The Centennial House of Apple.

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 CORRECTIO NORDERS 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 1: no fines or enforcement; Level 2: a fine of $500 per violation, in addition to any enforcement mechanism authorized in § 144G.20; Level 3: a fine of $1,000 per incident, in addition to any enforcement mechanism authorized in § 144G.20; An equal opportunity employer. Letter ID: IS7N REVISE D09/13/2021 The Centennial House Apple Valley January 13, 2026 Page 2 Level 4: a fine of $3,000 per incident, in addition to any enforcement mechanism authorized in § 144G.20; Level 5: a fine of $5,000 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 The refor e, in accor danc e wit h Minn. Sta t. §§ 144G.01 to 144G.999 9, the total amount you are assessed is $500.00. You will be invoiced approximately 30 days after receipt of this notice, subject to appeal . DOCUMENTATIO ONF ACTION TO COMPLY In accorda nce with Min n. Stat. § 144G.30, Sub d. 5(c), th e lic ens ee mus t docum ent ac tions taken t o 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 NORDER 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 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 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 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. The Centennial House Apple Valley January 13, 2026 Page 3 To submit a hearing request, please visit: https: / / forms. web. health. state. mn. us/ form/ HRDAppealsForm To appe al fi nes via re cons iderat ion , pl ease follow the procedu r e outl ined abo ve. Plea se no te tha t you may re que st a rec onside rati on or a hearing, bu t not bot h. If you wish to cont est ta gs with out fine s 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 conv enien ce at thi s link: https: / / forms. office.com/ g/ Bm5uQEpHVa. Your inpu t 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 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, Jodi Johnson, Supervisor State Evaluation Team Email: Jodi.Johnson@state. mn.us Telephone: 507-344-2730 Fax: 1-866-890-9290 CLN PRINTED: 01/ 13/ 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: ______________________ B. WING _____________________________ 20316 12/ 17/ 2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 14625 PENNOCK AVENUE THE CENTENNIAL HOUSE APPLE VAL APPLE VALLEY, MN 55124 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 144G. 08 to 144G. 95, these correction orders are far-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. SL20316016- 0 PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On December 15, 2025, through December 17, STATES, "PROVIDER' S PLAN OF 2025, the Minnesota Department of Health CORRECTION. " THIS APPLIES TO conducted a full survey at the above provider and FEDERAL DEFICIENCIES ONLY. THIS the following correction orders are issued. At the WILL APPEAR ON EACH PAGE. time of the survey, there were 71 residents; 70 receiving services under the Assisted Living THERE IS NO REQUIREMENT TO Facility with 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. 0 480 144G. 41 Subdivision 1 Subd. 1a (a-b) Minimum 0 480 SS= F requirements; required food services LABORATORY DIRECTOR' S OR PROVIDER/ SUPPLIER REPRESENTATIVE' S SIGNATURE TITLE (X6) DATE STATE FORM 6899 OC2711 If continuation sheet 1 of 36 PRINTED: 01/ 13/ 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: ______________________ B.

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) neglected the resident when the resident did not receive prescribed medications as ordered. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. Upon review of the resident record, transcription errors were present, and medications were not given to the resident as prescribed, however, the alleged perpetrator was unaware of errors in the order transcription process. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted the resident’s family member. The investigation included review of the resident record, hospital records, facility internal investigation, facility incident reports, personnel files, staff schedules, and related facility policy and procedures. Also, the investigator made an onsite visit observed staff interactions with residents. The resident resided in an assisted living facility. The resident’s diagnoses included congestive heart failure (inability of the heart to pump enough blood to meet the body’s needs), chronic obstructive pulmonary disease (a lung disease that restricts breathing) and atrial fibrillation (an abnormal heart rhythm) and a pacemaker. The resident’s service plan included assistance with medication management. The resident’s assessment indicated the resident was able to walk independently using a cane and was alert to person, place, time, and situation. One month a concern arose that the resident was not receiving her medications as ordered. During the previous several weeks, the resident had been out of the facility, then re-admitted twice with new medication orders. However, the new orders were missed, and the medication changes did not take place. Initial Hospitalization The resident’s medical record indicated the resident was sent to the hospital from the facility and remained there for nine days. The resident’s progress notes indicated the resident’s heart rate was 141 beats per minute when he was sent to the hospital. From the hospital the resident transferred to a nursing home for transitional care. The resident was at the nursing home for about two weeks before readmission back to the facility. Prior to this hospitalization, the resident’s electronic medication administration record (eMAR) indicated the following: The resident’s prescribed medications included carvedilol 1. The resident’s prescribed medications did not include metoprolol 2. As the end of the month approached, the nursing home prepared to discharge the resident back to the facility. Return from the Nursing Home On the 1st day of the month, the progress notes indicated the resident’s discharge orders from the nursing home would be faxed by the end of that day. The same note indicated the resident would return to the facility the following day (the 2nd day of the month). A fax dated the 1st day of the month from the nursing home indicated the resident had been hospitalized for more than a week and then went the nursing home for recovery. The fax indicated it included the orders from the nursing home for discharge back to the facility. The same document indicated the reason for the hospitalization was for CHF exacerbation and atrial fibrillation with “RVR” [rapid ventricular response]. The same document indicated the resident had been with a high heart rate which was attributed to a possible pacemaker malfunction and metoprolol was increased for the ongoing high heart rate. A review of the medications listed in the fax indicated the resident should receive metoprolol. The same review found no mention of carvedilol regarding continuing or discontinuing. A progress note dated the 2nd day of the month indicated the resident returned to the facility that day and that his “discharge paperwork” was in the resident’s chart. A review of the copy of the fax provided by the facility for the investigation indicated the fax had been sent to the attention of a nurse other than the alleged perpetrator. The copy of the fax included no indication any facility staff member from the facility reviewed it. A review of the resident’s eMAR indicated the following: The facility continued to administer carvedilol 1. The facility began administering metoprolol upon readmission 2. However, a comparison of the dose described in the fax did not match the dose that displayed on the eMAR. The resident’s eMAR indicated the facility did not perform medication reconciliation of the resident’s medication upon readmission, nor did the facility clarify the status of the carvedilol with the resident’s prescriber. Second Hospitalization On the 9th day of the month the progress notes indicated the resident had “flu-like” symptoms. The same document indicated the resident said he had caught a cold at the nursing home. The facility tested the resident for COVID but that was negative. The resident’s heart rate was 70 beats per minute. The same document indicated the resident’s medical provider was updated and he was encouraged to increase his fluid intake. The resident was encouraged to consider hospitalization, but he declined. A late entry progress note for the same day, entered on the 11th day of the month, indicated the facility sent the resident to the hospital for concerns regarding the resident’s breathing. Return from the Hospital On the 15th day of the month the resident readmitted to the facility. The medication orders indicated to discontinue carvedilol. The same orders included the same metoprolol dose as the fax dated the 1st day of the month. A progress note indicated the resident returned to the facility on the 15th of the month. The same note indicated there were new medication orders which included to discontinue carvedilol and to begin metoprolol. The same document indicated the resident’s medical provider would see the resident in two days. A review of the resident’s eMAR indicated the following: The facility continued to administer carvedilol for two days and then it was discontinued 1. The facility continued administering the incorrect dose of metoprolol for two days, then 2. began administering the medication dosage as indicated in the readmission orders. A progress note dated the 18th day of the month indicated the resident’s medical provider saw the resident the day prior and gave new orders which included discontinuing carvedilol. Facility Investigation The facility internal investigation summary indicated the resident’s medical provider informed the facility of possible medication errors on or about the 17th of the month. The same documents indicated on the 2nd and the 15th day of the month when the resident returned to the facility. The same documents indicated the alleged perpetrator was the nurse who readmitted the resident on both occasions. The facility investigation included notes taken during an interview with the alleged perpetrator. The notes indicated she had been unaware of the medication errors until the internal investigation was conducted. When asked if she understood the readmission process, the notes indicated she stated she felt like she understood the process. The notes indicated the alleged perpetrator described the following steps when a resident returns to the facility from another setting: Take the resident off LOA (leave of absence) in “service minder” [a reference to the  software used for the electronic medical record (EMR) Notify the medical provider of the return  Then enter details and review new orders  The same document indicated she described the medication reconciliation process, which included these points: Ask the social worker or nurse [from the discharging facility] if the prescriptions were  sent directly to the pharmacy or if the orders were sent with the resident. If there are new orders on the discharge paperwork, make sure the social worker or  nurse sent the prescriptions to the pharmacy If not, then fax them to the pharmacy  Then review the medications in the “Pending Review” in the “service minder” [a  reference to the functions of the electronic medical record software] Regarding the readmission on the 2nd day of the month, when asked if she had done the medication reconciliation upon return from the hospital the notes indicated the alleged perpetrator said yes. Regarding the readmission on the 15th day of the month the notes indicated the alleged perpetrator said when she learned the resident was returning to the facility, the resident was already being transported back.

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 the facility failed to ensure the resident was checked hourly, given meals, and given water per her plan of care. The resident experienced falls and had an instance when she was not given food and water for twenty hours. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was inconclusive. Although there were instances when the resident did not have meals, it could not be determined if the resident was declining meals or if meals were not offered. The resident was found on the floor, however, there was conflicting accounts of how often the resident was checked and it could not be determined if neglect contributed to the residents fall(s). The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigation included review of resident medical records, facility internal investigations, personnel files, staff schedules, and related facility policy and procedures. Also, the investigator observed staff providing care to residents. The resident resided in an assisted living memory care unit. The resident’s diagnoses included Alzheimer’s disease and history of falls. The resident’s service plan included assistance with escorts to and from meals, assistance with meals and monitoring of ability to chew and swallow liquids, re-offering food and fluids throughout shift, assist of two staff for transfers, and every two-hour repositioning. The resident’s assessment indicated the resident had weakness, multiple falls daily, experienced involuntary weight loss, and received hospice assistance. The assessment indicated a fall mat was used next to the resident’s bed along with a repositioning schedule and a mechanical lift, wheelchair, and shower chair. Review of facility internal investigation indicated the resident did not receive an evening meal and remained in her bedroom when the resident’s service plan indicated she should be brought to the dining room and assisted with meals. The investigation indicated an unlicensed staff member stated the resident refused dinner but was not offered a meal or snack later. Review of video footage indicated staff checked on the resident. During interview, a leadership member stated she received video footage from a family member regarding the resident not getting dinner. Staff members indicated the resident did not want to eat and staff did not reapproach the resident to offer food. Staff were educated to reapproach the resident after a refusal. During interview, a nurse stated there were occasions when the resident did not receive meals and believed this was due to staff thinking the resident was sleeping. Staff were under the impression that they should not wake the resident when she was sleeping. The nurse stated the resident was often agitated and wanted to get up and move. The facility attempted interventions to prevent falls such as a Broda Chair (a wheelchair that allows for tilt positioning and seating that redistributes pressure and helps prevent skin breakdown and promotes comfort). During interview, a family member stated the resident had a camera in her room that recorded footage with movement. The family member stated there were multiple instances recorded when a covered meal tray was left in the resident’s room and the resident would not be assisted or offered the food. Another video showed a staff member asking the resident if she was hungry, but no food or beverage was brought to the resident despite the resident stating she was hungry. The family member stated there were instances when the resident experienced falls and staff working during the following shifts would not be aware of the resident’s falls. Video footage was unavailable for investigator to review due to video footage storage expiring on the hosting website. During interview, a second family member of the resident stated the resident was not checked on for many hours during famiy visits and there was an instance when lunch was not offered to the resident. When the second family member inquired about the lunch, staff indicated the meal was thrown away because staff thought the resident was out of the building. The family member needed to request that a nutritious meal be given to the resident. 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, vulnerable adult was deceased. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Not Applicable. Action taken by facility: The facility conducted internal reviews of food related incidents. 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: 06/20/2024 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ C B. WING _____________________________ 20316 05/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 14625 PENNOCK AVENUE THE CENTENNIAL HOUSE APPLE VAL APPLE VALLEY, MN 55124 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 May 1, 2024, the Minnesota Department of Health initiated an investigation of complaint #HL203166951C/#HL203169267M. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 RP3P11 If continuation sheet 1 of 1