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Uniform Disclosure of Assisted LivingServices and AmenitiesPurposeThis is a required document per 144G.40 Subd. 2 (www.revisor.mn.gov/statutes/cite/144G.40)of all assisted living facilities to describe the services, supports, and amenities available at theassisted living facility. Prospective residents and their families can use this tool to determine ifthe assisted living facility can meet their needs, allow them to compare options among varioussettings, and make informed decisions about selecting an assisted living facility setting. Theinformation presented here may be important for a resident’s ability to age in place. Assistedliving facilities are not required to provide all the services listed, and available services aresubject to change. The facility will indicate which services are provided and any limitations thatmay pertain to the service.You are also encouraged to tour facilities, talk with other residents, residents’ family members,or meet one-on-one with facility staff during the selection process. The disclosure checklist isnot a substitute for the assisted living contract, which is a separate document that will includethe specific services to be provided to the individual resident and the fees per services.General Information05/03/2021This information is current as of (MM/DD/YYYY):Maplewood Homes of Faribault, Inc.Name of Assisted Living:House 2Unique building/unit descriptive (if applicable):428 NW 5th StreetPhysical Address:If the indicated services are provided for more than one building/unit (on the campus), list alladditional buildings/units this applies to. Use additional pages if necessary. No additional buildings/units Additional Building:Unique building/unit descriptive (if applicable):Physical Address (if different than above):Additional Building:House 2Unique building/unit descriptive (if applicable):Physical Address (if different than above):Additional Building:House 2Unique building/unit descriptive (if applicable):Physical Address (if different than above):1

UNIFORM DISCLOSURE OF ASSISTED LIVING SERVICES & AMENITIESFacility/Campus listed above has the following license. Check one: Assisted Living Facility License Assisted Living Facility with Dementia Care LicenseAvailability of Unlicensed Staff (ULP); check one: Unlicensed staff are in the building and available to respond to resident requests 24/7 Unlicensed staff may either be in the building, in an attached building, or within thecampus and available to respond to resident requests 24/7Availability of Licensed (RN/LPN) Staff (in addition to an RN who is required to be accessible tothe staff 24/7); check one if applicable: Licensed staff are on site 24/7 Licensed staff are either in the building, an attached building, or within the campus andavailable to respond to resident requests 24/7Number of unlicensed direct care staff typically scheduled per shift:3Day Shift:1Evening Shift:1Night shift:Payment OptionsThe facility will indicate by placing an “X” in the “Available” column if the payment option isaccepted (may check more than one). Please indicate in the “Comments” column below if apre-determined length of private funds payment source is required before acceptance ofMedicaid or waivered service funds; and if yes, indicate the number of months required.Payment Options for Housing ContractPayment OptionAcceptedXPrivate PaySliding ScaleHousing Support (formerly Minnesota GroupResidential Housing) PaymentsXFederal rent subsidy2Comments

UNIFORM DISCLOSURE OF ASSISTED LIVING SERVICES & AMENITIESPayment OptionAcceptedCommentsOther; explainPayment Options for ServicesPayment OptionAcceptedCommentsXWaivered Services (EW, CADI, BI); specify anylimitationsXPrivate PayLong Term Care InsuranceOther; explainServices and Amenities AvailableBelow is a list of services that are available to assisted living residents. The facility will indicateby placing a “yes” or “X” in the “Available” column if the service is provided or available at/onthe campus/unit of the location listed above. If the “Available” column is blank, the facilitydoes not provide that service.Section 1: Dementia Care (pertains only to an Assisted Living with Dementia Care license)Check each service available at the location(s) listed above.Dementia Care Services AvailableServiceAvailableSecured unit or building for wandering or exit-seekingbehaviorSecured outdoor grounds on facility premisesIndividualized digital/alarm monitoring for wandering orexit-seeking behaviorPrepared to manage challenging behaviors3Comments

UNIFORM DISCLOSURE OF ASSISTED LIVING SERVICES & AMENITIESServiceAvailableCommentsOther; specify in commentsSection 2: Medication ManagementCheck each service available at the location(s) listed above.Medication Management Services AvailableServiceAvailableVerbal or visual reminders to take regularly scheduledmedications; specify any limit to frequency in commentsXCommunication with physician/pharmacy about ordering orrefill requestsXMedication administration by licensed or unlicensedpersonnelXDelivery of medication to resident previously set up by thefacility nurseMedications set up by nurse for resident to self-administerDelivery of medication from the original containers toresidentXDelivery of liquid or food to resident if required to ingestmedicationXDelegation of medication management services by licensedhealth professional to unlicensed staffXCentral storage of medicationXDiabetic Care: insulin pen dosingXDiabetic Care: insulin pump managementDiabetic Care: insulin syringe dosingDiabetic Care: sliding scale insulin managementX4Comments

UNIFORM DISCLOSURE OF ASSISTED LIVING SERVICES & AMENITIESServiceAvailableClinical monitoring of labs related to medicationsXAnticoagulant medication managementXB-12 injectionsXNutritional supplement administrationX(IV) Intravenous managementPICC lines (Peripherally Inserted Central Catheter)Injections; specify types or limits in comments (IM, SQ)XNebulizersXInhalersXEar dropsXEye dropsXTopicalsXPatchesXMedication delivery via enteral (feeding) tubePain pump managementMedical cannabis administration (pill form) for certifiedpatientsMedical Cannabis storage for certified patientsCannabidiol oil administration for certified patients5Comments

UNIFORM DISCLOSURE OF ASSISTED LIVING SERVICES & AMENITIESServiceAvailableCommentsOther; specify in commentsSection 3: Treatments & TherapiesCheck each service available at the location(s) listed above.Treatments & Therapies AvailableServiceAvailableVerbal or visual reminders to perform regularly scheduledtreatments or exercisesXWound care: basicXWound care: complexXDiabetic care: blood glucose monitoringXDiabetic care: foot/nail careXC-PAPXBi-PAPXOxygen Management; specify any delivery systemlimitationsXOxygen saturation checksXVentilatorsSuctioningTracheostomy Care: cleaning of site and tubeTracheostomy Care: showering assistance6Comments

UNIFORM DISCLOSURE OF ASSISTED LIVING SERVICES & AMENITIESServiceAvailableTracheostomy Care: suctioning assistancePacemaker ChecksArrange for On-Site DialysisArrange for/set-up Off-Site DialysisPeritoneal Dialysis (on-site)XCompression stockingsLymphedema wrapsFall Prevention: balance assessmentsFall Prevention: exercise programsFall Prevention: strength trainingIntegrative Health Services: acupunctureIntegrative Health Services: aromatherapyIntegrative Health Services: healing touchIntegrative Health Services: massageBlood pressure checksXDaily weight checkXIndwelling urinary catheter care; emptying and bag changesXIndwelling urinary catheter replacement by nurseX7Comments

UNIFORM DISCLOSURE OF ASSISTED LIVING SERVICES & AMENITIESServiceAvailableStraight (intermittent) catheter assistanceXSuprapubic catheter careXCommentsOstomy careArrangements for and coordination with hospice careEnd-of-life palliative careAccess to and training on use of automatic electronicdefibrillators (AED)Training of and use of Cardiopulmonary Resuscitation (CPR)Other; specify in commentsSection 4: Assistance with Activities of Daily LivingCheck each service available at the location(s) listed above.Assistance with Daily Living Activities AvailableServiceAvailableDressingXBathing: showerXBathing: bathtubXOral hygieneXDenture careXXCueing/reminders for self-care8Comments

UNIFORM DISCLOSURE OF ASSISTED LIVING SERVICES & AMENITIESServiceAvailableUse of special utensilsFeeding assistance for residents with complicated eatingproblemsXSet-up and cut food at mealsManual Feeding; specify limits in commentsTube Feeding; specify limits in commentsFeeding in common area with one staff member per residentFeeding in resident’s apartment with one staff member perresidentGrooming: hair care, make-up, shaving, application of lotion,etc.XNail care: toenails, fingernailsXToileting: standby assistance/supervisionChanging incontinence products; perineal careXOrdering replacement incontinence productsAssistance with bowel and bladder control, devices, andtraining programsOther; specify in comments9Comments

UNIFORM DISCLOSURE OF ASSISTED LIVING SERVICES & AMENITIESSection 5: Mobility SupportCheck each service available at the location(s) listed above.Mobility Services AvailableServiceAvailableXStandby AssistanceTransfers with assist of one staffTransfers with assist of two staffTransfers utilizing sit-to-stand liftsTransfers utilizing sliding boardsTransfers utilizing bariatric equipmentCeiling lift transfersNon-mechanical transfers (trapeze)Mechanical lift: assist of 1 transferMechanical lift: assist of 2 transferAmbulation with assist of 1Bed mobilityAssistance with chair mobilityChair Glide SystemMechanical Stair Lift SystemXHandrails; in personal space10Comments

UNIFORM DISCLOSURE OF ASSISTED LIVING SERVICES & AMENITIESServiceAvailableCommentsElevatorsOther; specify in commentsSection 6: Security & MonitoringCheck each service/option available at the location(s) listed above.Security and Monitoring ServicesServiceAvailableEvery 15-minutes safety checksEvery 30-minutes safety checksHourly safety checksEvery two-hours safety checksXDaily safety checksEmergency call system; specify type in commentsNon-emergency call system; specify type in commentsDigital wander alert device on residentWander alert system at facility exitsStaff monitoring at facility exits; specify method incommentsVisitor check-in/check-out at facility main entranceBed alarms or movement sensing technology11Comments

UNIFORM DISCLOSURE OF ASSISTED LIVING SERVICES & AMENITIESServiceAvailableCommentsDoor sensors: specify locations (unit, resident room, exits,etc.)Security GuardSecurity cameras in common spacesKey card/fob access: specify locations (unit, resident room,exits, etc.)Other lock systems: specify locations (unit, resident room,exits, etc.)Emergency generator(s) to power the facility during poweroutagesOther; specify in commentsSection 7: Dining and NutritionCheck each service/option available at the location(s) listed above.Dining and Nutrition ServicesServiceAvailableThree meals available, plus snacksRequiredXBreakfast available in community spaceBreakfast available; delivered to apartmentXLunch available in community spaceLunch available; delivered to apartmentXDinner available in community spaceDinner available; delivered to apartment12Comments