Edgewood Brainerd Senior Livin.

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 alleged perpetrator (AP) abused the resident when she grabbed the resident forcefully by the left wrist and removed a glass of juice from her hand. Investigative Findings and Conclusion: The Minnesota Department of Health determined abuse was inconclusive. The AP denied the allegations, and the resident could not be interviewed due to her cognitive impairment. While there was a witness and the AP may have treated the residents in a discourteous manner, there is insufficient evidence to demonstrate abuse occurred. The investigator conducted interviews with facility staff members, including administrative staff, and unlicensed staff. The investigation included review of the resident’s records, personnel files, staff schedules, policies, and procedures. The resident resided in an assisted living secured memory care building. The resident’s diagnoses include dementia. The resident’s service plan included assistance with all activities of daily living. A concern arose when the facility received a report the AP took the resident by the wrist forcefully. During the internal investigation, the management team discovered an incident occurred a few days earlier in which the AP, an unlicensed caregiver, reportedly forcefully grabbed a resident’s left wrist and removed a glass of juice from her hand during mealtime. According to the facility’s internal investigation, the AP stated she was handing a different resident a glass of juice when the resident took it. The AP stated another caregiver, unlicensed caregiver #1, began to yell at the AP to “just let her have it”. The AP stated she found this frustrating to be yelled at and walked away to calm down. During an email exchange, the AP declined an interview. The email indicated the AP was nowhere near the resident. During an interview, the manager stated she received a report of the incident and spoke with unlicensed caregiver #1, who witnessed the event. The manager said she assessed the resident and observed a bruise on the resident’s left wrist. The resident denied any pain. The manager noted that the resident had experienced a fall two weeks prior, and the bruise could have resulted from that incident. However, the resident had been assessed by a different nurse at the time of the fall, and no injuries were noted. The manager also stated the resident is known to wander and could have sustained the injury by contacting objects such as a door. As a result, it could not be confirmed the bruise was caused by the AP. During an interview, unlicensed caregiver #1 stated she was in the dining room serving dinner when she observed the resident attempting to take a cup from another resident’s table. She said she saw AP approaching quickly and began tugging on the resident’s wrist. She stated she intervened and told the AP to stop, after which the AP yelled at her and walked away. She further stated he did not report the incident immediately because she did not recognize it as a serious issue but has since received education on timely reporting procedures. 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; (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; 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. (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. he Vulnerable Adult interviewed: no, unable to participate in an interview due to dementia. Family/Responsible Party interviewed: No, attempted but did not reach Alleged Perpetrator interviewed: Declined interview. Action taken by facility: The facility initiated an internal investigation and terminated the AP. The facility also retrained all staff involved on timely reporting procedures. 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: 04/ 24/ 2026 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/ SUPPLIER/ CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ C B. WING _____________________________ 30411 03/ 04/ 2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 14890 BEAVER DAM ROAD EDGEWOOD BRAINERD SENIOR LIVIN BRAINERD, MN 56401 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER' S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS- REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 000 Initial Comments 0 000 On March 4, 2026, the Minnesota Department of Health initiated an investigation of complaints #HL304119882M/ HL304114682C. No correction orders are issued. LABORATORY DIRECTOR' S OR PROVIDER/ SUPPLIER REPRESENTATIVE' S SIGNATURE TITLE (X6) DATE STATE FORM 6899 1HO011 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 necessar yto ensure the health, safety, and welfare of residents in your care. STATE CORRECTIO ONRDERS 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 Statemen tof Deficiencies "column. This column also includes the findings that are in violation of the state statute after the statement, "This MN Requiremen tis not met as evidenced by . . ." IMPOSITION OF FINES In accordance with Minn. Stat. § 144G3. 1, 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: Leve l1: no fines or enforcement; Leve l2: a fine of $500 per violation, in addition to any enforcement mechanism authorized in § 144G2. 0; Leve l3: a fine of $1,000 per incident, in addition to any enforcement mechanism authorized in § 144G2. 0; Leve l4: a fine of $3,000 per incident, in addition to any enforcement mechanism authorized in An equal opportunity employer . Letter ID: IS7N REVISE 0D9/13/2021 Edgewood Brainerd Senior Living October 31, 2025 Page 2 § 144G2. 0; Leve l5: a fine of $5,000 per violation, in addition to any enforcement mechanism authorized in § 144G2. 0. Therefore ,in accordance with Minn. Stat. §§ 144G0. 1 to 144G9. 999, the following fines are assessed pursuant to this survey: St - 0 - 0510 - 144g.41 Subd. 3 - Infection Control Program - $500.00 St - 0 - 0775 - 144g.45 Subd. 2. (a) - Fire Protection And Physica lEnvironment - $500.00 Therefore ,in accordance with Minn. Stat. §§ 144G0. 1 to 144G9. 999, the total amount you are assesse dis $1,000.00. You will be invoiced approximately 30 days after receipt of this notice, subject . to appeal DOCUMENTATIO ONF ACTION TO COMPLY In accordance with Minn. Stat. § 144G3. 0, Subd .5(c), the licensee must docum ent 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: x Identify how the area(s) of noncompliance was corrected related to the resident(s)/ employees( ) identified in the correction order. x 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. x Identify what changes to your systems and practices were made to ensure compliance with the specific statute(s). CORRECTIO ONRDER RECONSIDERATI OPRNOCESS In accordance with Minn. Stat. § 144G3. 2, Subd .2, you may challenge the correction order(s) issued, including the level and scope ,and any fine assesse dthrough 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 REQUESTIN AG HEARING Alternatively ,in accordance with Minn. Stat. § 144G3. 1, Subd .5(d), an assisted living provider that has been assesse da fine under this subdivision has a right to a reconsideration or a hearing under this section and chapter 14. Pursuan tto Minn. Stat. § 144G2. 0, 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. Edgewood Brainerd Senior Living October 31, 2025 Page 3 To submit a hearing request, please visit: https:/ / forms.web.health.state.mn.us/form/ HRDAppealsForm To appea lfines via reconside ration, please follow the pr ocedur e outlined above. Plea se note that you may request a reconsideration or 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: https:/ / forms.office.com/g/ Bm5uQEpHV.a Your input is important to us and will enable MDH to improve its processe sand communication with providers . If you have any questions regarding the questionnaire ,please contact Susan Winkelmann at susanw. inkelmann@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 organizations’ Governing Body. If you have any questions ,please contact me. Sincerely, Jessie Chenze ,Supervisor State Evaluation Team Email: JessieC. henze@state.mn.us Telephone :218-332-5175 Fax :1-866-890-9290 CLN PRINTED: 10/31/2025 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 _____________________________ 30411 10/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 14890 BEAVER DAM ROAD EDGEWOOD BRAINERD SENIOR LIVIN BRAINERD, MN 56401 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE PREFIX PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 000 Initial Comments 0 000 ****ATTENTION***** Minnesota Department of Health is documenting the State Correction Orders ASSISTED LIVING PROVIDER LICENSING using federal software. Tag numbers have CORRECTION ORDER(S) been assigned to Minnesota State Statutes for Assisted Living Facilities. The In accordance with Minnesota Statutes, section assigned tag number appears in the 144G.08 to 144G.95, these correction orders are far-left column entitled "ID Prefix Tag." issued pursuant to a survey. The state Statute number and the corresponding text of the state Statute out Determination of whether violations are corrected of compliance is listed in the "Summary requires compliance with all requirements Statement of Deficiencies" column. This provided at the Statute number indicated below. column also includes the findings which When Minnesota Statute contains several items, are in violation of the state requirement failure to comply with any of the items will be after the statement, "This Minnesota considered lack of compliance. requirement is not met as evidenced by." Following the evaluators ' findings is the INITIAL COMMENTS: Time Period for Correction. SL30411016-0 PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On September 29, 2025, through October 1, STATES,"PROVIDER'S PLAN OF 2025, 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 89 residents; all 89 receiving services under the Assisted Living THERE IS NO REQUIREMENT TO Facility with Dementia Care license. SUBMIT A PLAN OF CORRECTION FOR VIOLATIONS OF MINNESOTA STATE STATUTES. THE LETTER IN THE LEFT COLUMN IS USED FOR TRACKING PURPOSES AND REFLECTS THE SCOPE AND LEVEL ISSUED PURSUANT TO 144G.31 SUBDIVISION 1-3. 0 480 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 5D9J11 If continuation sheet 1 of 14 PRINTED: 10/31/2025 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.

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 the resident when the AP held the resident’s apartment door closed so she was unable to leave her apartment. Investigative Findings and Conclusion: The Minnesota Department of Health determined abuse was not substantiated. Although the AP held the door closed briefly to prevent the resident from exiting her apartment, the error was an isolated incident, and no harm occurred to the resident. The AP held the door to provide redirection of the resident’s wandering so she would go back to bed. The facility provided abuse re-training to all staff who work at the facility. 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 records, facility internal investigation, facility incident reports, personnel files, staff schedules, and related facility policies and procedures Also, the investigator toured the facility and observed facility staff members providing care to the residents. The resident resided in an assisted living memory care unit. The resident’s diagnoses included dementia, paranoid psychosis, and impulsivity. The resident’s service plan included assistance with behavioral redirection, escorts, and safety checks. The resident’s assessment indicated the resident was disoriented and needed redirection. The internal investigation indicated unlicensed personnel (ULP)-1 heard the AP held the resident’s apartment door shut to prevent the resident from exiting the room. ULP-2 observed the AP hold the door shut and told the AP holding a door shut was inappropriate. The AP admitted she held the resident’s door shut to redirect the resident back to bed. The AP never witnessed a staff member hold a resident’s door closed but said she was told by an unknown person she could. The internal investigation indicated five ULP were interviewed during the internal investigation. ULP-3 said she observed ULP-1 hold a door shut so a different resident was unable to exit their apartment. ULP-1 denied she ever held a door closed to prevent a resident from exiting their apartment and denied she ever witnessed someone hold an apartment door shut. The facility provided re-education to all staff who worked at the facility. A nursing assessment completed after the incident indicated no change in the resident’s mental or physical health. During an interview, the AP said she held the resident’s apartment door closed for 10 seconds to prevent the resident from exiting during the night shift. She said she tried to prevent the resident from leaving her apartment so she would go back to bed. The AP said she entered the resident’s apartment immediately after holding the door to ensure the resident was safe. She said she received training on vulnerable adult maltreatment before and after the incident. She said this was the only time she had held a resident’s door closed and said she would never do it again. During an interview, a member of management who was also a nurse, said ULP-2 reported she observed the AP hold the resident’s door closed. The facility conducted an internal investigation, the resident was assessed for safety, and the resident’s family member was notified. The facility mandated all staff members complete vulnerable adult maltreatment regardless of when they last received education. The AP was a newly hired ULP and was honest about the incident and her error. The facility had adequate staffing during the incident. During an interview, ULP-2 said she observed the AP hold the resident’s apartment door closed to prevent the resident from exiting her room. The AP held the door closed for 15 seconds. The AP wanted the resident to go back to bed and prevent her from wandering. She said she received vulnerable adult maltreatment training before and again after the incident. During an interview, ULP-3 said she thought she observed ULP-1 hold a different resident’s door closed but she never said anything to unlicensed personnel-1 during the incident. She said during this incident she was standing at the medication cart located across the dayroom. She reported this to management. This was the only time she witnessed this type of incident. During an interview, ULP-1 said she assisted with training the AP. She said she never told the AP she could hold a resident’s door closed to prevent them from exiting their room. She said the AP was a new staff member and this was her first healthcare job. She said all staff received re-education on maltreatment of vulnerable adults after the incident. She said she never held a resident’s door closed to prevent them from exiting their apartment. During an interview, ULP-4 said she had never witnessed a staff member hold a resident’s door closed to prevent them from exiting. She said she received vulnerable adult maltreatment training before and after the incident. A voice message from the resident’s family member indicated he was informed of the incident after it happened and the resident’s mental health was unchanged due to the incident. He had no further information to add. 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; 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. (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, due to cognitive deficit. Family/Responsible Party interviewed: No, family member left voicemail. No further information to add. Alleged Perpetrator interviewed: Yes.t Action taken by facility: The facility completed an internal investigation, assessed the resident, and re-educated all staff members. 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: 04/28/2025 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.

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 alleged perpetrator (AP) sexually abused a resident when the AP touched the resident’s vagina. Investigative Findings and Conclusion: The Minnesota Department of Health determined abuse was inconclusive. The investigation found there was conflicting evidence to determine if abuse occurred. The AP denied the allegations, and the resident could not be interviewed due to her cognitive impairment. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigation included review of the resident’s medical record, the facility investigation, law enforcement report, personnel files, facility policies and staff schedules. Also, the investigator toured the facility and observed interactions between staff and residents. An equal opportunity employer. The resident resided in an assisted living memory care unit. The resident’s diagnoses included major neurocognitive disorder (a deterioration of cognitive function,) and dementia. The resident’s service plan included assistance with toileting, dressing, bathing, and eating. The resident’s assessment indicated she required full help with all activities of daily living and is sometimes understood by staff which is limited to yes or no questions. During an interview, an unlicensed personnel (ULP) stated she witnessed the AP open the resident’s brief and place his hand inside of it. She stated he used his fingers to spread her labia. The ULP stated she told the nursing supervisor about the incident. The ULP stated she then told an administrative staff member, who was also working on the floor that day. The ULP stated the administrative staff member sighed and walked away. The incident was not reported until approximately two months later. The law enforcement report indicated the officer arrived to the facility and spoke to the administrative staff and registered nurse, who stated they had not heard of any allegations of sexual contact between a resident and the AP. The report indicated the officer met with the ULP. The ULP stated the residents brief was obviously soaked, viewing it from a distance. The AP pulled back the brief and placed his ungloved fingers inside of the resident’s labia. The ULP stated she reported the incident to administrative staff a couple days later. The internal investigation report, conducted after law enforcement initiated their investigation, indicated the AP made many staff feel uncomfortable. It indicated an assessment was completed on the resident and no concerns were noted. During an onsite visit, the investigator observed staff performing perineal care of the resident, The incontinence brief had moisture indicator lines on the outside of the brief. The staff performed appropriate perineal care. There was no adverse reaction noted from the resident. The staff member stated the resident often “leaks” urine while she is being turned. During an interview, the administrative staff member stated the resident did not exhibit any signs or symptoms of abuse. Administrative staff stated there had not been previous complaints of the AP regarding resident care, and that he remained on the staff roster at this time with no scheduled shifts until the law enforcement investigation was complete. During an interview, the AP denied ever inappropriately touching the resident. He stated he opened the brief and touched the inside of the brief to see if it was wet and needed to be changed. During an interview, a family member stated she felt the resident was safe at the facility and did not have any concerns for care received. She felt the abuse allegation was handled appropriately by the facility. The resident was unable to complete an interview. 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: (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: (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. Vulnerable Adult interviewed: No, unable to complete an interview. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Yes. Action taken by facility: The facility suspended the AP during the investigation. 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 Brainerd Police Department PRINTED: 11/14/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ C B. WING _____________________________ 30411 09/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 14890 BEAVER DAM ROAD EDGEWOOD BRAINERD SENIOR LIVIN G BRAINERD, MN 56401 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, assigned tag number appears in the far section144G.08 to 144G.95, these correction left column entitled "ID Prefix Tag." The orders are issued pursuant to a complaint state Statute number and the investigation. corresponding text of the state Statute out of compliance is listed in the "Summary Determination of whether a violation is corrected Statement of Deficiencies" column. This requires compliance with all requirements column also includes the findings which provided at the statute number indicated below. are in violation of the state requirement When a Minnesota Statute contains several after the statement, "This Minnesota items, failure to comply with any of the items will requirement is not met as evidenced by." be considered lack of compliance. Following the evaluators' findings is the Time Period for Correction. INITIAL COMMENTS: PLEASE DISREGARD THE HEADING OF #HL304114832C/#HL304117906M THE FOURTH COLUMN WHICH STATES,"PROVIDER'S PLAN OF On September 18, 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 99 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 orders are issued for #HL304114832C/#HL304117906M, tag THE LETTER IN THE LEFT COLUMN IS identification 620, 2310. USED FOR TRACKING PURPOSES AND REFLECTS THE SCOPE AND LEVEL ISSUED PURSUANT TO 144G.31 SUBDIVISION 1-3. 0 620 144G.42 Subd. 6 (a) / 626.557, Subd. 3 0 620 SS=D Compliance with requirements for reporting ma LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 O0YI11 If continuation sheet 1 of 7 PRINTED: 11/14/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ C B.