Clinique Healthcare Services I.

Finding: Not Substantiated Nature of Investigation: The Minnesota Department of Health investigated an allegation of maltreatment, in accordance with the Minnesota Reporting of Maltreatment of Vulnerable Adults Act, Minn. Stat. 626.557, and to evaluate compliance with applicable licensing standards for the provider type. Initial Investigation Allegation(s): The facility neglected the resident when the resident was found entrapped in the bedrail which resulted in bruising and hospitalization. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. The resident’s plan of care was followed at the time of the incident. When the resident was found on the bedrail with an injury, facility staff provided immediate assistance and contacted emergency medical services. The resident received medical treatment and returned to his baseline health condition. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigation included review of the resident records, hospital records, facility internal investigation, facility incident reports, staff schedules, and related facility policy and procedures. Also, the investigator observed cares provided to the resident and that the resident used bedrails to assist with bed mobility. In addition, the resident’s bed remote was clipped in a way that was not accessible for the resident. The resident resided in an assisted living memory care unit. The resident’s diagnoses included functional quadriplegia (term for complete immobility, requiring total assistance with daily living), multiple sclerosis, and stroke. The resident’s service plan included assistance with dressing, grooming, incontinence care, wheelchair and mobility assistance. The resident’s assessment indicated the resident had an electric bed with bedrails. The resident’s assessment indicated the resident used the bedrails for repositioning and turning in bed. An incident report indicated the resident used his bed remote to elevate the head of his bed. The resident fell to his left side coming to rest with his left arm hanging over the bedrail. The resident sustained a bruise to his left underarm and across his chest. The resident was assessed by the nurse and sent to the hospital for an evaluation. The hospital record indicated the resident sustained bruising and had no fractures. The resident was treated for pneumonia and discharged back to the facility. During an interview, the nurse stated the resident had been assessed to have the bedrails in place for bed mobility. The morning of the incident, an unlicensed staff member was getting clothes from the resident’s closet. The resident elevated his head of the bed and tipped over to the left side onto the bedrail. The resident was in pain and had a bruise. The resident was transported to the hospital for an evaluation. When the resident returned from the hospital, the resident was reassessed, and it was determined that a different style of bedrails would be applied to the resident’s bed. In addition, the bed remote would be kept out of reach of the resident. During an interview, the resident stated he uses the bedrails for bed mobility and had no concerns with the bedrails. The resident stated he had no concerns about staff care. During an interview, a family member stated they were aware of the incident and had no concerns with the resident’s cares from facility staff. An attempted interview was made with the unlicensed staff member that was a witness to the incident but was not successful. 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. Action taken by facility: Upon returning from the hospital, the resident was reassessed. A different style of bedrail was applied to his bed and the bed remote is to be placed out of reach of the resident. 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: 02/ 20/ 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 _____________________________ 35377 01/ 27/ 2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 7924 JUNE AVENUE NORTH CLINIQUE HEALTHCARE SERVICES I BROOKLYN PARK, MN 55443 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 January 27, 2026, the Minnesota Department of Health initiated an investigation of complaint #HL353777902M / HL353778422C. No correction orders are issued. LABORATORY DIRECTOR' S OR PROVIDER/ SUPPLIER REPRESENTATIVE' S SIGNATURE TITLE (X6) DATE STATE FORM 6899 M8BL11 If continuation sheet 1 of 1

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 Clinique Healthcare Services Inc. February 20, 2025 Page 2 0470 - 144g.41 Subdivision 1 - Minimum Requirements - $3,000.00 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 $6,000.00. 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. 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 Clinique Healthcare Services Inc. February 20, 2025 Page 3 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, Casey DeVries, Supervisor State Evaluation Team Email: casey.devries@state.mn.us Telephone: 651-201-5917 Fax: 1 -866-890-9290 JMD PRINTED: 02/20/2025 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 _____________________________ 35377 01/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 7924 JUNE AVENUE NORTH CLINIQUE HEALTHCARE SERVICES I BROOKLYN PARK, MN 55443 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 In accordance with Minnesota Statutes, section Statutes for Assisted Living License 144G.08 to 144G.95, these correction orders are Providers. The assigned tag number issued pursuant to a survey. appears in the far-left column entitled "ID Prefix Tag." The state Statute number and Determination of whether violations are corrected the corresponding text of the state Statute requires compliance with all requirements out of compliance is listed in the provided at the Statute number indicated below. "Summary Statement of Deficiencies" When Minnesota Statute contains several items, column. This column also includes the failure to comply with any of the items will be findings which are in violation of the state considered lack of compliance. requirement after the statement, "This Minnesota requirement is not met as INITIAL COMMENTS: evidenced by." Following the surveyors' findings is the Time Period for Correction. SL35377016-0 PLEASE DISREGARD THE HEADING OF On January 13, 2025, through January 15, 2025, THE FOURTH COLUMN WHICH the Minnesota Department of Health conducted a STATES,"PROVIDER'S PLAN OF full survey at the above provider, and the CORRECTION." THIS APPLIES TO following correction orders are issued. At the time FEDERAL DEFICIENCIES ONLY. THIS of the survey, there were three residents, all of WILL APPEAR ON EACH PAGE. whom received services under the Assisted Living license. THERE IS NO REQUIREMENT TO SUBMIT A PLAN OF CORRECTION FOR An immediate correction order was identified on VIOLATIONS OF MINNESOTA STATE January 13, 2025, issued for SL35377016-0, tag STATUTES. identification 1290. The letter in the left column is used for During the survey, the licensee took action to tracking purposes and reflects the scope mitigate the immediate risk. However, and level issued pursuant to 144G.31 noncompliance remained, and the scope and subd. 1, 2, and 3. level remain unchanged. An immediate correction order was identified on January 14, 2025, issued for SL35377016-0, tag identification 0470. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 G88911 If continuation sheet 1 of 58 PRINTED: 02/20/2025 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 _____________________________ 35377 01/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 7924 JUNE AVENUE NORTH CLINIQUE HEALTHCARE SERVICES I BROOKLYN PARK, MN 55443 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 Continued From page 1 0 000 During the survey, the licensee took action to mitigate the immediate risk. However, noncompliance remained, and the scope and level remain unchanged. 0 340 144G.30 Subd.