New Perspective White Bear Lak.

correction orders using federal software. Please disregard the heading of the fourth column that states, "Provider's Plan of Correction." A plan of correction is not required. 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, Jess Schoenecker, Supervisor State Evaluation Team Email: Jess.Schoenecker@state.mn.us Telephone: 651-201-3789 Fax: 1-866-890-9290 HHH An equal opportunity employer. Letter ID: IS7N REVISED 09/13/2021 PRINTED: 11/19/2024 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 32917 10/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3820 HOFFMAN ROAD THE WATERS OF WHITE BEAR LAKE WHITE BEAR LAKE, MN 55110 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 SL32917016-0 On October 14, 2024, through October 15, 2024, the Minnesota Department of Health conducted a survey at the above provider. At the time of the survey, there were 134 residents; 58 receiving services under the Assisted Living with Dementia Care license. As a result of the survey, the licensee was found to be in compliance with the assisted living statutes 144G.08 through 144G.95. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 OE6T11 If continuation sheet 1 of 1 Food Pools & Lodging Services St Paul, MN 55164-0975 Type: Full Page 1 Food and Beverage Establishment Date: 10/14/24 Inspection Report Time: 10:11:48 Report: 8058241267 Location: Establishment Info: The Waters Of White Bear Lake ID #: 0038043 Risk: 3820 Hoffman Road Announced Inspection: No White Bear Lake, MN55110 Ramsey County, 62 License Categories: Operator: Phone #: 6513136440 Expires on: / / ID #: The violations listed in this report include any previously issued orders and deficiencies identified during this inspection. Compliance dates are shown for each item. No NEW orders were issued during this inspection. Surface and Equipment Sanitizers Quaternary Ammonia: = 200 PPM at --- Degrees Fahrenheit Location: DISPENSER Violation Issued: No Hot Water: = --- at 171 Degrees Fahrenheit Location: DISH MACHINE Violation Issued: No Food and Equipment Temperatures Process/Item: TOMATO Temperature: 38 Degrees Fahrenheit - Location: PREP Violation Issued: No Process/Item: CHICKEN SALAD Temperature: 37 Degrees Fahrenheit - Location: PREP Violation Issued: No Process/Item: EGG SALAD Temperature: 41 Degrees Fahrenheit - Location: PREP Violation Issued: No Process/Item: HAM Temperature: 37 Degrees Fahrenheit - Location: PREP Violation Issued: No Process/Item: TURKEY Temperature: 38 Degrees Fahrenheit - Location: PREP Violation Issued: No Type: Full Page 2 Food and Beverage Establishment Date: 10/14/24 Inspection Report Time: 10:11:48 Report: 8058241267 The Waters Of White Bear Lake Process/Item: BEEF ROAST Temperature: 41 Degrees Fahrenheit - Location: WALK IN Violation Issued: No Process/Item: CHICKEN Temperature: 38 Degrees Fahrenheit - Location: WALK IN Violation Issued: No Process/Item: PORK Temperature: 40 Degrees Fahrenheit - Location: WALK IN Violation Issued: No Process/Item: STRAWBERRY Temperature: 38 Degrees Fahrenheit - Location: WALK IN Violation Issued: No Total Orders In This Report Priority 1 Priority 2 Priority 3 0 0 0 HRD INSPECTOR BRANDON MUELLER COMMERCIAL KITCHEN SPACE TWO REMOTE KITCHENS IN MEMORY CARE UNITS ARE NO LONGER USED FOR STORAGE AND ARE LIMITED TO USE ONLY DURING IMMEDIATE SERVICE DISCUSSED EMPLOYEE EXCLUSION, SICK TIME, PERSON TO PERSON ILLNESS POTENTIAL, SHELLED EGG USE, COOLING/COOKING OF WHOLE MUSCLE ROAST NOTE: Plans and specifications must be submitted for review and approval prior to new construction, remodeling or alterations. I acknowledge receipt of the Minnesota Department of Health inspection report number 8058241267 of 10/14/24. RYAN BECKER Certified Food Protection Manager: 87036 04/18/26 Certification Number: Expires: Inspection report reviewed with person in charge and emailed. Signed: Signed: RYAN BECKER Aaron Gertz PIC Sanitarian 3 MDH Metro Office health.foodlodging@state.mn.us

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 the resident when staff failed to provide supervision. The resident fell and sustained a head laceration. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. The facility staff provided services according to the resident’s service plan. The resident had an isolated, unwitnessed fall, and sustained a head laceration. When staff found the resident, they contacted the nurse, and transferred the resident to an emergency room for evaluation. The investigator conducted interviews with facility staff members including nursing staff. The investigator contacted the resident’s family member. The investigation included review of the resident’s record, assessments, service delivery records, incident report, and staff schedules. The investigator toured the facility, the resident’s memory care unit, and observed staff interactions with the resident. An equal opportunity employer. The resident resided in an assisted living memory care unit. The resident’s diagnoses included dementia. The resident’s service plan included assistance with dressing, grooming, escorts to meals, and every two-hour safety checks. The resident’s assessment indicated the resident stood and walked independently and wandered within the secured unit safely. The resident was disorientated to person, place, and time. The resident was unable to utilize a call pendent due to attempts to consume it. The resident’s fall risk assessment indicated the resident was at risk for falls, did not have a history of falls, and fall interventions were in place. The resident’s incident report and facility internal investigation indicated the resident had an unwitnessed fall. Staff found the resident sitting on the dining room floor. Staff contacted the nurse, took vital signs, and the nurse applied pressure to the back of the resident’s head to stop the bleeding. The resident also had a left-hand skin tear. The nurse called emergency medical services and transferred the resident to the emergency room for evaluation. The resident emergency room discharge records indicated the resident had two staples placed to his head laceration and discharged back to the facility the same day. The residents service delivery records indicated the resident received services according to the service plan, including every two-hour safety checks. During an interview, a nurse stated the day the resident fell, staff notified her of the fall. Staff found the resident was sitting on dining room floor. The nurse stated the resident was bleeding from the back of the head and she applied pressure to the resident’s wound and called emergency medical services. The nurse stated staff working on the unit did not know how the resident fell; the fall was unwitnessed. The nurse stated the resident did not have a history of falls and staff performed safety checks including visualizing the resident to ensure the resident’s safety. In conclusion, the Minnesota Department of Health determined neglect was not substantiated. “Not Substantiated” means: An investigatory conclusion indicating the preponderance of evidence shows that an act meeting the definition of maltreatment did not occur. Neglect: Minnesota Statutes, section 626.5572, subdivision 17 Neglect means neglect by a caregiver or self-neglect. (a) "Caregiver neglect" means the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to, food, clothing, shelter, health care, or supervision which is: (1) reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult; and (2) which is not the result of an accident or therapeutic conduct. Vulnerable Adult interviewed: No. Unable due to cognition. Family/Responsible Party interviewed: No, declined to interview. Alleged Perpetrator interviewed: Not Applicable. t Action taken by facility: The facility staff provided the residents services according to the service plan. Staff notified the nurse of the resident’s unwitnessed fall and transferred the resident to the emergency room for evaluation. 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: 08/04/2023 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 _____________________________ 32917 07/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3820 HOFFMAN ROAD THE WATERS OF WHITE BEAR LAKE WHITE BEAR LAKE, MN 55110 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 July 24, 2023, the Minnesota Department of Health initiated an investigation of complaint #HL329175452C/#HL329173423M. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 982G11 If continuation sheet 1 of 1