Blaine Wp Llc.

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: An equal opportunity employer. Letter ID: IS7N REVISED 09/13/2021 Blaine White Pine August 21, 2025 Page 2 St - 0 - 0775 - 144g.45 Subd. 2. (a) - Fire Protection And Physical Environment - $500.00 St - 0 - 0780 - 144g.45 Subd. 2 (a) (1) - 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 $1,000.00. 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. 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 Blaine White Pine August 21, 2025 Page 3 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, Kelly Thorson, Supervisor State Evaluation Team Email: Kelly.Thorson@state.mn.us Telephone: 320-223-7336 Fax: 1-866-890-9290 AH PRINTED: 08/21/2025 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 _____________________________ 30650 07/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 12446 JAMESTOWN STREET NE BLAINE WHITE PINE BLAINE, MN 55449 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. SL30650016-0 PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On June 30, 2025, through July 2, 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 66 residents; 66 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. 0 130 144G.12, Subd. 1 Application for Licensure 0 130 SS=C Each application for an assisted living facility LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 81TF11 If continuation sheet 1 of 23 PRINTED: 08/21/2025 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 _____________________________ 30650 07/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 12446 JAMESTOWN STREET NE BLAINE WHITE PINE BLAINE, MN 55449 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) 0 130 Continued From page 1 0 130 license, including provisional and renewal applications, must include information sufficient to show that the applicant meets the requirements of licensure, including: (1) the business name and legal entity name of the licensee, and the street address and mailing address of the facility; (2) the names, e-mail addresses, telephone numbers, and mailing addresses of all owners, controlling individuals, managerial officials, and the assisted living director; (3) the name and e-mail address of the managing agent and manager, if applicable; (4) the licensed resident capacity and the license category; (5) the license fee in the amount specified in section 144.

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 multiple staff members failed to administer nine doses of lorazepam to the resident over one weekend. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. Over the course of one weekend, three staff members signed off in the resident’s medication administration record (MAR) the resident’s lorazepam (a narcotic medication used to manage anxiety) was not available. None of the three staff members notified the on-call nurse resulting in the resident missing eight doses of Lorazepam. Although the resident missed eight doses of lorazepam, the resident had no adverse effects, and the incident did not rise to the level of maltreatment. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator also contacted a family member. The investigation included review of the resident records, death record, pharmacy records, facility incident reports, personnel files, staff schedules, and related facility policy and procedures Also, the investigator observed cares and staff interactions with residents. The resident resided in an assisted living memory care unit. The resident’s diagnoses included dementia and chronic heart failure. The resident’s assessment indicated the facility managed her medications, the resident required total staff assistance for all cares and received hospice services. The resident’s progress notes indicated she was prescribed lorazepam 0.5mg every four hours PRN (as needed). One weekend (Saturday and Sunday), the resident missed eight doses of lorazepam. There was no lorazepam in the medication cart for staff to administer and staff did not notify the nurse. The on-call nurse called the facility Sunday morning and staff told her the resident did not have any lorazepam available for administration. The on-call nurse arrived at the facility, obtained lorazepam from the overstock lockbox, and placed it in the medication cart for staff to administer. The on-call nurse checked on the resident and found the resident sleeping soundly with no signs of distress. The on-call nurse provided verbal and written warnings to the three staff members who had not contacted her regarding the resident’s lorazepam. The resident’s MAR indicated on Saturday all three staff members documented the resident’s lorazepam as either “Other: med ordered,” or “Medication Ordered” as the reasons they did not administer lorazepam to the resident. On the Sunday overnight shift, one of the staff members documented three doses of lorazepam as “Medication Ordered.” When interviewed, the on-call nurse said although the resident did not have lorazepam available in the medication cart, there was lorazepam available in the overstock lock box located in the nurse’s office. If staff had contacted her about the lorazepam, the on-call nurse said she would have gone to the facility, obtained the lorazepam from overstock, and placed it in the medication cart for staff to use. By the time the on-call nurse was notified, the resident had already missed eight doses of the lorazepam. Once staff notified the on-call nurse of the missing lorazepam, she corrected the situation immediately and the resident continued to receive lorazepam. The staff member who worked overnights that weekend did not respond to requests for interview. When interviewed, the staff member who worked the day shift said the overnight staff member told her she had notified the on-call nurse. The day shift staff member said it did not occur to her to call the on-call nurse when the medication did not arrive because she kept expecting the medication to be delivered and the overnight staff member had already called her. When interviewed, a staff member who worked the evening shift said she was told the resident was out of lorazepam, but the on-call nurse had been notified and the medication had been ordered. The staff member did not call the on-call nurse when the lorazepam never arrived because she was told the on-call nurse already knew about the missing medication. A family member stated they had no concerns regarding the resident not receiving medications and felt the resident received good care when at the facility. 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: Yes. Alleged Perpetrator interviewed: Yes, two of the three staff members interviewed; the third did not respond to requests. the Action taken by facility: Staff leadership counseled the three staff members and provided re-training regarding medication management policies and procedures. The procedure for reordering medications was updated. Action taken by the Minnesota Department of Health: The facility was found to be in noncompliance. To view a copy of the Statement of Deficiencies and/or correction orders, please visit: https://www.health.state.mn.us/facilities/regulation/directory/provcompselect.html If you are viewing this report on the MDH website, please see the attached Statement of Deficiencies. You may also call 651-201-4200 to receive a copy via mail or email. cc: The Office of Ombudsman for Long Term Care The Office of Ombudsman for Mental Health and Developmental Disabilities PRINTED: 12/06/2024 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 _____________________________ 30650 11/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 12446 JAMESTOWN STREET NE BLAINE WHITE PINE BLAINE, MN 55449 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 CORRECTION using federal software. Tag numbers have ORDER 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 complaint investigation. state Statute number and the corresponding text of the state Statute out Determination of whether a violation is 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 a Minnesota Statute contains several are in violation of the state requirement items, failure to comply with any of the items will after the statement, "This Minnesota be considered lack of compliance. requirement is not met as evidenced by." Following the evaluators' findings is the INITIAL COMMENTS: Time Period for Correction. #HL306507561C/#HL306505442M PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On November 5, 2024, the Minnesota STATES,"PROVIDER'S PLAN OF Department of Health conducted a complaint CORRECTION." THIS APPLIES TO investigation at the above provider, and the FEDERAL DEFICIENCIES ONLY. THIS following correction orders are issued. At the time WILL APPEAR ON EACH PAGE. of the complaint investigation, there were 55 residents receiving services under the provider's THERE IS NO REQUIREMENT TO Assisted Living with Dementia Care license. SUBMIT A PLAN OF CORRECTION FOR VIOLATIONS OF MINNESOTA STATE The following correction order is issued for STATUTES. #HL306507561C/#HL306505442M, tag identification 1760. 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. 01760 144G.71 Subd.

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 resident did not receive wound care and medications/ treatments for comfort when she was going through her last days of life. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. The facility provided cares and medication administration according to the resident’s individual plan of care. The residents’ wounds were being cared for by hospice and documentation indicated wound care was completed and the wounds continued to worsen. The resident had physician orders for Emla cream (topical numbing cream) to be applied to the resident’s kidney dialysis access prior to dialysis treatment. The facility failed to document applying the Emla cream for approximately three months. However, the resident received the Emla cream when the dialysis unit applied the Emla cream on the resident’s dialysis access prior to treatment. An equal opportunity employer. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted the resident’s family, the dialysis treatment center, and the pharmacy. The investigation included review of medical records, pharmacy records, hospice notes, facility policies and procedures, nurses’ notes, staff charting, and medication administration records. Also, the investigator observed staff providing cares and medications to residents. The resident resided in an assisted living facility. The resident’s diagnoses included end stage renal disease, pressure sores, and chronic pain. The resident’s service plan included assistance with activities of daily living, medication administration, meals, laundry, housekeeping, bathing, and skin care. Facility nursing notes indicated the resident had a decline of health status requiring hospitalization. The nursing notes indicated the resident was hospitalized for fluid volume overload and returned to the facility two days later. When the resident returned, she was admitted to hospice care for end-of-life care and remained in the facility for continued care under the direction of hospice. Hospice nursing notes indicated the resident received hospice care for 23 days prior to passing away. The documentation included wounds on the residents left and right medial (mid) buttocks/ coccyx (tailbone). The wound care was documented, as well as the progression of the wounds. A coordination of care note completed by the hospice nurse to the facility nine days prior to the resident’s death indicated hospice did not complete wound care due to the resident’s family request. The family requested if the resident was comfortable and refused wound care it should not be completed. The residents nursing notes indicated eleven days after the resident was admitted to hospice the “wounds look healthy, skin extremely macerated (wet) calmoseptine (wound cream) and repositioning every two hours”. Five days later, the nurse documented she went to change the dressing on the residents’ wounds, but family told staff they wanted hospice to take care of the wounds. The resident’s medication administration record indicated the residents pain medication was increased and scheduled (instead of as needed) the days prior to the resident’s death. The facility staff were documenting the resident was repositioned every two hours and staff were monitoring the resident’s pain and documenting administration of pain medications as ordered. When interviewed a resident family member stated the resident’s health declined and she was hospitalized. The resident was discharged from the hospital back to the facility with hospice care. The family member stated the resident’s wounds on her bottom were getting worse and she did not see facility nursing ever change the residents’ wound dressings. The family also stated after the resident passed away the facility gave the family several boxes of leftover Emla cream. 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: Yes Alleged Perpetrator interviewed: Not Applicable Action taken by facility: No action taken Action taken by the Minnesota Department of Health: No further action taken. cc: The Office of Ombudsman for Long Term Care The Office of Ombudsman for Mental Health and Developmental Disabilities PRINTED: 07/21/2023 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 _____________________________ 30650 06/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 12446 JAMESTOWN STREET NE BLAINE WHITE PINE BLAINE, MN 55449 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 6, 2023, the Minnesota Department of Health initiated an investigation of complaint #HL306502391C/#HL306506626M and #HL306508881C/ #HL306505166M. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 Y59S11 If continuation sheet 1 of 1

correction orders issued pursuant to the June 15, 2023 survey. The Department of Health concludes the licensee is in substantial compliance. State law requires the facility must take action to correct the state 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. In accordance with Minn. Stat. § 144G.31 Subd. 4 (a), state correction orders issued pursuant to the last survey completed on June 15, 2023, found not corrected at the time of the August 23, 2023, follow-up survey and/ or subject to penalty assessment are as follows: 0485-Minimum Requirements- 144g.41 Subdivision 1. (13)(i)(a)and( c) = $500.00 1640-Service Plan, Implementation And Revisions To-144g.70 Subd. 4 (a-E) = $500.00 1880-Storage Of Medications- 144g.71 Subd. 19 = $500.00 1890-Prescription Drugs-144g.71 Subd. 20 = $500.00 The details of the violations noted at the time of this follow-up survey completed on August 23, 2023 (listed above), are on the attached State Form. Brackets around the ID Prefix Tag in the left hand column, e.g., {2 ----} will identify the uncorrected tags. The re fore , in accorda nc e wi th Mi nn. Sta t. §§ 144G. 01 to 144 G .9999, the total amount you are assessed is $2,000.00. You will be invoiced approximately 30 days after receipt of this notice, subject to appeal. Also, at the time of this follow-up survey completed on August 23, 2023, we identified the following violation(s): 0620-Compliance With Requirements For Reporting Ma-144g.42 Subd. 6 (a) An equal opportunity employer. Le tter ID: 8GKP Revised 04/14/2023 Blaine White Pine September 21, 2023 Pa ge 2 1760-Documentation Of Administration Of Medication- 144g.71 Subd. 8 1960-Documentation Of Administration Of Treatments- 144g.72 Subd. 5 3000-Timing Of Report- 626.557 Subd. 3 The details of the violation(s) noted at the time of this follow-up survey are delineated on the attached State Form. Only the ID Prefix Tag in the left hand column without brackets will identify these state correction orders. It is not necessary to develop a plan of correction. DOCUMENTATIO ONF ACTION TO COMPLY In accorda nc e wi th Mi nn. Sta t. § 144G.30, Subd. 5(c), the licens ee mus t doc ument acti ons ta ken 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. IMPOSITION OF FINES: 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. 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 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. Pl ea se ema il rec ons idera ti on reques ts to: Health. HRDA. ppeals@state. mn. us. Pl ea se atta c h thi s letter 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 Blaine White Pine September 21, 2023 Pa ge 3 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 hea ri ng ma y be ema iled to: Health. HRDA. ppeals@state. mn. us. To appe al fi ne s vi a rec ons ider a ti on, pl ease fol low the proc edure outl ined above . Pl ease note tha t you ma y re ques t a rec ons idera ti on or a hea ri ng , but not both. We urge you to review these orders carefully. If you have questions, please contact Casey Devries at You are encouraged to retain this document for your records. It is your responsibility to share the information contained in the letter and/ or state form with your organization’s Governing Body. Sincerely, Casey DeVries, Supervisor State Evaluation Team Email: casey. devries@state. mn.us Telephone: 651-201-5917 Fax: 651-281-9796 PMB PRINTED: 09/ 21/ 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: ______________________ R B. WING _____________________________ 30650 08/ 23/ 2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 12446 JAMESTOWN STREET NE BLAINE WHITE PINE BLAINE, MN 55449 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 been assigned to Minnesota State Statutes for Assisted Living License In accordance with Minnesota Statutes, section Providers. The assigned tag number 144G. 08 to 144G. 95 this correction order( s) has appears in the far-left column entitled "ID been issued pursuant to a survey. Prefix Tag." The state Statute number and the corresponding text of the state Statute Determination of whether a violation has been out of compliance is listed in the corrected requires compliance with all "Summary Statement of Deficiencies" requirements provided at the Statute number column. This column also includes the indicated below. When Minnesota Statute findings which are in violation of the state contains several items, failure to comply with any requirement after the statement, "This of the items will be considered lack of Minnesota requirement is not met as compliance. evidenced by." Following the surveyors' findings is the Time Period for Correction. INITIAL COMMENTS: SL30650015- 1 PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On August 22, 2023, through August 23, 2023, STATES, "PROVIDER' S PLAN OF the Minnesota Department of Health conducted a CORRECTION. " THIS APPLIES TO revisit at the above provider to follow-up on FEDERAL DEFICIENCIES ONLY. THIS orders issued pursuant to a survey completed on WILL APPEAR ON EACH PAGE. June 16, 2023. At the time of the survey, there were 61 residents: 58 of whom received services THERE IS NO REQUIREMENT TO under the Assisted Living with Dementia Care SUBMIT A PLAN OF CORRECTION FOR license. As a result of the revisit, the following VIOLATIONS OF MINNESOTA STATE orders were reissued and/ or issued. STATUTES. The letter in the left column is used for tracking purposes and reflects the scope and level issued pursuant to 144G. 31 subd. 1, 2, and 3. {0 485} 144G. 41 Subdivision 1. (13)(i)(A)and( C) Minimum {0 485} SS= F Requirements (13) offer to provide or make available at least the LABORATORY DIRECTOR' S OR PROVIDER/ SUPPLIER REPRESENTATIVE' S SIGNATURE TITLE (X6) DATE STATE FORM 6899 SMO712 If continuation sheet 1 of 32 PRINTED: 09/ 21/ 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: ______________________ R 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 facility neglected a resident when the facility staff failed to provide the resident an anti-psychotic medication, Clozaril, according to the physician orders. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. Staff provided the resident Clozaril according to the provider order. The investigator conducted interviews with facility staff members, including administrative staff, and nursing staff. The investigator contacted the family member. The investigation included review of resident’s medical record and facility policies and procedures. Also, the investigator observed common areas in the facility. The resident resided in an assisted living facility. The resident’s diagnoses included mood disorder, anxiety, Parkinson’s disease, and psychotic disorder. The resident’s service plan An equal opportunity employer. included staff assistance with medication management and administration. The resident’s assessment indicated the resident was prescribed a psychotropic medication. The resident’s assessment indicated unlicensed personnel administered medications to the resident. The resident was able to make her needs known to staff. The resident’s medication administration record (MAR) indicated the resident was prescribed Clozaril for Parkinson’s disease. The MAR indicated the resident received 12.5 milligrams (mg) at noon and 50 mg at eight at night. Staff provided the resident with Clozaril as prescribed. Additional concerns included missed doses of other medications. The resident’s progress notes indicated the day of admission, the resident received all the medications from the pharmacy but Clonazepam, used for anxiety. The pharmacy required a separate hand-written prescription for the resident’s Clonazepam according to the pharmacy-controlled substance policy. The pharmacy provided the facility with the resident’s Clonazepam the following afternoon. During the investigation, the facility’s medication incident report form indicated the resident was to take Clonazepam, one-half tablet (0.25) mg twice a day and daily as needed for anxiety. Staff failed to provide the resident one dose of Clonazepam six days after admission, and one time a day for four days. Despite missing one dose a day of Clonazepam, the resident did not complain of increased anxiety or require an as needed dose until the day the error was discovered by staff. Another concern investigated included a 17-hour delay in the resident’s medication administration due to a broken key in the medication cart preventing staff access to the cart. When the key broke off in the medication cart, facility staff contacted a locksmith who repaired the lock in three and one-half hours. At that time, staff provided the resident with her medications. During an interview, the family member stated facility staff made them aware of the medication errors, but the family decided to transfer the resident to a different facility due to the errors. During an interview, the nurse stated the resident’s medication, Clonazepam was to be given twice a day for anxiety. The nurse stated multiple staff missed one dose of the medication two days in a row, then five days later multiple staff missed one dose of the medication for four days. The resident either missed a morning dose or the evening dose. During an interview, management stated there was an issue the day of the resident’s admission to the facility when the pharmacy failed to deliver the resident Clonazepam. Management could not recall the exact reason for the delay but did recall facility staff requested the pharmacy deliver the medication within four hours. Management stated there was also concerns with staff missing doses of the resident’s Clonazepam. The resident either received the morning dose and not the evening dose or would not receive the morning dose and receive the evening dose. Once aware of the medication error, facility staff were provided education and the family was updated. 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 to contact. Family/Responsible Party interviewed: Yes Alleged Perpetrator interviewed: Not Applicable the Action taken by facility: The facility notified the resident’s provider of the Clonazepam medication error and provided education to the staff involved with the medication error. 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: 06/02/2023 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 _____________________________ 30650 04/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 12446 JAMESTOWN STREET NE BLAINE WHITE PINE BLAINE, MN 55449 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 April 26, 2023, the Minnesota Department of Health initiated an investigation of complaint HL306505843M/HL306501040C. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 01DV11 If continuation sheet 1 of 1