienced nausea, vomiting, and an increase in body heat. Facility staff arranged for the resident to be evaluated at a hospital.. The hospital record indicated the resident arrived at the emergency room. The resident was experiencing vomiting most likely due to a side effect of donepezil. The resident was treated with intravenous fluids, anti-nausea medications, and observation. The resident was discharged back to the assisted living the next day. During an interview, leadership stated when the AP made the medication error, the process for medication administration for staff was to keep the medication cart in a central area on the top floor of the facility. After staff set up the medications, they would have to take the residents’ medications down two floors. In the process, the AP forgot whose medication she had and gave the wrong medications to the wrong resident. After the incident, the process was changed, and staff are required to pass the residents medication with the medication cart just outside of each residents’ apartment. Leadership stated the AP was retrained on medication pass. The AP had no prior medication errors before the incident and no medication errors after the incident. During an interview, the AP stated at the time of the incident, the medication cart with all the facility residents’ medication was kept on the memory care unit. The AP stated, staff would set up the medications for residents not in the memory care unit in medication cups, place the room number on the paper cup, and deliver the medications for the residents. The AP stated at that medication pass she set up two separate resident medications and delivered them in the cups to a different floor. Both residents had two medications each. The AP recognized her error after giving the resident the incorrect medications. The AP stated she called an on-call nurse right away and when the resident stated she was not feeling well, the resident’s vital signs were checked, and the resident was sent to the hospital. The AP stated it was not intentional, she made an error and reported the error to an on-call nurse right away. The AP stated following the medication error, staff now take the medication cart with them to each resident apartment. During an interview, a family member stated the resident returned to her baseline condition. 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 resident was sent to the hospital and AP was retrained on the medication administration. In addition, the facility required staff to no longer park the medication cart in one location. The staff are required to pass medications to residents with the medication cart outside of the resident’s apartment. 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: 03/11/2025 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 _____________________________ 31949 02/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 678 SNELLING AVENUE SOUTH THE WATERS OF HIGHLAND PARK 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 On February 10, 2025, the Minnesota Department of Health initiated an investigation of complaint #HL319496708M / #HL319491153C. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 S6RD11 If continuation sheet 1 of 1