Northern Oaks Place.

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 resident was neglected when the resident fell and was improperly transferred off of the floor by a facility staff member/alleged perpetrator (AP), resulting in the resident's right shoulder being dislocated. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was inconclusive. Although staff did not follow facility protocol when transferring the resident off of the floor following a fall, it was unable to be determined if the resident’s right shoulder dislocation was a result of the transfer. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted hospital staff. The investigation included review of the resident record(s), hospital records, facility internal investigation documentation, facility incident reports, personnel files, staff schedules, and related facility policy and procedures. Also, the investigator observed the facility environment and staff interactions with residents. The resident resided in an assisted living memory care unit. The resident’s diagnoses included dementia and osteoporosis. The resident’s service plan included daily staff assistance with dressing, grooming, transfers, toileting, wheelchair mobility, ambulation assistance, medication management, behavior monitoring and five safety checks per day. The resident’s assessment indicated the resident was oriented to person, place, and time with occasional evening disorientation, anxiety, and agitation. The assessment also indicated the resident had a history of falls. The resident’s assessment indicated the resident was unable to lift herself independently from a knee-height chair but could ambulate short distances with staff assistance and a transfer belt. The resident’s physical therapy notes recommended staff to use a gait belt when the resident was transferred. Facility documentation indicated that one evening the resident sat too close to the edge of the bed and slid down to the floor landing on her buttocks. The AP transferred the resident back to bed by having the resident hold on to her walker, putting an arm under one of the resident’s arms and lifted the resident off the floor holding on to the back of the resident’s pants. The AP reported that the resident did not have any observed injury and did not complain of pain. The resident’s medical records indicated staff communicated with the resident and checked on the resident throughout the remainder of that night and the resident had no complaints of pain until the following morning when staff attempted to remove the resident’s sweater and the resident complained of pain in her arm. The staff member immediately reported the resident’s complaints of pain to nursing staff. The resident’s medical records indicated dayshift staff administered the resident’s prescribed pain medication and later was informed by the resident that the pain medication was ineffective. Dayshift staff reported the resident’s pain to the family and the facility administrative nurse. The resident’s medical records indicated the resident’s family decided to transport the resident to the hospital later that day due to the resident’s continued complaints of right arm pain. The resident’s hospital records indicated an x-ray of the resident’s right shoulder revealed a dislocation. The medical records indicated hospital medical staff attempted to reduce the dislocation but were unsuccessful and the resident required surgical intervention to repair the dislocated shoulder. During an interview, the AP stated she assisted the resident to get ready for bed and while the resident was in bed, the AP turned around to clean next to the resident’s bed. When the AP turned back around, the resident attempted to get out of bed and was sliding down the side of the bed. The AP stated she did not have time to grab the call light on the wall or a gait belt. Instead, she blocked the resident from falling on the floor, then slid the resident between herself and the bed and assisted the resident to a seated position on the floor. The AP then grabbed the resident’s nearby walker, placed it in front of the resident, placed the resident’s two hands on the walker, and assisted the resident to stand by placing her arms under the resident’s arms. The AP stated she waited a few seconds for the resident to stabilize then transferred the resident back onto the bed. The AP stated there was no observations of injury or any abnormal movements from the resident’s arm joints. The AP stated she did not want to leave the resident on the floor which is why she did not call for assistance with the transfer. The AP stated she forgot about the incident which was why she did not report it or complete a facility incident report. The AP stated she recalled checking on the resident’s later in the shift, and the resident did not complain of pain or discomfort. During an interview, the facility administrative nurse stated the resident was in physical therapy (PT) at the time of the fall and the resident had a history of falls. The facility administrative staff stated the resident was able to vocalize pain and recalled the AP was confident the resident had no complaints of pain after the improper transfer. The facility, administrative nurse stated he interviewed night staff who worked the night following the resident’s improper transfer and stated staff informed safety checks were completed throughout the night and there were no complaints of pain until the report made to morning shift staff. In conclusion, the Minnesota Department of Health determined neglect was inconclusive. Inconclusive: Minnesota Statutes, section 626.5572, Subdivision 11. "Inconclusive" means there is less than a preponderance of evidence to show that maltreatment did or did not occur. Neglect: Minnesota Statutes, section 626.5572, subdivision 17 “Neglect” means neglect by a caregiver or self-neglect. (a) "Caregiver neglect" means the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to, food, clothing, shelter, health care, or supervision which is: (1) reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult; and (2) which is not the result of an accident or therapeutic conduct. Vulnerable Adult interviewed: No, per family and cognitive deficits Family/Responsible Party interviewed: No, family declined to interview Alleged Perpetrator interviewed: Yes Action taken by facility: Staff were re-educated on falls, incident reports and proper procedure for resident transfer with a gait belt. 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: 08/14/2025 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 _____________________________ 30625 07/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1005 PAUL PARKWAY NE NORTHERN OAK PLACE 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 July 17, 2025, the Minnesota Department of Health initiated an investigation of complaint #HL306257529C/#HL306253902M. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 LQZN11 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; 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 Northern Oak Place August 20, 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. Northern Oak Place August 20, 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: 08/20/2025 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 _____________________________ 30625 07/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1005 PAUL PARKWAY NE NORTHERN OAK PLACE 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. SL30625016 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 11 residents; all 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. 0 480 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 LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 O45N11 If continuation sheet 1 of 16 PRINTED: 08/20/2025 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 _____________________________ 30625 07/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1005 PAUL PARKWAY NE NORTHERN OAK PLACE 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) 0 480 Continued From page 1 0 480 must be prepared and served according to the Minnesota Food Code, Minnesota Rules, chapter 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 Heath investigated an aegation of matreatment, in accordance with the Minnesota Reporting of Matreatment of Vunerabe Aduts Act, Minn. Stat. 626.557, and to evauate compiance with appicabe icensing standards for the provider type. Initial Investigation Allegation(s): The faciity negected the resident when the resident had a change in condition, was sent to the hospita and was found with an injury of unknown origin. Investigative Findings and Conclusion: The Minnesota Department of Heath determined negect was not substantiated. When staff observed a change in the resident’s condition, staff assessed the resident and arranged for the resident to be evauated at a hospita. The resident’s diagnoses incuded a chronic (ong term) previous hardware fracture with dispacement (joint pushed out of usua pace) of the resident’s right ebow. The investigator conducted interviews with faciity staff members, incuding administrative staff, nursing staff, and unicensed staff. The investigator contacted the resident’s famiy member. The investigation incuded review of the resident records, death record, hospita records, faciity incident reports, staff schedues, and reated faciity poicy and procedures. Aso, the investigator observed staff interacting with residents at the faciity. The resident resided in an assisted iving memory care unit. The resident’s diagnoses incuded dementia, haucinations, and deusions. The resident’s service pan incuded assistance with dressing, toieting, medication administration, and safety checks. The resident’s assessment indicated the resident transferred independenty and waked with occasiona supervision from staff. The resident had severe cognitive impairment and had no fas. The faciity’s progress notes indicated one afternoon the resident refused to come out of his room for unch. Approximatey 30 minutes ater, the resident was checked on and was found aseep. The progress note did not identify any further concerns that evening. The next morning the progress notes indicated the resident needed assistances with eating breakfast. After breakfast the resident went back to seep. At mid-day a faciity nurse checked on the resident and observed the resident woud not open his eyes upon wakening and did not have equa hand grip strength. The resident’s provider was notified, and the resident was transported to the hospita. The resident’s daiy schedue services indicated services were provided to the resident as care panned. The resident had no prior fas reported for the 16 months that were reviewed. The hospita records indicated the resident had an x-ray competed and was found to have a chronic fracture of previousy paced hardware of the resident’s right ebow with dispacement of the joint. The resident was not a candidate for surgica interventions. The resident’s death record indicated the resident passed away from throat cancer ess than two months after being sent to the hospita. During an interview, eadership stated the resident waked in the faciity without any assistive devices. Leadership stated they were not aware of the resident having any fas at the faciity. The resident often woud put himsef on the foor in a controed manner ooking for unknown objects or attempting to fix imaginary items on the foor. During an interview, the resident’s famiy member stated the resident worked as a tree trimmer and fe from a tree many years ago. The resident suffered a fractured anke and had a meta pate in his anke. The famiy member stated they were not aware of a meta pate in the resident’s right ebow, but figured the meta pate in the ebow came when the resident fractured his anke. The famiy member stated the resident was discharged from the hospita to a higher eve of care faciity. In concusion, the Minnesota Department of Heath determined negect was not substantiated. “Not Substantiated” means: An investigatory concusion indicating the preponderance of evidence shows that an act meeting the definition of matreatment did not occur. Neglect: Minnesota Statutes, section 626.5572, subdivision 17 “Negect” means negect by a caregiver or sef-negect. (a) "Caregiver negect" means the faiure or omission by a caregiver to suppy a vunerabe adut with care or services, incuding but not imited to, food, cothing, sheter, heath care, or supervision which is: (1) reasonabe and necessary to obtain or maintain the vunerabe adut's physica or menta heath or safety, considering the physica and menta capacity or dysfunction of the vunerabe adut; and (2) which is not the resut of an accident or therapeutic conduct. Vulnerable Adult interviewed: No. The resident was deceased. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Not Appicabe. the Action taken by facility: The resident was sent to the hospita when a change in condition was observed. 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 Menta Heath and Deveopmenta Disabiities PRINTED: 08/08/2024 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 _____________________________ 30625 07/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1005 PAUL PARKWAY NE NORTHERN OAK PLACE 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 July 15, 2024, the Minnesota Department of Health initiated an investigation of complaint #HL306253702M/#HL306254086C. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 S4W811 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): An unknown facility staff member sexually abused the resident when the staff member touched the breast of the resident in front of the resident’s family members. After some of the family members left, the staff member returned and touched the resident’s breast two more times. In addition, the resident had a fall and bruising to both wrists. Investigative Findings and Conclusion: The Minnesota Department of Health determined abuse was not substantiated. During the investigation an alleged perpetrator (AP) was identified. Although the AP displayed inappropriate behavior by touching the resident’s breast, the behavior did not rise to the level of abuse. In addition, while supervised by a facility staff member, the resident fell while walking in the facility. The facility arranged for a wheelchair following the fall. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, unlicensed staff, and the AP. The investigator contacted law enforcement and the case worker. The investigation included review of the resident records, death record, facility internal investigation, facility incident reports, personnel files, staff schedules, and related facility policy and procedures. Also, the investigator toured the facility and observed staff interactions with the residents. The resident resided in an assisted living memory care unit. The resident’s diagnoses included dementia. The resident’s service plan included assistance with dressing and grooming. The resident was severely cognitively impaired, required supervision from staff when transferring and used a walker to assist with ambulation. The resident was vulnerable to abuse and staff were trained to observe the resident for signs of abuse and neglect. The facility’s incident report indicated one day the resident’s family members witnessed the AP touch the resident’s breast. When asked by leadership about the incident, the AP said she touched the resident’s breast to be funny. A facility nurse educated the AP about professional boundaries of joking and touching the resident. The family of the resident did not want any disciplinary action against the AP because there was no ill will or intent to harm or abuse of the resident. During an interview, the facility nurse stated the AP was interviewed about the incident with the resident. The AP had lifted the resident’s breast from the bottom and made a comment about how large the resident’s breast were. The facility nurse stated it was a joke between the resident and the AP. During an interview, the regional director of operations stated the AP had developed a strong relationship with the resident and did not maintain professional boundaries. The resident liked to dance, sing, and joke, and the AP often danced, sang, and joked with the resident. During an interview, the AP stated the resident had clothes on and that she touched the underside of the resident’s breast over the clothes just the one time. The AP stated the resident liked to joke and made comments about the AP’s large breasts. The AP stated she was joking with the resident when she touched the resident’s breast and said you have a bra on. During an interview, a family member stated after the incident, the resident just laughed. The family member stated they had no concerns with the AP’s treatment of the resident. The family member also stated they did not have concerns with the resident’s fall. The additional concern of the resident’s fall was investigated. A facility incident report indicated the resident was supervised by an unlicensed staff member when she became dizzy, fell backwards, and hit the back of the resident’s head. The resident sustained a cut to the back of the resident’s head, staff applied a dressing to the area, and updated the resident’s hospice provider. The hospice provider arranged for the resident to use a wheelchair for mobility. There was no evidence in the resident’s record of bruising of the resident’s wrists. In conclusion, the Minnesota Department of Health determined abuse 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. Vulnerable Adult interviewed: No. The resident was deceased. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Yes. the Action taken by facility: Education was provided to the AP about maintaining professional boundaries. 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: 05/01/2024 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 _____________________________ 30625 04/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1005 PAUL PARKWAY NE NORTHERN OAK PLACE 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 April 15, 2024, the Minnesota Department of Health initiated an investigation of complaint #HL306259948M/#HL306258145C. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 8TKF11 If continuation sheet 1 of 1

Finding: Not Substantiated Nature of the 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 nurse failed to conduct an assessment for a change of condition, and upon the resident's return from the hospital. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. The resident experienced three falls during her first month at the facility, and the staff follow the fall protocol to ensure her well-being. Although the facility could not provide a fall assessment document after each incident, they did have fall incident reports. The resident received proper care and returned to her baseline health condition. The investigator conducted interviews with nursing staff. The investigator contacted the resident's family member. The investigation included review of resident's records, facility's policies and procedures, incident reports, and the resident's external medical record. The An equal opportunity employer. investigation included an onsite visit, observations, and interactions between residents and facility staff. The resident resided in an assisted living memory care unit and had a diagnosis of dementia. The resident’s service plan included assistance of one with a walker and safety check every two hours. The resident’s assessment indicated the resident was non-verbal. The first fall indicated the resident was found on the floor of her room the day after admission with a noticeable bump on her forehead. The facility notified the medical provider, supervisor, and family. Immediate actions included performing vital signs and neuro checks while new interventions included safety checks and a referral for a physical therapy evaluation. The next day the resident was transported to the emergency room the next day for further assessment due to home health nurse request. While in the emergency room the resident received a computed tomography (X-ray imaging combined with computer technology) which did not show injury. The emergency room returned the resident to the facility with no new orders. Three days later the second fall incident report indicated the resident was found on the bathroom floor with a skin tear on her left elbow. The immediate action afterwards included vital signs and increases safety checks while awaiting the referral for a physical therapy evaluation. A month later the third fall incident report indicated the resident was found on the bathroom floor with no apparent injuries. The facility obtained vital signs, notified the medical provider and the family. Two days later the resident’s progress notes indicated two days later a nurse contacted the resident’s medical provider and requested an X-ray for the resident including her left shoulder, which showed left arm fracture. The resident saw an orthopedist a week later when the decision was made to not provide further treatment but rather monitor for pain or discomfort. Approximately a month later, the same documents indicated the resident showed sing of healing. During an interview, a licensed practical nurse confirmed the resident fell three times since her admission to the facility. She explained that the resident's first fall occurred a day after admission, and the home health nurse observed a bump on her head the next day, prompting a request to send her to the hospital. The licensed practical nurse mentioned vital signs and a neuro check were conducted. The resident fell again a couple of days later, resulting in a skin tear. The nurse stated she did not record notifying the physician, but she recalled discussing the incident with the physician in person. Regarding the third fall, the nurse stated there were no apparent injuries at the time of the incident. However, a couple of days later, the resident did not use her left arm and appeared guarded. In response, the nurse requested an X-ray. During an interview, a registered nurse stated she was not on site when the resident fell, however she was notified of the incident. While unable to recall the exact day of notification, she stated she reviewed the fall incident report a few days following the occurrence. According to policy, assessments were conducted after a resident return from the hospital or experiences any changes in condition. The nurse stated no changes were made to the resident's care services after the last fall, except for adjustments in the timing of her morning care. Additionally, she stated the resident has not experienced any further falls since then. 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, the resident had dementia. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Not Applicable. the Action taken by facility: No action required. 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: 11/20/2023 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 _____________________________ 30625 10/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1005 PAUL PARKWAY NE NORTHERN OAK PLACE 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 October 17, 2023, the Minnesota Department of Health initiated an investigation of complaint HL306257106M/HL306253427C. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 0LNG11 If continuation sheet 1 of 1