The Ridge at Blaine.

CORRECTION ORDERS The enclosed State Form documents the state correction orders. MDH documents state licensing correction orders using federal software. Tag numbers are assigned to Minnesota state statutes for Assisted Living Facilities. The assigned tag number appears in the far left column entitled "ID Prefix Tag." The state statute number and the corresponding text of the state statute out of compliance are listed in the "Summary Statement of Deficiencies" column. This column also includes the findings that are in violation of the state statute after the statement, "This MN Requirement is not met as evidenced by . . ." IMPOSITION OF FINES In accordance with Minn. Stat. § 144G.31, Subd. 4, fines and enforcement actions may be imposed based on the level and scope of the violations and may be imposed immediately with no opportunity to correct the violation first as follows: Level 1: no fines or enforcement. Level 2: a fine of $500 per violation, in addition to any enforcement mechanism authorized in § 144G.20 for widespread violations; Level 3: a fine of $3,000 per violation per incident, in addition to any enforcement mechanism authorized in § 144G.20. Level 4: a fine of $5,000 per incident, in addition to any enforcement mechanism authorized in § 144G.20. Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, the following fines are assessed pursuant to this survey: An equal opportunity employer. Letter ID: IS7N REVISED 09/13/2021 Edgemont Place January 24, 2025 Page 2 St - 0 - 1290 - 144g.60 Subdivision 1 - Background Studies Required - $3,000.00 Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, t he total amount you are assessed is $3,000.00. You will be invoiced approximately 30 days after receipt of this notice, subject to appeal. fDOCUMENTATION 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 a reconsideration and tags with the fines at a hearing, please submit two separate appeals forms at Edgemont Place January 24, 2025 Page 3 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, Casey DeVries, Supervisor State Evaluation Team Email: Casey.DeVries@state.mn.us Telephone: 651-201-5917 Fax: 1 -866-890-9290 HHH PRINTED: 01/24/2025 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 _____________________________ 32457 12/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 11748 ULYSSES LANE NE EDGEMONT 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 Correction Orders ASSISTED LIVING PROVIDER LICENSING using federal software. Tag numbers have CORRECTION ORDER(S) 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, these correction orders are appears in the far-left column entitled "ID issued pursuant to a survey. Prefix Tag." The state Statute number and the corresponding text of the state Statute Determination of whether violations are corrected out of compliance is listed in the requires compliance with all requirements "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. SL32457016-0 PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On December 2, 2024, through December 4, STATES,"PROVIDER'S PLAN OF 2024, the Minnesota Department of Health CORRECTION." THIS APPLIES TO conducted a full survey at the above provider, and FEDERAL DEFICIENCIES ONLY. THIS the following correction orders are issued. At the WILL APPEAR ON EACH PAGE. time of the survey, there were 31 residents, all of whom received services under the Assisted Living THERE IS NO REQUIREMENT TO license. SUBMIT A PLAN OF CORRECTION FOR VIOLATIONS OF MINNESOTA STATE An immediate correction order was identified on STATUTES. December 2, 2024, issued for SL32457016-0, tag identification 1290. The letter in the left column is used for tracking purposes and reflects the scope During the survey, the licensee took action to and level issued pursuant to 144G.31 mitigate the immediate risk. However, subd. 1, 2, and 3. noncompliance remained, and the scope and level remain unchanged. 0 480 144G.41 Subdivision 1 Subd. 1a (a-b) Minimum 0 480 SS=F requirements; required food services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 0EKV11 If continuation sheet 1 of 31 PRINTED: 01/24/2025 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 _____________________________ 32457 12/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 11748 ULYSSES LANE NE EDGEMONT 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 (a) Except as provided in paragraph (b), food 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 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 sufficient supervision was not provided in the dining room and the resident choked. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. The facility acted appropriately and contacted emergency medical services (EMS) immediately upon the resident’s change in condition. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted the resident’s family member. The investigation included review of the resident record, death record, hospital records, facility internal investigation, facility incident reports, staff schedules, and related facility policy and procedures. Also, the investigator made an onsite visit and observed staff members facility providing care to and interacting with current residents. The resident resided in an assisted living memory care unit. The resident’s diagnoses included dementia, high blood pressure and recurrent falls. The resident’s service plan included assistance with meals, requiring a mechanical soft diet and nectar thick liquids. The resident’s assessment indicated the resident had limited communication and needed assistance of one staff member for transfers and a wheelchair for mobility. A facility report indicated the resident became agitated at mealtime requesting a dietary item not allowed on mechanical soft foods with nectar thickened liquids diet. Shortly thereafter, facility staff members noticed the resident’s breathing pattern changed and, when a nurse asked him if he was okay, he did not respond verbally. The nurse initiated the Heimlich maneuver (a first aid technique used to help someone who is choking) and transferred the resident to the hospital via EMS. Hospital records indicated the resident’s heart stopped and cardiopulmonary resuscitation (CPR) was initiated in the ambulance enroute to the hospital. The same document indicated the resident was pronounced dead in the emergency room. During an interview, the nurse stated the resident became agitated during the evening meal and was upset due to dietary restrictions. The resident then began breathing loudly and did not respond to the nurse. The nurse asked for EMS to be called, then initiated the Heimlich maneuver. The nurse stated they followed the instructions given by EMS dispatch operator until EMS arrived and transferred the resident to the hospital. During an interview, the resident’s family member stated the facility manager notified her of the resident’s change in condition and she went directly to the hospital. At the hospital, the physician met with her and stated the resident had died from a stroke. 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, vulnerable adult is deceased Family/Responsible Party interviewed: Yes Alleged Perpetrator interviewed: Not Applicable Action taken by facility: No action required. 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: 10/02/2024 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 _____________________________ 32457 09/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 11748 ULYSSES LANE NE EDGEMONT PLACE ALZHEIMER'S SPE CIALTY 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 September 26, 2024, the Minnesota Department of Health initiated an investigation of complaint #HL324576303C/#HL324574784M. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 IHI311 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 a resident when multiple, various skin injuries were found during an assessment. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. The facility communicated changes with the provider and provided medical care as ordered. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted a family member. The investigation included review of the resident’s internal and external medical records, provider notes, staff schedules, facility policies and a law enforcement report. Also, the investigator completed an onsite visit and observed staff assisting the resident with cares. An equal opportunity employer. The resident resided in an assisted living memory care unit. The resident’s diagnoses included cognitive impairment and arthritis. The resident’s service plan included assistance with dressing, bathing, medication administration and mobility. The resident’s assessment indicated she was alert to only herself, used a wheelchair with assistance, and was at risk for falls. The resident took a blood thinner medication (Coumadin) daily. After one month of residing at the facility, an incident report indicated staff found the resident to be on the floor in her bedroom during the overnight shift. Staff assisted her back to bed and noted abrasion, bruising, and swelling injuries to the resident’s face. Staff updated the medical provider and family. The resident went to the emergency room for evaluation. Hospital records indicated hospital staff noted multiple various skin injuries. The emergency room physician did not state a diagnosis for the skin injuries. The resident returned to the facility with treatment orders in place. The facility nurses’ notes indicated the resident’s left arm was noted to be more swollen than the right with intact blisters present. When rechecked later in the shift, staff reported to the nurse some of the blisters had opened while others remained intact. The nurse indicated there were no signs or symptoms of infection, staff were to continue to monitor and report any changes. The same document indicated two days later, a family member brought the resident to a second nurse and showed the nurse the resident’s left arm which had a row of blisters present with some of which were open. The nurse updated the provider at that time and received treatment orders the following day. The nurses’ notes indicated the blisters had dried and redness resolved five days later. Three days after they resolved, the notes indicated staff noted the resident’s left arm was swollen and tender. The resident was unable to feed herself as a result. Staff sent the resident to the emergency room for evaluation and returned to the facility the following day with treatment orders. Hospital records indicated the medical provider provide no diagnosis during her evaluation in the emergency room. The provider ruled out cellulitis (skin infection), shingles, septic joint, and sepsis (blood infection). The medical provider discussed hospital admission with the resident’s family member due to the family members concerns about the facility. The family member declined hospital admission and the resident returned to the facility with orders for treatment. After returning from the hospital, the resident’s primary medical provider notes indicated the provider ordered steroid and antibiotic medications for the diagnosis of Bullous Pemphigoid (a skin condition caused by an autoimmune response at the epidermal level of skin). During an interview, the registered nurse stated when staff find a skin concern, nursing instructed staff to assume they are the first to see it and report it right away. She stated a nurse completed resident skin checks on Mondays, and unlicensed staff also check residents’ skin on their bath days. During an interview, an unlicensed personnel stated if she found a skin concern on a resident, she would report it right away and chart it. During an interview, when asked if staff had ever treated her badly, the resident stated no. The resident denied any rough handling by staff. The resident stated she felt safe in the facility and denied any skin concerns. During an interview, a family member stated she did not feel the resident was abused. The family member stated it made sense the blisters could have been from an autoimmune reaction. 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: Yes. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Not Applicable. the Action taken by facility: The facility provided medical care as ordered by the provider. 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: 12/29/2023 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 _____________________________ 32457 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 11748 ULYSSES LANE NE EDGEMONT PLACE ALZHEIMER'S SPE 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. 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 far 144G.08 to 144G.95, these correction orders are 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. #HL324574867C/#HL324577925M, PLEASE DISREGARD THE HEADING OF #HL324573964C/#HL324577404M. THE FOURTH COLUMN WHICH STATES,"PROVIDER'S PLAN OF On December 7, 2023, the Minnesota CORRECTION." THIS APPLIES TO Department of Health conducted a complaint FEDERAL DEFICIENCIES ONLY. THIS investigation at the above provider, and the WILL APPEAR ON EACH PAGE. following correction orders are issued. At the time of the complaint investigation, there were 42 THERE IS NO REQUIREMENT TO residents receiving services under the provider's SUBMIT A PLAN OF CORRECTION FOR Assisted Living with Dementia Care license. VIOLATIONS OF MINNESOTA STATE STATUTES. The following correction order is issued for #HL324573964C/#HL324577404M, tag THE LETTER IN THE LEFT COLUMN IS identification 0730 and 2310. USED FOR TRACKING PURPOSES AND REFLECTS THE SCOPE AND LEVEL No corrections orders are issued for ISSUED PURSUANT TO 144G.31 #HL324574867C/#HL324577925M. SUBDIVISION 1-3. 0 730 144G.43 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 alleged perpetrator (AP) abused a resident when she hit the resident on the head. Investigative Findings and Conclusion: The Minnesota Department of Health determined abuse was not substantiated. The AP denied the allegation and passed a polygraph (lie detector) examination administered by law enforcement. The case was closed with no charges. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted a family member. The investigation included review of the resident’s medical record, staff schedules, personnel files, the facility’s investigation report and law enforcement report. Also, the investigator conducted an onsite visit to the facility and observed staff performing care assistance with the resident. An equal opportunity employer. The resident resided in an assisted living memory care unit. The resident’s diagnoses included Alzheimer’s disease and osteoarthritis. The resident’s service plan included assistance with behavior management, toileting, dressing, bathing, and medication administration. The resident’s assessment indicated use of a wheelchair and memory loss. On the date of the incident, an unlicensed personnel (ULP) reported hearing screaming coming from the resident’s room. Upon entering the room, the ULP stated she saw the AP hit the resident with an open hand on the right side of her head. The ULP left the room and notified another staff member who went to the resident’s room and directed the AP to leave the resident’s room. The facility incident report indicated administrative staff assessed the resident as soon as she entered the facility once notified of the incident by phone. The administrative staff did not note any bruising or marks on the resident’s skin. The following morning, the resident remained free of any skin markings. A law enforcement report indicated law enforcement spoke with the AP. The AP denied hitting the resident and stated she wanted to take a polygraph test. The report indicated the AP was being truthful and did not harm or injure the resident. Law enforcement updated the resident’s son with the case information. The report indicated the case was closed. During an interview, the AP denied abusing the resident. The AP stated the evening of the alleged incident, the resident needed her brief changed before going to bed, and the resident was being resistive to toileting assistance. The AP stated she attempted to convince the resident more than six times without success, so she requested assist from another staff member to help. The AP stated the resident was hitting and scratching her while she and the other staff member attempted to change the resident and clean her skin. The AP stated she witnessed the ULP leave the room but was not aware that she had re-entered the room. The AP stated she heard the ULP stating she was calling management, and she did not understand why. The AP stated the police contacted her a few days later and she was interviewed by them. The AP requested a polygraph test, which law enforcement staff administered. The AP stated she passed the test, and she was cleared of everything. The AP stated she felt the ULP made up the abuse claim because she did not like her and had a conspiracy against her. During an interview, the resident stated she felt safe at the facility. The resident denied staff treating her badly. The resident did not recall staff ever forcing her to do something she did not want to do. During an interview, the nurse stated all staff receive abuse and neglect training upon hire. The nurse stated the resident does have memory loss and can have simple conversation making her needs known. The nurse stated she was notified of the allegation the next morning. The nurse started an investigation and spoke with the resident who kept referring to somebody hitting her repeatedly. During an interview, a family member stated the resident has dementia, and her long-term memory was better than her short-term memory. The family member stated he visited the resident the following day of the alleged incident and did not see any cuts or bruises. He asked the resident if the staff were treating her well; she stated yes, and that she liked it at the facility. The family member stated he did not know if the resident was hit or not, but the resident did not remember it if it did happen. The family member stated he did not pursue criminal charges on the staff member because she passed the polygraph test, and he was not sure if it happened or not. The family member stated he felt the resident was safe at the facility. 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; 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; Vulnerable Adult interviewed: Yes. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Yes. Action taken by facility: The facility reported to the Minnesota Adult Abuse Reporting Center. 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: 12/29/2023 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 _____________________________ 32457 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 11748 ULYSSES LANE NE EDGEMONT PLACE ALZHEIMER'S SPE 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. 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 far 144G.08 to 144G.95, these correction orders are 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. #HL324574867C/#HL324577925M, PLEASE DISREGARD THE HEADING OF #HL324573964C/#HL324577404M. THE FOURTH COLUMN WHICH STATES,"PROVIDER'S PLAN OF On December 7, 2023, the Minnesota CORRECTION." THIS APPLIES TO Department of Health conducted a complaint FEDERAL DEFICIENCIES ONLY. THIS investigation at the above provider, and the WILL APPEAR ON EACH PAGE. following correction orders are issued. At the time of the complaint investigation, there were 42 THERE IS NO REQUIREMENT TO residents receiving services under the provider's SUBMIT A PLAN OF CORRECTION FOR Assisted Living with Dementia Care license. VIOLATIONS OF MINNESOTA STATE STATUTES. The following correction order is issued for #HL324573964C/#HL324577404M, tag THE LETTER IN THE LEFT COLUMN IS identification 0730 and 2310.