Suite Living Senior Care.

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), a facility staff member neglected the resident when the AP failed to follow the resident’s plan of care, and the resident sustained a left fractured tibia (the primary weight-bearing bone in the lower leg) and fibula (the smaller of the two bones in the lower leg). Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. Although the AP did not follow the resident’s plan of care of placing foot pedals on the resident’s wheelchair, the error was an isolated incident. The resident sustained a fractured tibia, was hospitalized for two days, and returned to the resident’s 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, personnel files, staff schedules, and related facility policy and procedures. Also, the investigator observed staff and resident interactions. The resident resided in an assisted living facility. The resident’s diagnoses included a previous fractured left femur (thigh bone). The resident’s service plan included assistance with dressing, toileting, and two staff for transfers with a mechanical lift. The resident’s assessment indicated the resident was forgetful but cognitively intact and required a wheelchair for mobility. Review of a facility recorded camera footage showed the AP as she pushed the resident out of a room and down a hallway. The resident lifted her feet of the ground without foot pedals as they proceeded down the carpeted hallway. After a few seconds of moving forward, the resident’s left foot caught on the carpet causing the left leg to bend under the wheelchair and a cracking noise could be heard. The resident yelled out and grabbed her left knee. The resident said, “oh my gosh, did you hear that.” The staff member bent down next to the resident and said, “what was that and the resident replied, “that was my knee.” The resident stated, “I don’t have my feet (foot pedals) on my chair.” The staff member stood and walked back to the resident’s apartment. The incident report indicated the staff member assisted the resident to the nurse’s office following the incident. The resident was assessed by the nurse and was sent to the hospital for an evaluation. The hospital records indicated the resident fractured her left tibia (shin bone) and was hospitalized for two days. The resident required a knee immobilizer and was two days later was discharged back to the facility. During an interview, the AP stated she usually worked overnight shifts, and had worked the previous overnight shift and into the day shift. The AP stated around lunch time, the resident called for assistance, appeared anxious, and stated she wanted to go to the nurse’s office because she had questions about a doctor appointment. The resident was in her wheelchair and was just inside the doorway of her apartment. The AP stated she assisted the resident out of her apartment and down the hallway. The AP stated they did not get very far down the hallway when a cracking noise was heard. The AP stated she stopped immediately and checked on the resident. The resident was screaming in pain. The AP stated the resident’s foot pedals were put on her wheelchair immediately after the cracking noise was heard. The AP stated she wheeled the resident to the nurse’s office, explained to the nurse what had happened, and the resident was sent to the hospital. During an interview nursing leadership stated the AP brought the resident to the nursing office and the resident was assessed. The resident could not move her left leg and was sent to the hospital for an evaluation. Leadership stated after the incident, all staff including the AP were trained to apply foot pedals when escorting residents in their wheelchairs. During an interview, a family member stated the resident moved into the facility due to needing assistance because of a fractured left femur and that the resident had osteoporosis (a disease that weakens bones, making them more fragile and susceptible to fractures). 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: Yes. Action taken by facility: Following the incident, the resident was assessed and transported to the hospital for evaluation. In addition, the facility and the AP were educated on resident’s that required foot pedals. 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: 07/24/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ C B. WING _____________________________ 38412 07/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1880 134TH STREET EAST SUITE LIVING SENIOR CARE OF BURNSVILLE BURNSVILLE, MN 55337 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 000 Initial Comments 0 000 On July 2, 2025, the Minnesota Department of Minnesota Department of Health is Health initiated an investigation of complaint documenting the State Correction Orders #HL384122762M/#HL384124937C. No correction using federal software. Tag numbers have orders are issued. been 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 is listed in the "Summary Statement of Deficiencies" column. This column also includes the findings which are in violation of the state requirement after the statement, "This Minnesota requirement is not met as evidenced by." Following the evaluators' findings is the Time Period for Correction. PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH STATES,"PROVIDER'S PLAN OF CORRECTION." THIS APPLIES TO FEDERAL DEFICIENCIES ONLY. THIS WILL APPEAR ON EACH PAGE. 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. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 MMW511 If continuation sheet 1 of 1

correction orders and document the actions taken to comply in the facility's records. The Department reserves the right to return to the facility at any time should the Department receive a complaint or deem it necessary to ensure the health, safety, and welfare of residents in your care. STATE CORRECTION ORDERS The enclosed State Form documents the state correction orders. MDH documents state licensing correction orders using federal software. Tag numbers are assigned to Minnesota state statutes for Assisted Living Facilities. The assigned tag number appears in the far left column entitled "ID Prefix Tag." The state statute number and the corresponding text of the state statute out of compliance are listed in the "Summary Statement of Deficiencies" column. This column also includes the findings that are in violation of the state statute after the statement, "This MN Requirement is not met as evidenced by . . ." IMPOSITION OF FINES In accordance with Minn. Stat. § 144G.31, Subd. 4, fines and enforcement actions may be imposed based on the level and scope of the violations and may be imposed immediately with no opportunity to correct the violation first as follows: Level 1: no fines or enforcement; Level 2: a fine of $500 per violation, in addition to any enforcement mechanism authorized in § 144G.20; Level 3: a fine of $1,000 per incident, in addition to any enforcement mechanism authorized in § 144G.20; Level 4: a fine of $3,000 per incident, in addition to any enforcement mechanism authorized in An equal opportunity employer. Letter ID: IS7N REVISED 09/13/2021 Suite Living Senior Care of Burnsville LLC August 4, 2025 Page 2 § 144G.20; Level 5: a fine of $5,000 per violation, in addtion to any enforcement mechanism authorized in § 144G.20. Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, the following fines are assessed pursuant to this survey: St - 0 - 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. Suite Living Senior Care of Burnsville LLC August 4, 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, Jodi Johnson, Supervisor State Evaluation Team Email: Jodi.Johnson@state.mn.us Telephone: 507-344-2730 Fax: 1-866-890-9290 AH PRINTED: 08/04/2025 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 _____________________________ 38412 06/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1880 134TH STREET EAST SUITE LIVING SENIOR CARE OF BURNSVILLE BURNSVILLE, MN 55337 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 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." The issued pursuant to a survey. 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. SL38412016-0 PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On June 2, 2025, through Jue 4, 2025, the STATES,"PROVIDER'S PLAN OF survey at the above provider and the following FEDERAL DEFICIENCIES ONLY. THIS correction orders are issued. At the time of the WILL APPEAR ON EACH PAGE. survey, there were 30 residents; 30 receiving services under the Assisted Living Facility with THERE IS NO REQUIREMENT TO Dementia Care license. SUBMIT A PLAN OF CORRECTION FOR VIOLATIONS OF MINNESOTA STATE STATUTES. THE LETTER IN THE LEFT COLUMN IS USED FOR TRACKING PURPOSES AND REFLECTS THE SCOPE AND LEVEL ISSUED PURSUANT TO 144G.31 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 DNSG11 If continuation sheet 1 of 28 PRINTED: 08/04/2025 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 _____________________________ 38412 06/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1880 134TH STREET EAST SUITE LIVING SENIOR CARE OF BURNSVILLE BURNSVILLE, MN 55337 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.

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 resulting in an unwitnessed fall and sustained a fracture. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. Although the resident fell and sustained an injury, the facility had appropriate interventions in place to prevent falls and/or injury. While the resident wandered the unit continuously the staff members had provided safety checks, was aware the resident was at risk for falls, and contacted nursing to send resident to emergency department for evaluation appropriately when the fall occur 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 service plan, assessments, progress notes, hospital records, and facility internal investigation. Also, the investigator completed an onsite visit to observe resident to staff interactions and the resident’s mobility. The resident resided in an assisted living memory care unit. The resident’s diagnoses included dementia, osteoporosis, and multiple mental health issues. The resident’s service plan included even though the resident chose to ambulate independently, the staff members were to encourage resident to use walker. The resident was also encouraged to sit and rest when exhibiting signs of weakness and instability. The resident was unable to understand and/or follow directions and required frequent cues and reminders. The resident demonstrated inappropriate judgment related to safety including refusals to use a walker. The service plan also indicated fall interventions to include keeping the resident’s room clutter free, clear all pathways, wear proper footwear, offer the bathroom, and safety checks. The resident’s individual abuse prevention plan dated five months prior to the fall indicated the resident was vulnerable to falls related to her chronic back pain which may cause her to become unstable while ambulating. The resident does have a walker but refuses to use it as she forgets to use the walker as the walker is not familiar to the resident even with caregiver reminders. The resident could become agitated with staff or raise her voice with caregivers when she became frustrated. Progress notes indicated resident was evaluated by psychiatry/behavioral health. The same document indicated the resident at times refused care and safety checks were required every 2 hours. Overnight the resident had a history of wandering and tended to nap during the day. To address the resident’s fall risk, the facility completed a risk assessment. The resident exhibited normal gait but with her diagnosis of dementia did not always know her limits and was at high risk for falls. An incident report indicated during an overnight safety check the staff found the resident on the floor in her room. Staff notified the nurse on call of the incident and were instructed to send the resident to the emergency department for evaluation. The emergency department records indicated the resident had a leg bone fracture that required surgical repair. After the surgery, the resident returned to the facility after about five days. During an interview, multiple facility nurses stated the resident continuously walked and paced the unit. The resident had experienced a fall the previous day with no injury. Multiple nurses stated previous attempts of PT/OT had been attempted but unsuccessful. Caregivers did direct the resident to use her walker, however; the resident would either drag or carry the device placing her at yet further risk for a fall. During an interview, an unlicensed caregiver stated the resident wanders the unit and visits with people. The caregiver stated the resident generally did not use the walker. During an interview, a family member stated the resident would not use the walker as this was not something she used prior to her diagnosis of dementia. The family member stated the resident wanted to complete tasks on her own and the fall occurred because the resident having both of her legs in one leg of her pajama bottoms causing her to lose her balance and fall. The family member stated even prior to her diagnosis of dementia, the resident went for long walks all the time. 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, due to cognitive status Family/Responsible Party interviewed: Yes Alleged Perpetrator interviewed: NA Action taken by facility: No action required. Action taken by the Minnesota Department of Health: No further action taken at this time. cc: The Office of Ombudsman for Long Term Care The Office of Ombudsman for Mental Health and Developmental Disabilities PRINTED: 09/03/2024 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 _____________________________ 38412 07/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1880 134TH STREET EAST SUITE LIVING SENIOR CARE OF BURNSVILLE BURNSVILLE, MN 55337 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****** ASSISTED LIVING PROVIDER CORRECTION ORDER In accordance with Minnesota Statutes, section 144G.08 to 144G.95, these correction orders are issued pursuant to a complaint investigation. Determination of whether a violation is corrected requires compliance with all requirements provided at the statute number indicated below. When a Minnesota Statute contains several items, failure to comply with any of the items will be considered lack of compliance. INITIAL COMMENTS: HL384123080M/HL384123000C HL384124262M/ HL384124996C On July 18, 2024, the Minnesota Department of Health conducted a complaint investigation at the above provider, and the following correction orders are issued. At the time of the complaint investigation, there were 28 Residents receiving services under the provider's Assisted Living with Dementia Care license. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 YYK111 If continuation sheet 1 of 1