Crest View Senior Community at.

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 AP, who is an unlicensed caregiver, abused the resident when providing personal cares caused bruising to the top of the resident’s hand. Investigative Findings and Conclusion: The Minnesota Department of Health determined abuse was inconclusive. Although an incident did occur, it could not be determined what took place due to the inconsistencies of the statements provided by the AP and resident. The resident did not require medical attention and returned to baseline. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigation included review of the resident record(s), facility internal investigation, facility incident reports, personnel files, staff schedules, and related facility policy and procedures. Also, the investigator observed type of bed resident used and the location of the bed in her apartment. The resident resided in an assisted living facility. The resident’s diagnoses included Parkinson’s Disease, chronic back pain, and anxiety. The resident’s service plan included assistance with toileting, dressing, transfer, and bed mobility with assist of one staff. The resident’s assessment indicated the resident was alert and oriented and able to give accurate information but not consistently. The resident could communicate needs but was also hard of hearing. The resident’s side rail assessment indicated the resident had a hospital bed with bilateral ¼ bedrails she used to during repositioning in bed during cares. The medical record indicated the resident’s medication included an anticoagulant (blood thinner) which increased her risk for bruising. A concern arose during an overnight shift when it was reported that while the AP assisted the resident with bed mobility during incontinence cares the resident asked the AP to stop. Initially, the AP did not stop, and the resident pushed the AP’s hand away and then the AP took hold of the resident’s hand. The AP discontinued the cares at that point leaving the resident’s incontinence pad not completely fastened. Later, a bruise developed on the resident’s hand. The facility task list report and signed tasks list completed record indicated the resident has a history of becoming upset during cares if the resident feels she is being rushed, for resident not to be anxious staff are to approach cares more slowly. This same document indicated resistance to toileting during the overnight. This task lists no specific check and changing time on the overnight shift, does not indicate resident is not gotten up out of bed or walked to the toilet, but that the resident is actually changed in bed, and does not specify number of staff required for the tasks. The facility’s internal investigation indicated there were conflicting narratives of what occurred. The document indicated the resident said the AP rolled her quickly from side-to-side and she asked the AP to stop. However, the AP continued so the resident grabbed and pushed the AP’s hand away while the AP grasped the resident’s hand while she finished placed the incontinence brief. The resident indicated the AP gave up and left the room. The same document indicated the AP acknowledged she was having difficulty rolling the resident while changing her. The AP stated she may not have stopped immediately because she was in mid-task, however the resident’s voice became very serious, and she seemed upset, so the AP stopped and left the room leaving the incontinence pad partly unfastened. The AP denied a physical struggle occurred or grasping the resident’s hands. During an interview, the AP stated the resident required assistance on the overnight shift with toileting which was completed in bed. AP stated the resident was listed as a one staff assist on the task list report [guide for cares which staff provide]. The AP stated the resident was able to help roll some from side-to-side but not all the way. The AP stated at some point mid-task the resident asked her to stop, and she tried to finish with the incontinence pad but ended up leaving it not completely closed on one side due to the resident’s request and left the room. The AP stated when she exited the resident’s room the second staff was outside near the room when AP explained she had a difficult time turning the resident. AP stated task list indicated the resident was a one person assist with night changes, but a two person assist with transfers. During an interview, an unlicensed caregiver stated the AP did tell her the resident had been combative with changing, so AP had left the room. The caregiver stated she told the AP that next time she went into change resident that they would both go in together. The caregiver stated at the time of the incident the resident was a one person assist for changing, but after that night became two persons assist for bed mobility. The caregiver stated the resident was able to turn to one side better than the other side and uses the side rails on her bed to assist with the turning. The caregiver stated the resident has been known to display behaviors especially with staff with which she is not familiar. During an interview, a facility nurse stated the resident is heavier cares and requires assistance. The nurse stated at the time of the incident the resident was a one person assist with overnight changes in bed. The nurse stated staff do have difficulty removing the brief from under the resident. The nurse stated staff are provided direction for tasks to be completed by what is located on the Task List Report. The nurse stated since the incident the resident has requested two staff for cares for the resident’s comfort. The nurse stated she made this change to the resident service plan and documented a note in the resident’s progress notes. In conclusion, the Minnesota Department of Health determined abuse 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. 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; 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; or (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 unless authorized under applicable licensing requirements or Minnesota Rules, chapter 9544. Vulnerable Adult interviewed: Yes Family/Responsible Party interviewed: No, attempts to interview were unsuccessful Alleged Perpetrator interviewed: Yes the Action taken by facility: The facility conducted an internal investigation and updated the service plan to two people for bed mobility. The AP was no longer employed by the facility. 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.

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; Level 3: a fine of $1,000 per incident, in addition to any enforcement mechanism authorized in § 144G.20; Level 4: a fine of $3,000 per incident, in addition to any enforcement mechanism authorized in An equal opportunity employer. Letter ID: IS7N REVISED 09/13/2021 Crest View Senior Community at Blaine August 11, 2025 Page 2 § 144G.20; Level 5: a fine of $5,000 per violation, in addtion 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. Crest View Senior Community at Blaine August 11, 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, Kelly Thorson, Supervisor State Evaluation Team Email: Kelly.Thorson@state.mn.us Telephone: 320-223-7336 Fax: 1-866-890-9290 AH PRINTED: 08/11/2025 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 _____________________________ 32676 07/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 12016 ULYSSES STREET NE CREST VIEW SENIOR COMMUNITY AT BLAINE BLAINE, MN 55434 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. SL32676016 PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On July 21, 2025, through July 23, 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 86 residents; 77 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 subd. 1, 2, and 3. 0 775 144G.45 Subd. 2. (a) Fire protection and physical 0 775 SS=F environment Each assisted living facility must comply with the LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 9DCY11 If continuation sheet 1 of 4 PRINTED: 08/11/2025 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 _____________________________ 32676 07/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 12016 ULYSSES STREET NE CREST VIEW SENIOR COMMUNITY AT BLAINE, MN 55434 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) 0 775 Continued From page 1 0 775 State Fire Code in Minnesota Rules, chapter 7511, and: This MN Requirement is not met as evidenced by: Based on observation and interview, the licensee failed to comply with Minnesota State Fire Code in Minnesota Rules chapter 7511.

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 the resident was hospitalized twice after ingesting hand sanitizer. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. When facility staff observed the resident pumping the hand sanitizer into his hands then bringing his hand to his mouth, the resident was assessed, monitored, and treated. Facility staff facilitated meetings with the resident’s family, medical provider(s) and the resident to develop and implement interventions for alcohol abuse. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigation included review of the resident record(s), hospital records, internal investigation documentation, incident reports, personnel files, staff schedules, and related facility policy and procedures. Also, the investigator observed the facility environment and staff interaction with the residents. The resident resided in an assisted living facility. The resident’s diagnoses included cerebellar stroke syndrome (a group of neurological deficits resulting from impaired blood flow to the cerebellum, a region of the brain responsible for coordination and balance), major depressive disorder and alcohol abuse. The resident’s service plan included assistance with medication management. The resident’s assessment indicated the resident had a history of alcohol abuse that involved ingesting rubbing alcohol, the resident was alert and orient to person, place, and time. The resident’s assessment indicated the resident was independent with all activities of daily living, including mobility, but received staff assistance with medication management and encouragement to attend facility activities. The resident’s medical records indicated the resident received outpatient counseling services for mental health concerns. The medical records indicated the resident’s family reported hand sanitizer was found in the resident’s room, inside snack boxes. Facility staff investigated the incidents, discussed the risks of ingesting hand sanitizer, and encouraged the resident to wash his hands with soap and water to reduce the temptation of ingestion. The resident’s medical records indicated the resident was observed by staff after pumping hand sanitizer in his hands and bringing his hands up to his mouth. Although the resident did not always admit to ingesting the hand sanitizer, facility staff investigated each incident, monitored the resident and reported the incidents to the resident’s family and provider. The facility implemented services for medication management to ensure the resident was taking his prescribed Antabuse medication (medication that would produce a sensitivity to alcohol causing symptoms such as: nausea, vomiting, dizziness, weakness and confusion). Following implementation of medication management services, the resident reported on two different occasions that he ingested hand sanitizer, felt nauseous, was vomiting and unsteady. Staff assessed the resident, reported the incidents to family and the medical provider, then transported the resident to the hospital for evaluation. During the second hospitalization, the resident refused in-patient treatment and returned to the facility. The facility decreased access to hand sanitizer by keeping hand sanitizers only with facility staff, and facilitated meetings with the resident, family, and medical providers to schedule a psychiatric evaluation and an outpatient treatment program. During an interview, a facility administrative nurse stated video footage was reviewed during facility investigations. The facility administrative nurse stated the video locations made it difficult to view if the resident pumped the hand sanitizer in his hands and it could not be determined if, after the resident brought his hands to his face, if he was smelling or ingesting it. During an interview, a floor nurse recalled staff reporting the hand sanitizer missing off of a medication cart that was located in the same room the resident had been sitting. The floor nurse then interviewed the resident, who denied taking the hand sanitizer at first, but gave permission for the floor nurse to look in his room for the bottle. A bottle of sanitizer was found in the resident’s closet. The resident then admitted to taking the hand sanitizer bottle and apologized. The floor nurse stated she updated the resident’s provider regarding the incident. During an interview, a facility administrative staff stated the resident like to walk around the facility independently where he had access to various hand sanitizers throughout the building. Facility administrative staff stated the resident, the resident’s family, and the medical provider were agreeable to a plan that included the resident to be transported directly to a hospital inpatient treatment program if other incidents occurred. During an interview, the resident’s family member stated the resident’s alcohol abuse had gone on for decades and was the reason for the resident’s admission to the facility. The family member stated they completed audits of the resident’s room and found hand sanitizer bottles in various places then removed them and reported the findings to facility staff. The family member stated they were grateful for the collaboration with the facility to assist the resident with the alcohol abuse concerns. 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, per family request. Family/Responsible Party interviewed: Yes Alleged Perpetrator interviewed: Not Applicable Action taken by facility: The facility assessed and monitored the resident after each incident, completed facility internal investigations of the incidents, reported the incidents to family and the resident’s provider and implemented interventions to prevent further occurrance. 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: 06/25/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ C B. WING _____________________________ 32676 05/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 12016 ULYSSES STREET NE CREST VIEW SENIOR COMMUNITY AT BLAINE, MN 55434 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 6, 2025, the Minnesota Department of Health initiated an investigation of complaint #HL326769902C/#HL326769962M. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 JNU711 If continuation sheet 1 of 1

Finding: Not Substantiated Nature of Investigation: The Minnesota Department of Health investigated an allegation of maltreatment, in accordance with the Minnesota Reporting of Maltreatment of Vulnerable Adults Act, Minn. Stat. 626.557, and to evaluate compliance with applicable licensing standards for the provider type. Initial Investigation Allegation(s): The facility neglected the resident when staff failed to provide hygiene care, proper nutrition, and follow medication orders. As a result, the resident was hospitalized on two separate occasions. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. The facility moved the resident to the memory care unit upon hospital return to accommodate her increased support needs, updated the resident’s provider on changes in status and made medication adjustments. The investigator conducted interviews with facility staff members, including administrative staff and nursing staff. The investigator also interviewed family. The investigation included review of medical records, hospital records and facility policies. Also, the investigator toured the facility and observed resident cares including medication administration and grooming. An equal opportunity employer. The resident resided in an assisted living memory care unit. The resident’s diagnoses included Alzheimer’s disease, heart failure, and depression. The resident’s service plan included assistance with bathing, grooming, medication management, and behavioral interventions. The resident’s assessment indicated the resident had cognitive impairment with poor decision making and was an increased elopement risk. According to the resident’s progress notes, the resident had a behavioral episode where she was physically and verbally aggressive towards staff. Staff sent the resident to the hospital for further evaluation. According to the hospital record, the resident presented with escalated agitation upon admission. The hospital physician diagnosed the resident with a urinary tract infection. The resident was delirious and placed on a one-to-one staff ratio for supervision. The resident had impaired memory, judgement, and safety awareness. The hospital physician recommended increased assistance once medically stable. In addition, the hospital discharge orders included an order to discontinue the resident’s antipsychotic medication (quetiapine). During an interview, a family member said she questioned whether the resident should have admitted to the memory care unit upon hospital return but said another family member may have approved the move. The family member said upon discharge, the hospital discontinued one medication, but the facility re-ordered it. In addition, the family member was concerned about the recent medication changes made while at the hospital. She said the resident appeared overly sedated when she came to visit after the resident readmitted to the facility and the resident recently fell twice. She reported her concerns to the facility staff. She said the facility reviewed and adjusted medications at that time. The family member said the resident appeared unkept and had dry mucus membranes possibly related to dehydration. The facility staff sent the resident back to the hospital due to low oxygen saturation level. She was diagnosed with pneumonia at the hospital. The resident’s service delivery records indicated the resident’s scheduled bath was left blank without documentation as being completed. The family reported staff completed an unscheduled bath later that same week, however the facility staff failed to document completion of the unscheduled bath on the service delivery record. The resident’s medication administration record (MAR) indicated medication order changes were made after family voiced concern. The MAR showed a medication transcription error when quetiapine was not discontinued and was given to the resident for 10 days after returning to the facility. The resident’s nurse practitioner (NP) visit note indicated the NP saw the resident six days after returning from the hospital (five days after the transcription error). The NP noted the hospital order to discontinue quetiapine, reviewed the MAR and additionally wrote an order to discontinue quetiapine. The NP ordered laboratory tests for the resident. The NP assessed the resident and found no clinical symptoms for respiratory concerns at that time. The NP noted concern for continued weakness, other signs for increased fluid within the brain related to congestive heart failure and ordered additional laboratory tests. The visit note however was not completed and provided to the facility until five days after the visit. The resident’s progress notes indicated two days after receiving the NP’s orders, the resident presented with breathing changes and the NP ordered supplemental oxygen and a weight recheck (for increased fluid). The resident’s weight had increased 3.5 pounds from her hospital discharge and the NP ordered a change to her Lasix (water pill). A week later, the NP discontinued the resident’s other antipsychotic medication (Haldol), which had started in the hospital. Four days later, the progress note indicated the resident had a rapid decline and changes in the past 24 hours, including requiring three staff for assistance due to inability to stand and the facility staff sent the resident to the hospital. The resident’s discharge summary indicated she had a rapid decline and was sent to the hospital. The resident passed away at the hospital. During an interview, a member of management said resident became extremely agitated during a group activity. When resident was asked to leave, she became physically aggressive towards a staff member. The member of management said the resident had dementia and a history of verbal aggression, but the resident was not physically aggressive in the past. Staff sent her to the hospital for evaluation for the change in condition. At the hospital she was diagnosed with a urinary tract infection. The member of management stated upon return to the facility, she admitted to the locked memory care unit, which family approved. The resident received one bath a week. The member of management stated staff were instructed to assist with additional showers upon resident request or as needed. The member of management was unsure why staff did not document the resident’s bath on the service record. The member of management stated later after returning from the first hospitalization, the resident had a significant change in a 24-hour period and sent back to the hospital for the second hospitalization. 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: The facility moved the resident to memory for increased care assistance. The facility followed orders received by the resident’s NP. After a significant change in status, the facility sent the resident to the hospital for a second admission. The facility made changes to management staff to ensure timely communication to families and ensure nursing processes are carried out accurately and timely. 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: 07/05/2024 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 _____________________________ 32676 03/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 12016 ULYSSES STREET NE CREST VIEW SENIOR COMMUNITY AT BLAINE, MN 55434 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.

CORRECTION ORDERS The enclosed State Form documents the state correction orders. The 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 . . ." In accordance with Minn. Stat. § 144G.31 Subd. 4, MDH may assess fines and enforcement actions based on the level and scope of the violations; however, no immediate fines are assessed for this survey of your facility. 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). An equal opportunity employer. Letter ID: IS7N REVISED 09/13/2021 Crest View Senior Community At July 14, 2023 Page 2 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 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. Please email reconsideration requests to: Health.HRD.Appeals@state.mn.us. Please attach this 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 You are encouraged to retain this document for your records. It is your responsibility to share the information contained in the letter and state form with your organization’s Governing Body. If you have any questions, please contact me. Sincerely, Jess Schoenecker, Supervisor State Evaluation Team Email: jess.schoenecker@state.mn.us Telephone: 651‐201‐3789 Fax: 651‐281‐9796 JMD PRINTED: 07/14/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ 32676 B. WING _____________________________ 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 12016 ULYSSES STREET NE CREST VIEW SENIOR COMMUNITY AT BLAINE, MN 55434 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE 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 Facilities. The assigned tag 144G.08 to 144G.95, these correction orders are 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 evaluators' INITIAL COMMENTS: findings is the Time Period for Correction. SL32676015 PLEASE DISREGARD THE HEADING OF On June 12, 2023 through June 15, 2023, the THE FOURTH COLUMN WHICH survey at the above provider, and the following CORRECTION." THIS APPLIES TO correction orders are issued. At the time of the FEDERAL DEFICIENCIES ONLY. THIS survey, there were eighty-eight (88) active WILL APPEAR ON EACH PAGE. residents receiving services under the Assisted Living license with Dementia Care. THERE IS NO REQUIREMENT TO SUBMIT A PLAN OF CORRECTION FOR On June 13, 2023, at 2:53 p.m., immediacy order VIOLATIONS OF MINNESOTA STATE was issued tag identification 2310. STATUTES. On June 13, 2023, at 4:33 p.m., the immediacy THE LETTER IN THE LEFT COLUMN IS was removed, and the scope and level remain the USED FOR TRACKING PURPOSES AND same REFLECTS THE SCOPE AND LEVEL ISSUED PURSUANT TO 144G.31 SUBDIVISION 1-3. 0 650 144G.42 Subd. 8 Employee records 0 650 SS=D (a) The facility must maintain current records of LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 N5BN11 If continuation sheet 1 of 24 PRINTED: 07/14/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ 32676 B. WING _____________________________ 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 12016 ULYSSES STREET NE CREST VIEW SENIOR COMMUNITY AT BLAINE, MN 55434 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 0 650 Continued From page 1 0 650 each paid employee, each regularly scheduled volunteer providing services, and each individual contractor providing services. The records must include the following information: (1) evidence of current professional licensure, registration, or certification if licensure, registration, or certification is required by this chapter or rules; (2) records of orientation, required annual training and infection control training, and competency evaluations; (3) current job description, including qualifications, responsibilities, and identification of staff persons providing supervision; (4) documentation of annual performance reviews that identify areas of improvement needed and training needs; (5) for individuals providing assisted living services, verification that required health screenings under subdivision 9 have taken place and the dates of those screenings; and (6) documentation of the background study as required under section 144.057. This MN Requirement is not met as evidenced by: Based on observation and interview, the licensee failed to ensure the employee record contained the required content to include an annual performance evaluation for one of one unlicensed personnel ((ULP)-B). This practice resulted in a level two violation (a violation that did not harm a resident's health or safety but had the potential to have harmed a resident's health or safety, but was not likely to cause serious injury, impairment, or death), and was issued at an isolated scope (when one or a limited number of residents are affected or one or a limited number of staff are involved or the STATE FORM 6899 N5BN11 If continuation sheet 2 of 24 PRINTED: 07/14/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ 32676 B. WING _____________________________ 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 12016 ULYSSES STREET NE CREST VIEW SENIOR COMMUNITY AT BLAINE, MN 55434 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 0 650 Continued From page 2 0 650 situation has occurred only occasionally). The findings include: ULP-B was hired September 27, 2018, to provide direct cares for the residents of the licensee.