Croixdale.

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 resident sustained fall. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. The resident independently exited his apartment and fell against a doorway. Although the AP did not follow the facility’s protocol after the resident fell, there was not a preponderance of evidence to indicate the AP’s actions or inactions caused the resident’s left shoulder blade fracture. The resident was sent to the hospital for an evaluation and returned to the facility. The investigator conducted interviews with facility staff members, including nursing staff, and unlicensed staff. The investigation included review of the resident records, hospital records, facility internal investigation, facility incident reports, facility camera footage, personnel files, staff schedules, and related facility policy and procedures. Also, the investigator observed staff and resident interactions. The resident resided in an assisted living memory care unit. The resident’s diagnoses included Alzheimer’s disease and abnormalities of gait and mobility. The resident’s service plan included assistance with morning and evening care, and staff were to escort the resident to activities. The resident’s assessment indicated the resident had cognitive impairment, required supervision with ambulation, and used a walker. The facility camera footage showed the resident walking out of his apartment into the hallway while using his walker independently. As the resident came through his apartment doorway, the resident fell to his left side, hitting the back of his left shoulder against the bottom of an adjacent doorway and landing on his left elbow. The resident rolled himself onto his right side and then onto his back. After one minute and 10 seconds, the AP came to the side of the resident. The AP took the resident by his hands and pulled him up to a seated position. After a few seconds the resident rolled back onto his back. While standing behind the resident, the AP pushed the resident back into a seated position and placed her right knee into the back of the resident. Then the AP assisted the resident onto his hands and knees and then left the frame of the camera footage. After a few seconds, the AP returned to the frame of the camera footage with a chair and positioned the chair in front of the resident facing towards him. The AP assisted the resident into a standing position, placed the resident’s walker next to him and resident grabbed the walker. The AP assisted the resident back into his apartment. After a few seconds, the AP walked out of the resident’s apartment and down the hallway away from the resident’s apartment. The resident’s medical record indicated that the resident self-reported a fall to a different staff member and the facility’s camera footage was reviewed. The resident was assessed and was found with an abrasion on his left knee and severe left shoulder pain. The resident’s provider ordered an x-ray. As the day went on, the resident had unrelieved shoulder pain, the on-call nurse was notified, and the resident was sent to the hospital via emergency medical services. The hospital record indicated the resident presented to the hospital with left shoulder pain. The resident had a computed tomography (CT) scan completed and it revealed the resident had a non-displaced left shoulder blade (scapula) fracture. The resident’s left arm was placed in a sling and was discharged back to the facility. During an interview, unlicensed staff member stated a nurse was notified after the resident reported he fell into the doorway and hit his shoulder. During an interview, a nurse stated towards the end of the AP’s shift, the resident fell. The AP assisted the resident off the floor and back into this room. The AP did follow the facility’s fall protocol and did not report the fall appropriately. Another staff member went into the resident’s room, and the resident reported that he fell. An assessment and an x-ray were completed on the resident. Initially the x-ray indicated the resident did not have a fracture, but as the day went on, the resident’s pain was unrelieved. Late in the evening the resident was transferred to the hospital for an evaluation. The hospital determined the resident had fractured his left shoulder blade, placed his arm in a sling and the resident returned to the facility. The nurse stated the AP had reported and followed the facility’s fall protocol appropriately during previous falls of other residents. A nurse stated during her investigation she interviewed the AP who stated she thought if the resident could get up, she did not have to report the fall. The nurse stated education was completed with all staff that when a resident falls a nurse is to be notified, vital signs are to be completed on the resident, and two staff are to use a mechanical lift to get the resident off the floor, unless the resident can get up off the floor without any staff assistance. During an interview, a family member stated after the resident fell, he went to the hospital for a few hours. The resident returned to the facility, had his left arm placed in a sling, and the fractured healed. The family member stated the resident worked with therapy and the resident’s left arm was stronger than it ever had been. The AP did not respond to interview requests. 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. Due to cognitive impairment, the resident as not able to be interviewed. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: No. Several attempts to interview the AP were made unsuccessfully. Action taken by facility: The resident was transferred to the hospital for an evaluation, treated and returned to the facility. Staff education was completed regarding the facility’s fall protocol. The AP is no longer employed by 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/ 30/ 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. WING _____________________________ 31272 03/ 16/ 2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 850 HIGHWAY 95 NORTH CROIXDALE BAYPORT, MN 55003 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 March 16, 2026, the Minnesota Department of Health initiated an investigation of complaint #HL312728542M / #HL312721460C. No correction orders are issued. LABORATORY DIRECTOR' S OR PROVIDER/ SUPPLIER REPRESENTATIVE' S SIGNATURE TITLE (X6) DATE STATE FORM 6899 P84G11 If continuation sheet 1 of 1

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 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. An equal opportunity employer. Letter ID: IS7N REVISED 09/13/2021 Croixdale May 5, 2025 Page 2 Level 4: a fine of $5,000 per incident, 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 Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, t he total amount you are assessed is $500.00. You will be invoiced approximately 30 days after receipt of this notice, subject to appeal. 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 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. Croixdale May 5, 2025 Page 3 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. P lease note that you may request a reconsideration o r a hearing, but not both. If you wish to contest tags without 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: 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 L. Anderson, Supervisor State Evaluation Team Email: Renee.L.Anderson@state.mn.us Telephone: 651-201-5871 Fax: 1-866-890-9290 HHH PRINTED: 05/05/2025 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 _____________________________ 31272 02/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 850 HIGHWAY 95 NORTH CROIXDALE BAYPORT, MN 55003 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#31272016-0 PLEASE DISREGARD THE HEADING OF On February 24, 2025, through February 26, THE FOURTH COLUMN WHICH 2025, the Minnesota Department of Health STATES,"PROVIDER'S PLAN OF conducted a survey at the above provider, and CORRECTION." THIS APPLIES TO the following correction orders are issued. At the FEDERAL DEFICIENCIES ONLY. THIS time of the survey, there were 55 residents, all of WILL APPEAR ON EACH PAGE. whom were receiving services under the provider's Assisted Living with Dementia Care THERE IS NO REQUIREMENT TO 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 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 RF3711 If continuation sheet 1 of 5 PRINTED: 05/05/2025 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 _____________________________ 31272 02/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 850 HIGHWAY 95 NORTH CROIXDALE BAYPORT, MN 55003 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.

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), facility staff, financially exploited the resident when the resident inquired with facility staff how to add the AP to lease agreement. In addition, the AP sexually abused the resident when the AP and resident kissed and began a personal relationship. Investigative Findings and Conclusion: The Minnesota Department of Health determined abuse and financial exploitation was not substantiated. The resident requested the facility allow the resident to add the AP to the new lease agreement. The facility did not agree to the resident’s request and took action to protect the resident. Although the AP and resident shared a relationship it did not meet the definition of sexual abuse. The investigator conducted interviews with facility staff members. The investigation included review of the resident’s facility record, facility internal investigation, personnel files, staff schedules and related facility policies and procedures. Also, the investigator observed other staff and resident interactions. The resident resided in an assisted living facility with diagnoses including quadriparesis (weakness in legs and arms). The resident's service plan included assistance with housekeeping and meals. The resident's assessment indicated he had no cognitive impairment, was his own decision-maker, and was independent with personal needs. One month after the resident's admission, a meeting was arranged to review the resident's care and services. The resident expressed a desire to move to an independent living apartment within the same community, as they believed they did not require or receive any personal care services from assisted living. The resident was placed on a waitlist for independent living and later decided to move when an apartment became available. Two days prior to the resident's move from assisted living to independent living, the resident inquired about adding an occupant, the AP, to the new lease agreement. The facility investigated the relationship between the resident and the AP. The resident stated the relationship was not romantic, they [the AP and resident] were good friends, and the resident wanted to live with the AP. The facility's internal investigation indicated facility leadership met with the AP, and the AP acknowledged a relationship with the resident. The AP was placed on administrative leave and asked not to visit the community. Later, the AP resigned and stated the relationship was more important than the job. During an interview, facility leadership stated the facility policy prohibited staff members from personal relationships with residents, regardless of the resident residing in assisted living or independent living, a staff member cannot become a second occupant or sign a resident lease agreement. The resident disagreed with the facility decision not to allow the AP to join the residents lease agreement and decided to move out of the facility and return to his previous home. During an interview, the resident stated there was no problem with the AP and no coercion. He stated the facility did not handle the situation well, and he felt terrible for the AP. He believed it shouldn't have reached this point, as nothing was going on, and he lived independently. In conclusion, the Minnesota Department of Health determined abuse and financial exploitation 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; (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; and (4) use of any aversive or deprivation procedures for persons with developmental disabilities or related conditions not authorized under section 245.825. (c) Any sexual contact or penetration as defined in section 609.341, between a facility staff person or a person providing services in the facility and a resident, patient, or client of that facility. (d) The act of forcing, compelling, coercing, or enticing a vulnerable adult against the vulnerable adult's will to perform services for the advantage of another. Financial exploitation: Minnesota Statutes, section 626.5572, subdivision 9 "Financial exploitation" means: (a) In breach of a fiduciary obligation recognized elsewhere in law, including pertinent regulations, contractual obligations, documented consent by a competent person, or the obligations of a responsible party under section 144.6501, a person: (1) engages in unauthorized expenditure of funds entrusted to the actor by the vulnerable adult which results or is likely to result in detriment to the vulnerable adult; or (2) fails to use the financial resources of the vulnerable adult to provide food, clothing, shelter, health care, therapeutic conduct or supervision for the vulnerable adult, and the failure results or is likely to result in detriment to the vulnerable adult. (b) In the absence of legal authority a person: (1) willfully uses, withholds, or disposes of funds or property of a vulnerable adult; (2) obtains for the actor or another the performance of services by a third person for the wrongful profit or advantage of the actor or another to the detriment of the vulnerable adult; (3) acquires possession or control of, or an interest in, funds or property of a vulnerable adult through the use of undue influence, harassment, duress, deception, or fraud; or (4) forces, compels, coerces, or entices a vulnerable adult against the vulnerable adult's will to perform services for the profit or advantage of another. Vulnerable Adult interviewed: Yes Family/Responsible Party interviewed: Not applicable. Alleged Perpetrator interviewed: No, did not respond to requests. Action taken by facility: The facility investigated the incident, made required reports, and took steps to ensure the resident’s safety. 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: 08/14/2024 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 _____________________________ 31272 06/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 850 HIGHWAY 95 NORTH CROIXDALE BAYPORT, MN 55003 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 June 13, 2024, the Minnesota Department of Health initiated an investigation of complaint #HL312723160M/#HL312723123C. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 VVM011 If continuation sheet 1 of 1