Nagel Assisted Living.

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), an unlicensed staff, abused the resident when the AP verbally made an inappropriate statement prior to physically restraining the resident’s wrists/lower arms during personal cares. Investigative Findings and Conclusion: The Minnesota Department of Health determined abuse was not substantiated. Although the AP’s actions were inappropriate, the actions did not meet the definition of abuse. An incident occurred with a resident’s brief while providing incontinent care for the resident. The AP did make a verbal statement and briefly restricted the resident’s hands protecting another unlicensed staff from harm for the resident’s care to be completed safely. The resident received the care to prevent skin breakdown and provide dignity. No medical attention was necessary, and the resident returned to her baseline. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted a family member. The investigation included a review of the resident record, facility internal investigation, personnel file, staff schedules, related facility policy and procedures. Also, the investigator observed facility residents and staff member interactions during an onsite visit. The resident resided in an assisted living memory care unit. The residents’ diagnoses included dementia with behaviors and multiple mental health disorders. The resident’s service plan included physical assistance with dressing, toileting, and medication administration. The resident’s assessment indicated the resident needed assistance with all activities of daily living. The resident resided in the facility for less than a 5-month period and was non-compliant with personal cares daily (requiring additional team member(s) for safety). A concern arose one evening when staff were required to physically assist the resident to wash up and apply a clean brief and clothing related to an incontinent bowel movement. Two unlicensed staff were located on the unit and notified staff from another unit to assist related to aggressive behaviors of the resident. A total of four staff (AP along with three other unlicensed staff) responded to provide the care. The resident had a history of becoming physically aggressive towards staff including pulling of hair, pinching, punching, and kicking. The facility internal investigation report indicated there were conflicting narratives between the AP and other witnesses present. The document indicated an incident had occurred and possibly caused emotional distress and physical pain with no injuries. The resident quickly returned to baseline when the AP released the resident’s wrists/arms and the incontinent care was completed by staff. During an interview, unlicensed staff #1 stated it was normal for three to four staff to complete cares due to the resident’s aggressions towards staff. Unlicensed staff #1 stated AP had made an inappropriate comment to the resident and then grabbed her wrists when the resident became aggressive. Unlicensed staff #1 stated she was caught off guard by the AP’s actions. During an interview, an unlicensed staff #2 stated there were four unlicensed staff in the room. Unlicensed staff #2 was in the process of starting cares when the resident punched her in the chest hard and pulled her hair. Unlicensed staff #2 stated the resident moved around a lot when trying to provide cares. Unlicensed staff #2 stated it was at that time when the AP made an inappropriate comment towards the resident and then grabbed the resident’s arms to hold them down as the resident was pulling unlicensed staff #2’s hair. The AP continued to hold down the resident’s arms above the wrists so cares could be completed. Unlicensed staff #2 stated that was the first time she had heard the AP swear at a resident and unlicensed staff #2 felt it was less than a minute when she asked AP to let go of the resident wrists which the AP did and left the room. Unlicensed staff #2 stated when she came out of the room AP no longer working and was not sure if she asked to leave her shift early or if she was sent home. During an interview, unlicensed staff #3 stated she thought the AP restrained the resident using a bearhug hold which would hold down the resident’s arms so the resident could not continue to strike out at staff. Unlicensed staff #3 was not certain but stated AP would have had to have been standing behind the resident and would have had her arms wrapped around her chest to keep her arms close to her body as the resident was standing up while staff were trying to clean her up and get a clean brief and clothes on her. I did not hear exactly what AP had said to the resident. The resident calmed down after cares were completed. Unlicensed staff #3 stated she reported the incident to the lead staff immediately after leaving the room. During an interview, a licensed nurse stated the resident had multiple interventions in place to include redirect, reapproach, and nursing continued to come up with new interventions. It was not unusual for two to three staff present to assist with care and provide safety for both staff and the resident. The AP was sent home just before the licensed nurse arrived at work. Licensed nurse stated she had never witnessed the AP having any bad interactions with the resident or any other resident’s prior and was surprised to hear what had happened. In conclusion, the Minnesota Department of Health determined abuse 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. 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; or (3) use of any aversive or deprivation procedure, unreasonable confinement, or involuntary seclusion, including the forced separation of the vulnerable adult from other persons against the will of the vulnerable adult or the legal representative of the vulnerable adult unless authorized under applicable licensing requirements or Minnesota Rules, chapter 9544. Vulnerable Adult interviewed: No. Family/Responsible Party interviewed: Yes Alleged Perpetrator interviewed: No, The AP declined to complete an interview the Action taken by facility: The facility suspended the AP and completed an investigation. The AP is no longer employed at the facility. 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/ 23/ 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.

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 . . ." 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 2: a fine of $500 per violation, in addition to any enforcement mechanism authorized in § 144G.20; 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 Theref ore, in accordance with Mi nn. Stat. §§ 144G.01 to 144G.9999, the total amount you are assessed is $500.00. You will be invoiced approximately 30 days after receipt of this notice, subject to appeal. An equal opportunity employer. Letter ID: IS7N REVISED 09/13/2021 Nagel Assisted Living August 15, 2025 Pa ge 2 DOCUMENTATION OF ACTION TO COMPLY In accordance wi th 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 To appeal fines via reconsideration, please follow the procedure outlined above. Please note that you may request a reconsideration or a hearing, but not both . If you wish to contest tags wi thout 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: https: //forms.office.com/g/Bm5uQEpHVa . Your input is import ant 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 Nagel Assisted Living August 15, 2025 Pa ge 3 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, Kelly Thorson , Supervisor State Evaluation Team Email: Kelly.Thorson@state.mn.us Telephone: 320-223-7336 Fax: 1-866-890-9290 KKM PRINTED: 08/15/2025 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 _____________________________ 31214 06/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 232 ELM STREET SOUTH NAGEL ASSISTED LIVING WACONIA, MN 55387 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 far 144G.08 to 144G.95, these correction orders are 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. SL#31214016 PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On June 23, 2025, through June 25, 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 45 residents; 45 receiving services under the Assisted Living Facility with THERE IS NO REQUIREMENT TO Dementia Care license. SUBMIT A PLAN OF CORRECTION FOR VIOLATIONS OF MINNESOTA STATE STATUTES. THE LETTER IN THE LEFT COLUMN IS USED FOR TRACKING PURPOSES AND REFLECTS THE SCOPE AND LEVEL ISSUED PURSUANT TO 144G.31 SUBDIVISION 1-3. 0 680 144G.42 Subd. 10 Disaster planning and 0 680 SS=F emergency preparedness LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 6MZQ11 If continuation sheet 1 of 22 PRINTED: 08/15/2025 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 _____________________________ 31214 06/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 232 ELM STREET SOUTH NAGEL ASSISTED LIVING WACONIA, MN 55387 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) 0 680 Continued From page 1 0 680 (a) The facility must meet the following requirements: (1) have a written emergency disaster plan that contains a plan for evacuation, addresses elements of sheltering in place, identifies temporary relocation sites, and details staff assignments in the event of a disaster or an emergency; (2) post an emergency disaster plan prominently; (3) provide building emergency exit diagrams to all residents; (4) post emergency exit diagrams on each floor; and (5) have a written policy and procedure regarding missing residents. (b) The facility must provide emergency and disaster training to all staff during the initial staff orientation and annually thereafter and must make emergency and disaster training annually available to all residents.

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 the facility failed to report resident health concerns to the resident’s provider. Staff found the resident deceased in her room. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. The facility made the resident’s medical provider aware of the resident’s health concerns and offered to have emergency services take the resident to the hospital when she reported not feeling well. The resident declined going to the hospital or seeking further treatment around the time of her death. The staff provided care according to the residents individual needs and as the resident would allow. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted the resident’s case worker and An equal opportunity employer. medical provider. The investigation included review of medical records, staffing records, facility policies and procedures. Also, the investigator observed staff interacting with residents. The resident resided in an assisted living facility. The resident’s diagnoses included bipolar disorder (a mental illness that causes unusual shifts in a person’s mood, energy, activity levels, and concentration), post-traumatic stress disorder, kidney disease, and lung disease. The resident’s service plan included assistance with making appointments, medication management, weight monitoring, and behavioral management. The resident’s assessment indicated the resident had swelling to her legs and a sleep disorder that she declined follow-up care to address. Notes in the resident’s medical record indicated despite facility staff arranging medical appointments, appointment transportation, and giving appointment reminders to the resident, the resident would often cancel or decline appointments. During interviews, multiple staff members stated they encouraged the resident to seek medical attention or accept emergency services when she reported not feeling well the days prior to her death. The staff members stated the resident was her own decision maker and declined further medical intervention and going to the hospital. During interview, the resident’s medical provider stated the facility kept her aware of medical and behavioral concerns regarding the resident. The medical provider stated on average she saw the resident one or two times per month and it was common for the resident to not adhere to medical advice or decline services from specialty providers for health issues. The medical provider also stated the resident would often miss appointments with her or other medical professionals. During interview, an unlicensed staff member stated she cared for the resident the evening before the resident died. The staff member administered medication prescribed to the resident to assist with breathing issues and checked her vital signs because the resident reported issues with her chest and difficulty breathing. The staff member stated the resident’s vital signs were not unusual and the resident declined recommendations to go to the hospital. 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, family not involved with resident care. Alleged Perpetrator interviewed: Not Applicable. Action taken by facility: No action taken. 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: 11/06/2023 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 _____________________________ 31214 10/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 232 ELM STREET SOUTH NAGEL ASSISTED LIVING WACONIA, MN 55387 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 October 13, 2023, the Minnesota Department of Health initiated an investigation of complaint #HL312143758C/#HL312147304M. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 XJ5411 If continuation sheet 1 of 1

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 . . ." 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. In accordance with Minn. Stat. § 144G.31, Subd. 4 (a)(5), the MDH may impose fine amounts of either $1,000 or $5,000 to licensees who are found to be responsible for maltreatment. The MDH may impose a fine of $1,000 for each substantiated maltreatment violation that consists of abuse, neglect, or financial exploitation according to Minn. Stat. § 626.5572, Subds. 2, 9, 17. The MDH An equal opportunity employer. Letter ID: IS7N REVISED 09/13/2021 Nagel Assisted Living July 25, 2023 Pag e 2 also may impose a fine of $5,000 for each substantiated maltreatment violation consisting of sexual assault, death, or abuse resulting in serious injury. In accordance with Minn. Stat. § 144G.31, Subd. 4 (b), when a fine is assessed against a facility for substantiated maltreatment, the commissioner shall not also impose an immediate fine under this chapter for the same circumstance. Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, the following fines are assessed pursuant to this survey: St - 0 - 0510 - 144g.41 Subd. 3 - Infection Control Program = $500.00 St - 0 - 2310 - 144g.91 Subd. 4 (a) - Appropriate Care And Services = $3,000.00 The re fore , in ac corda nce wit h Minn . St at . §§ 144G. 01 to 144G .9999, the total amount you are assessed is $3,500.00. You will be invoiced approximately 30 days after receipt of this notice, subject to appeal . DOCUMENTATIO ONF ACTION TO COMPLY In ac cordanc e with Minn. Stat. § 144G .30, Subd . 5(c), the lice ns ee mus t doc um ent ac tion s 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). CORRECTIO ONRDER RECONSIDERATIO PNROCESS 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. Plea se ema il recons ideration reque sts to: Health. HRDA. ppeals@state. mn. us. Please atta ch t his lett er Nagel Assisted Living July 25, 2023 Pag e 3 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 REQUESTIN GA 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 MDH 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. Requests for he aring may be emailed to: Health. HRDA. ppeals@state. mn. us. To appeal fines via rec onsideration, plea se follow the procedure outline d abov e. Ple as e note that you may reque st a rec ons ide rat ion or a he aring , but not bot h. 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, Kelly Thorson, Supervisor State Evaluation Team Email: kelly.thorson@ state. mn.us Telephone: 320-223-7336 Fax: 651-281-9796 PMB PRINTED: 07/ 25/ 2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/ SUPPLIER/ CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 31214 06/ 23/ 2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 232 ELM STREET SOUTH NAGEL ASSISTED LIVING WACONIA, MN 55387 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. SL31214015 PLEASE DISREGARD THE HEADING OF On June 20, 2023, through June 23, 2023, the THE FOURTH COLUMN WHICH survey at the above provider, and the following CORRECTION. " THIS APPLIES TO correction orders are issued. At the time of the FEDERAL DEFICIENCIES ONLY. THIS survey, there were 48 active residents; all WILL APPEAR ON EACH PAGE. receiving services under the Assisted Living with Dementia Care license. THERE IS NO REQUIREMENT TO SUBMIT A PLAN OF CORRECTION FOR VIOLATIONS OF MINNESOTA STATE 2310: An immediate correction order was issued STATUTES. on June 22, 2023. The immediacy was removed; however, non- compliance remains at a level 3, The letter in the left column is used for widespread scope (I). tracking purposes and reflects the scope and level issued pursuant to 144G. 31 subd. 1, 2, and 3. 0 250 144G.