Amira Choice Champlin.

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 she fell forward during a transfer from a recliner to her wheelchair, resulting in fractures in both upper arms and subsequent surgical intervention. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. While an unlicensed caregiver assisted the resident transfer, the resident did fall and sustain fractures. However, while it was true the wheelchair was not locked, a video recording shows the resident sit in the wheelchair but then partially stand and fall forward when an unlocked four-wheeled walker rolled forward. Unfortunately, the resident did sustain fractures, however the facility sought medical attention after the fall occurred appropriately. It was possible the resident sustained the right arm fracture when the caregiver reached out to her as she fell forward, however this injury would be accidental. The investigator conducted interviews with family members. The investigation included review of the resident’s records, internal investigation documentation, incident reports, staff schedules, policies, and procedures. The resident resided in an assisted living facility. The resident’s diagnoses Bell's palsy and repeated falls. The resident’s service plan included assist of one-person assist with transfers and a walker. The resident used supplemental oxygen. One day an unlicensed caregiver was assisting a resident transfer from a chair to a wheelchair when she fell to the floor and sustained fractures. The facility’s internal investigation indicated the unlicensed caregiver was assisting the resident in transferring from a recliner to a wheelchair. The caregiver put a gait belt and helped the resident stand and pivot using her walker before allowing her to sit in the wheelchair. The resident then attempted to scoot herself back using the walker; however, the walker’s brakes were not engaged, causing it to slide forward. The unlicensed caregiver attempted to pull the resident back into a seated position but was unsuccessful. The resident broke her fall with her arms. A recording device placed in the resident’s room captured a video of what occurred and was reviewed. The video opens with the resident arising from a power-lift recliner tipped forward. The  video shows an unlicensed caregiver standing on the left side of the resident with her right hand on a transfer belt guiding the resident. The caregiver had positioned the wheelchair at a right angle and stood between the recliner and the wheelchair. The video continues with the resident moving forward using a four-wheeled walker and  pivot to sit in the wheelchair. Meanwhile, with her right hand still on the transfer belt, the caregiver used her left hand to position the wheelchair behind the resident. As the resident lowered herself on to the seat of the wheelchair, the caregiver removed her hand from the transfer belt and used it to position the resident oxygen tubing, while continuing to hold the wheelchair in place with her left hand. At this moment, the video showed, the resident lifted herself off the seat of the  wheelchair while her four-wheel walker rolled forward, and her upper body tipper forward as she fell to the floor initially on to her knees face forward and towards the floor. The resident’s impact on the floor was out of view of the video. As the resident began to fall forward, the caregiver attempted to stop her and hung on  to the transfer belt but was stepped and/or pulled forward with the resident. As the resident fell further, the caregiver released the resident’s arm and held onto her shoulder in an attempt to lift her back into the wheelchair but was unable to do so. She then lowered the resident to the floor. At this point, the resident was positioned between the power recliner, the wheelchair, and the walker. The wheelchair had remained in place until the caregiver let go to catch the resident. The video continued with the caregiver stepping forward to move the four-wheel walker  out of the way and attempted help the resident reposition herself on the ground by grasping resident’s right wrist to turn her onto her back. The resident cried out, “Ouch, my arm.” The caregiver let go of the wrist and instead held her upper arm to roll her onto her left side. After the fall, the caregiver called her supervisor, the resident’s family, and 911. The medical records indicated the resident was hospitalized and underwent surgery for a torn ligament and a right distal humerus fracture. She had pre-existing injuries with hardware in her left arm, and now had similar trauma on both sides. During an interview, a family member stated she was not present when the fall occurred but had had watched the video. The family member stated the caregiver put a gait belt, placed the walker in front of the resident, and brought the wheelchair behind her without locking the brakes. The family member stated the caregiver held the gait belt incorrectly: from the side rather than from behind. The resident stood, turned, and began to sit while the caregiver pulled the wheelchair closer. The resident at the edge of the wheelchair, still holding the walker, and tried to scoot back into the wheelchair. The family member stated because the brakes were not locked, the wheelchair moved, causing her to fall forward. The family member stated the caregiver failed to control the resident’s descent with the gait belt and pulled on her right arm, which had prior fractures and limited mobility due to a frozen shoulder. The caregiver pulled resident’s arm back, let go, and the resident fell to her left, catching herself with her left arm and knee. During the investigation, the investigator attempts to reach the unlicensed caregiver were unsuccessful. 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 was in the nursing home. Family/Responsible Party interviewed: Yes. Action taken by facility: The facility initiated an internal investigation, reported the incident to Minnesota Adult Abuse Reporting Center and reviewed proper transfer techniques with the unlicensed caregiver. 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: 04/18/2025 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 _____________________________ 30284 03/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 119 EAST HAYDEN LAKE ROAD AMIRA CHOICE CHAMPLIN CHAMPLIN, MN 55316 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 17, 2025, the Minnesota Department of Health initiated an investigation of complaints #HL302847582M/HL302843040C. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 TYK011 If continuation sheet 1 of 1

STATE LICENSING COMPLIANCE REPORT Report #: HL302846007C Date Concluded: February 13, 2025 Name, Address, and County of Facility Investigated: Amira Choice Champlin 119 East Hayden Lake Road Champlin, MN 55316 Hennepin County Facility Type: Assisted Living Facility with Evaluator’s Name: Jessica Sellner, RN, Special Dementia Care (ALFDC) 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: 02/14/2025 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 _____________________________ 30284 01/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 119 EAST HAYDEN LAKE ROAD AMIRA CHOICE CHAMPLIN CHAMPLIN, MN 55316 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 23, 2025, the Minnesota Department of Health initiated an investigation of complaint #HL302846007C. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 72Z511 If continuation sheet 1 of 1

Finding: Not Substantiated Nature of Investigation: The Minnesota Department of Health investigated an allegation of maltreatment, in accordance with the Minnesota Reporting of Maltreatment of Vulnerable Adults Act, Minn. Stat. 626.557, and to evaluate compliance with applicable licensing standards for the provider type. Initial Investigation Allegation(s): The facility neglected the resident when they failed to administer scheduled medications as prescribed. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. There was not a preponderance of evidence to support that the actions of facility staff met the definition of neglect. Although a medication error occurred, when staff became aware of the error, the resident was assessed and monitored and returned to their baseline health condition. The investigator conducted interviews with facility staff members, including administrative staff and nursing staff. The investigation included review of the resident record, death record, facility internal investigation documentation, personnel files, staff schedules, and facility policies and procedures. The investigator also toured the facility, observed staff members interacting with residents, and medication administration. The resident resided in an assisted living facility memory care unit with a diagnosis of dementia. The resident’s service plan included assistance with housekeeping, laundry, medication administration, and safety checks. The resident’s assessment indicated that the resident was independent with most activities of daily living but required queuing and reorientation to place and situation as needed. During a routine medication pass, a facility staff member noticed a discrepancy between the amount of available medication and the medication count log and reported this information to the nurse. The nurse initiated an audit of the available medication and medial record documentation and identified that an incorrect dose of the medication had been administered. The nurse contacted the resident’s hospice provider who directed to withhold additional medication administration and closely monitor the resident for signs of distress. The resident returned to his baseline condition without need for hospitalization. The resident remained at the facility and received hospice care until he passed away the following week. An internal investigation completed by the facility identified that on four separate occasions, over a two-day period, an unlicensed staff member administered the resident’s Morphine (narcotic pain medication) incorrectly. This oversite resulted in the resident receiving a dose three times greater than that which was ordered. During an interview, a facility administrator stated that one of the unlicensed personnel identified in the internal investigation had a documented history of not following facility policy and procedures relating to medication administration but was reeducated and deemed competent by the nurse four months prior to the incident. Upon completion of the internal investigation the unlicensed personnel was dismissed. During investigative interviews, multiple nursing staff members stated that a physician’s order for morphine was updated days before the medication error occurred and there were inconsistencies in the process between the processing and verification of the physician’s order between the facility and the pharmacy. Nursing staff also acknowledged errors within the facility’s system of documentation of receipt of narcotic medication from the pharmacy and narcotic count and storage processes. Further review of the medication administration record for this resident also identified on at least two other occasions, additional facility staff may have administered the resident’s morphine at incorrect times or incorrect dosages. During an interview with a family member of the resident, she could not recall specific details of the incident but felt the facility handled the situation appropriately. The family member did not have further concerns with the care provided by the facility’s licensed staff. 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, deceased. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Not Applicable. Action taken by facility: The facility conducted an internal investigation. As a result, an unlicensed staff member’s employment was terminated, and all facility staff received additional training regarding medication administration process and procedure. Action taken by the Minnesota Department of Health: The facility was found to be in noncompliance. To view a copy of the Statement of Deficiencies and/or correction orders, please visit: https://www.health.state.mn.us/facilities/regulation/directory/provcompselect.html If you are viewing this report on the MDH website, please see the attached Statement of Deficiencies. You may also call 651-201-4200 to receive a copy via mail or email cc: The Office of Ombudsman for Long Term Care The Office of Ombudsman for Mental Health and Developmental Disabilities PRINTED: 12/03/2024 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 _____________________________ 30284 09/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 119 EAST HAYDEN LAKE ROAD AMIRA CHOICE CHAMPLIN CHAMPLIN, MN 55316 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 144G. ASSISTED LIVING PROVIDER CORRECTION Minnesota Department of Health is ORDER 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 complaint investigation. assigned tag number appears in the far-left column entitled "ID Prefix Tag." The Determination of whether a violation is 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 a Minnesota Statute contains several Statement of Deficiencies" column. This items, failure to comply with any of the items will column also includes the findings which be 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 #HL302844781C/#HL302844121M Time Period for Correction. On September 17, 2024, the Minnesota PLEASE DISREGARD THE HEADING OF Department of Health conducted a complaint THE FOURTH COLUMN WHICH investigation at the above provider, and the STATES,"PROVIDER'S PLAN OF following correction orders are issued. At the time CORRECTION." THIS APPLIES TO of the complaint investigation, there were 80 FEDERAL DEFICIENCIES ONLY. THIS residents receiving services under the provider's WILL APPEAR ON EACH PAGE. Assisted Living with Dementia Care license. THERE IS NO REQUIREMENT TO The following correction order is issued for SUBMIT A PLAN OF CORRECTION FOR #HL302844781C/#HL302844121M, tag VIOLATIONS OF MINNESOTA STATE identification 1690 and 1760. 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 UC8S11 If continuation sheet 1 of 12 PRINTED: 12/03/2024 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 _____________________________ 30284 09/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 119 EAST HAYDEN LAKE ROAD AMIRA CHOICE CHAMPLIN CHAMPLIN, MN 55316 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) 01690 Continued From page 1 01690 01690 144G.71 Subdivision 1 Medication management 01690 SS=F services (a) This section applies only to assisted living facilities that provide medication management services. (b) An assisted living facility that provides medication management services must develop, implement, and maintain current written medication management policies and procedures.

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 Amira Choice Champlin November 15, 2024 Page 2 St - 0 - 2310 - 144g.91 Subd. 4 (a) - Appropriate Care And Services - $3,000.00 Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, t he total amount you are assessed is $3,000.00. You will be invoiced approximately 30 days after receipt of this notice, subject to appeal. 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 a reconsideration and tags with the fines at a hearing, please submit two separate appeals forms at the website listed above. Amira Choice Champlin November 15, 2024 Page 3 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, Jess Schoenecker, Supervisor State Evaluation Team Email: Jess.Schoenecker@state.mn.us Telephone: 651-201-3789 Fax: 1-866-890-9290 HHH PRINTED: 11/15/2024 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 30284 10/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 119 EAST HAYDEN LAKE ROAD AMIRA CHOICE CHAMPLIN CHAMPLIN, MN 55316 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 SL30284015-0 Time Period for Correction. On October 14, 2024, through October 17, 2024, PLEASE DISREGARD THE HEADING OF the Minnesota Department of Health conducted a THE FOURTH COLUMN WHICH full survey at the above provider. At the time of STATES,"PROVIDER'S PLAN OF the survey, there were 80 residents; 60 receiving CORRECTION." THIS APPLIES TO services under the Assisted Living Facility with FEDERAL DEFICIENCIES ONLY. THIS Dementia Care license. WILL APPEAR ON EACH PAGE. An immediate correction order was issued for tag THERE IS NO REQUIREMENT TO identification 2310 on October 16, 2024. SUBMIT A PLAN OF CORRECTION FOR VIOLATIONS OF MINNESOTA STATE During the course of the survey, the licensee took STATUTES. action to mitigate the immediate risk. Noncompliance remained, and the scope and THE LETTER IN THE LEFT COLUMN IS level of the order remain unchanged. 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=E (a) All assisted living facilities must establish and LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 G59T11 If continuation sheet 1 of 10 PRINTED: 11/15/2024 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 30284 10/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 119 EAST HAYDEN LAKE ROAD AMIRA CHOICE CHAMPLIN CHAMPLIN, MN 55316 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. (c) The facility must maintain written evidence of compliance with this subdivision.

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) neglected a resident when the AP left the resident alone while toileting. The resident fell and broke her pelvis. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. Although the resident fell while alone in the bathroom, the error was an isolated incident. The resident sustained a pelvic fracture, went to the hospital, then a transitional care unit (TCU), and returned to their 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’s medical record, facility incident reports, and policies regarding falls, emergencies, and vulnerable adults. The investigation also included review of the resident’s hospital and hospice records, the AP’s An equal opportunity employer. personnel record, and the facility’s internal investigation of the incident. Also, the investigator observed toileting and transfers. The resident resided in an assisted living memory care unit. The resident’s diagnoses included Alzheimer’s disease. The resident’s service plan included hands-on assistance with transfers and a gait belt. The resident’s assessment indicated the resident used a manual wheelchair for mobility and assistance with toileting. An incident report indicated the AP helped the resident onto the toilet and left her unattended. The AP came back and found the resident on the floor. The resident had a cut on her face and had thrown up. Staff sent the resident to the emergency department. The hospital after visit summary indicated the resident received sutures for a cut on the head. The resident returned to the facility the same day. Over the next two days, nursing notes indicated the resident had been complaining of right hip and low back pain. Nursing requested an x-ray from the provider. The provider requested to continue with pain medication, checking the leg length for discrepancy, and using ice packs. The pain continued, and nursing followed up with the provider. The provider ordered the x-ray. The following morning, results from the x-ray came in which showed a broken pelvis. Nursing notified the provider group who recommended hospitalization. Nursing staff spoke with family and sent the resident to the hospital. The resident admitted to the hospital, then transferred to a TCU before returning to the facility. During an interview, a nurse stated she went to the resident’s bathroom after being called by staff and found the resident lying on the floor with a cut on her head. The resident had thrown up as well. The nurse assessed the resident, ensured comfort, and called 911. The nurse stated nursing notified the provider and requested an x-ray when the resident started complaining of pain. During an interview, a family member stated communication with her from the facility should have been better. During an interview, the AP stated the resident wanted to use the bathroom before bed. The AP helped the resident onto the toilet and waited in the bathroom. The resident requested privacy, so the AP stood outside the bathroom door with the door halfway closed. After the resident toileted, the AP went back into the bathroom to help but realized there were no wipes. The AP went into the resident’s bedroom to look for wipes. While the AP looked for wipes, she heard the resident fall. She immediately went back into the bathroom and found the resident on the floor. The AP notified the medication passer who called the nurse. 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. Insert maltreatment definition here. 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; unable to interview. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Yes. Action taken by facility: The facility completed an internal investigation. The facility obtained medical care for the resident after the fall. AP is no longer employed by the facility. 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: 09/13/2023 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 _____________________________ 30284 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 119 EAST HAYDEN LAKE ROAD CHAMPLIN SHORES CHAMPLIN, MN 55316 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 Licensing ASSISTED LIVING PROVIDER LICENSING Correction Orders using federal software. CORRECTION ORDER Tag numbers have been assigned to Minnesota State Statutes for Assisted In accordance with Minnesota Statutes, section Living Facilities. The assigned tag 144G.08 to 144G.95, these correction orders are number appears in the far left column issued pursuant to a complaint investigation. entitled "ID Prefix Tag." The state Statute number and the corresponding text of the Determination of whether a violation is corrected state Statute out of compliance is listed in requires compliance with all requirements the "Summary Statement of Deficiencies" provided at the statute number indicated below. column. This column also includes the When a Minnesota Statute contains several findings which are in violation of the state items, failure to comply with any of the items will requirement after the statement, "This be considered lack of compliance. Minnesota requirement is not met as evidenced by." Following the evaluators' INITIAL COMMENTS: findings is the Time Period for Correction. #HL302849398C/#HL302845483M PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On July 14, 2023, the Minnesota Department of STATES,"PROVIDER'S PLAN OF Health conducted a complaint investigation at the CORRECTION." THIS APPLIES TO above provider, and the following correction FEDERAL DEFICIENCIES ONLY. THIS orders are issued. At the time of the complaint WILL APPEAR ON EACH PAGE. investigation, there were 85 residents receiving services under the provider's Assisted Living with THERE IS NO REQUIREMENT TO Dementia Care license. SUBMIT A PLAN OF CORRECTION FOR VIOLATIONS OF MINNESOTA STATE The following correction order is issued for STATUTES. #HL302849398C/#HL302845483M, tag identification 2310. 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. 02310 144G.91 Subd. 4 (a) Appropriate care and 02310 SS=G services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 TY1S11 If continuation sheet 1 of 4 PRINTED: 09/13/2023 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.