The Sanctuary at Brooklyn Cent.

STATE LICENSING COMPLIANCE REPORT Report #: HL337722080C Date Concluded: December 31, 2024 Name, Address, and County of Facility Investigated: The Sanctuary at Brooklyn Center 6121 Brooklyn Boulevard Brooklyn Center, MN 55429 Hennepin County Facility Type: Assisted Living Facility with Evaluator’s Name: Holly German, RN Dementia Care (ALFDC) Special Investigator The Minnesota Department of Health conducted a complaint investigation to determine compliance with state laws and rules governing the provision of care under Minnesota Statutes, Chapter 144G. The purpose of this complaint investigation was to review if facility policies and practices comply with applicable laws and rules. No maltreatment under Minnesota Statutes, Chapter 626 was alleged. To view a copy of the correction orders, if any, please visit: https://www.health.state.mn.us/facilities/regulation/directory/provcompselect.html, or call website, please see the attached state form. PRINTED: 01/02/2025 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 _____________________________ 33772 12/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6121 BROOKLYN BOULEVARD THE SANCTUARY AT BROOKLYN CENT ER BROOKLYN CENTER, MN 55429 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 December 30, 2024, the Minnesota Department of Health initiated an investigation of complaint #HL337722080C. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 IC1711 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 for widespread violations; Level 3: a fine of $3,000 per violation per incident, in addition to any enforcement mechanism authorized in § 144G.20. An equal opportunity employer. Letter ID: IS7N REVISED 09/13/2021 The Sanctuary At Brooklyn Center February 3, 2025 Page 2 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: 0510 - 144g.41 Subd. 3 - Infection Control Program - $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. The Sanctuary At Brooklyn Center February 3, 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 JMD PRINTED: 02/03/2025 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 _____________________________ 33772 12/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6121 BROOKLYN BOULEVARD THE SANCTUARY AT BROOKLYN CENT BROOKLYN CENTER, MN 55429 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 ASSISTED LIVING PROVIDER LICENSING Minnesota Department of Health is CORRECTION ORDER(S) documenting the State Correction Orders using federal software. Tag numbers have In accordance with Minnesota Statutes, section been assigned to Minnesota State 144G.08 to 144G.95, these correction orders are Statutes for Assisted Living Facilities. The issued pursuant to a survey. assigned tag number appears in the far left column entitled "ID Prefix Tag." The Determination of whether violations are corrected state Statute number and the requires compliance with all requirements corresponding text of the state Statute out provided at the Statute number indicated below. of compliance is listed in the "Summary When Minnesota Statute contains several items, Statement of Deficiencies" column. This failure to comply with any of the items will be column also includes the findings which considered lack of compliance. are in violation of the state requirement after the statement, "This Minnesota INITIAL COMMENTS: requirement is not met as evidenced by." Following the evaluators ' findings is the SL33772016-0 Time Period for Correction. On December 9, 2024, through December 12, PLEASE DISREGARD THE HEADING OF 2024, the Minnesota Department of Health THE FOURTH COLUMN WHICH conducted a full survey at the above provider. At STATES,"PROVIDER'S PLAN OF the time of the survey, there were 142 residents; CORRECTION." THIS APPLIES TO all of whom were receiving services under the FEDERAL DEFICIENCIES ONLY. THIS Assisted Living facility with Dementia Care WILL APPEAR ON EACH PAGE. license. THERE IS NO REQUIREMENT TO 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. 0 510 144G.41 Subd. 3 Infection control program 0 510 SS=F (a) All assisted living facilities must establish and LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 HTH511 If continuation sheet 1 of 19 PRINTED: 02/03/2025 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 _____________________________ 33772 12/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6121 BROOKLYN BOULEVARD THE SANCTUARY AT BROOKLYN CENT BROOKLYN CENTER, MN 55429 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) 0 510 Continued From page 1 0 510 maintain an infection control program that complies with accepted health care, medical, and nursing standards for infection control. (b)The facility's infection control program must be consistent with current guidelines from the national Centers for Disease Control and Prevention (CDC) for infection prevention and control in long-term care facilities and, as applicable, for infection prevention and control in assisted living facilities.

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 to provide up to date medical information about the resident’s wish regarding cardiopulmonary resuscitation (CPR). Staff provided emergency medical service (EMS) providers with a provider order for life-sustaining treatment document (POLST) that indicated do not resuscitate (DNR), so paramedics did not initiate CPR when the resident’s heart stopped on the way to the hospital and the resident died. When they arrived at the hospital, the hospital discovered a newer POLST which indicated the resident did wish to receive CPR. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. The resident had a POLST on file at the hospital from when she had a surgical procedure earlier in the year. The hospital discharged the resident to a transitional care unit (TCU) for four months. When the resident returned to the facility, she identified that she did not want CPR as reflected on her admission POLST. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator reached out to family and the medical examiner. The investigation included review of the resident records, death record, hospital records, facility internal investigation, staff schedules, ambulance run report, and related facility policy and procedures. Also, the investigator observed the staff offices which contained the” grab and go” binders with resident information envelopes prepared for hand off to EMS. The resident lived in an assisted living facility for several years. The resident’s diagnoses included emphysema, obstructive sleep apnea, and history of gall bladder removal. The resident’s service plan included assistance with storage of controlled substances, bathing, compression stockings application and removal, and medication set-up. The service plan indicated the resident was independent with activities of daily living, transfers, mobility, and medication administration/reordering. All the resident’s assessments conducted at the facility indicated the resident requested staff do not attempt cardiopulmonary resuscitation in the event of cardiac arrest and breathing stoppage (DNR). Resident progress notes indicated a speech therapist working with the resident one day noted the resident became unusually tired during the session and requested to lay down. The progress note indicated the speech therapist continued to check on the resident and when the resident became less responsive, asked an emergency medical technician (EMT) (who was in the building for another resident) to assess the resident. The EMT assessed the resident and called for another ambulance to bring the resident to the hospital. The progress note indicated staff provided the EMT with paperwork regarding the resident (face sheet with medical contacts, allergies, diagnoses, and POLST). Ambulance narrative notes indicated they responded to the facility for a resident in respiratory distress. The notes indicated the EMTs assessed the resident, began monitoring the resident’s heart, provided oxygen, loaded the resident into the ambulance, and headed toward the hospital. The notes indicated the resident’s heart rate and respiratory effort decreased on the way to the hospital. The facility paperwork indicated the resident was DNR, so when the resident’s heart and respirations stopped, the EMTs did not initiate CPR. Hospital records indicated the doctor pronounced the resident deceased at the hospital. The hospital records indicated they later found a POLST on file that indicated the resident wished to receive full CPR. (The resident signed the POLST while hospitalized to have her gallbladder removed seven months before the incident.) During an interview, a nurse stated she had reviewed with the resident her wishes regarding CPR three months before the incident when the resident returned from a nursing home stay after surgical removal of her gallbladder. The nurse verified the resident stated she wanted no CPR (do not resuscitate (DNR)) in the event her heart stopped, and breathing stopped. The nurse stated since the resident’s decision was the same as when she admitted to the facility, the nurse did not fill out a new POLST form but documented the conversation in the resident’s assessment. During an interview, the resident’s medical provider stated she spoke with the resident when the resident returned to the facility after gallbladder surgery. The medical provider stated she believed the POLST the resident signed at the hospital was only for the gallbladder surgery and conversations the provider had with the resident confirmed that she did not want CPR while at the facility. The provider stated it was not her practice to create a new POLST form if it was still accurate. During investigative interviews, multiple staff members stated the resident was independent with most of her cares, loved to watch movies, and was able to express her wants and needs. 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 passed away. Family/Responsible Party interviewed: No, attempted. Alleged Perpetrator interviewed: Not Applicable. the Action taken by facility: The facility investigated the incident, reviewed all residents’ POLST documents for accuracy, re-educated clinical staff on reviewing code status at all assessments to clarify any discrepancies. 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: 10/21/2024 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 _____________________________ 33772 10/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6121 BROOKLYN BOULEVARD THE SANCTUARY AT BROOKLYN CENT ER BROOKLYN CENTER, MN 55429 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 10, 2024, the Minnesota Department of Health initiated an investigation of complaint #HL337727389C/#HL337725387M. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 TCMK11 If continuation sheet 1 of 1