Maple Woods Assisted Living.

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 § 144G.20; Level 5: a fine of $5,000 per violation, in addition to any enforcement mechanism authorized in § 144G.20. An equal opportunity employer. Letter ID: IS7N REVISE D09/13/2021 Maple Woods Assisted Living February 19, 2026 Page 2 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 St - 0 - 0775 - 144g.45 Subd. 2. (a) - Fire Protection And Physical Environment - $500.00 The refor e, in accor danc e wit h Minn. Sta t. §§ 144G.01 to 144G.999 9, the total amount you are assessed is $1,000.00. You will be invoiced approximately 30 days after receipt of this notice, subject to appeal . DOCUMENTATIO ONF ACTION TO COMPLY In accorda nce with Min n. Stat. § 144G.30, Sub d. 5(c), th e lic ens ee mus t docum ent ac tions taken t o 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). CORRECTIO NORDER RECONSIDERATIO PNROCESS 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 REQUESTIN GA 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 Maple Woods Assisted Living February 19, 2026 Page 3 To appe al fi nes via re cons iderat ion , pl ease follow the procedu r e outl ined abo ve. Plea se no te tha t you may re que st a rec onside rati on or a hearing, bu t not bot h. If you wish to cont est ta gs with out fine s 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 conv enien ce at thi s link: https: / / forms. office.com/ g/ Bm5uQEpHVa. Your inpu t is import ant 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, Jessie Chenze, Supervisor State Evaluation Team Email: Jessie.Chenze@state. mn.us Telephone: 218-332-5175 Fax: 1-866-890-9290 HHH PRINTED: 02/ 19/ 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: ______________________ B. WING _____________________________ 33975 01/ 14/ 2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 33310 STATE HIGHWAY 6 MAPLE WOODS ASSISTED LIVING DEER RIVER, MN 56636 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. SL33975016- 0 PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On January 12, 2026, through January 14, 2026, STATES, "PROVIDER' S PLAN OF the Minnesota Department of Health conducted a CORRECTION. " THIS APPLIES TO full 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 23 residents; 23 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. 0 480 144G. 41 Subdivision 1 Subd. 1a (a-b) Minimum 0 480 SS= F requirements; required food services LABORATORY DIRECTOR' S OR PROVIDER/ SUPPLIER REPRESENTATIVE' S SIGNATURE TITLE (X6) DATE STATE FORM 6899 0NEW11 If continuation sheet 1 of 49 PRINTED: 02/ 19/ 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: ______________________ B.

Finding: Not Substantiated Nature of Investigation: The Minnesota Department of Health investigated an allegation of maltreatment, in accordance with the Minnesota Reporting of Maltreatment of Vulnerable Adults Act, Minn. Stat. 626.557, and to evaluate compliance with applicable licensing standards for the provider type. Initial Investigation Allegation(s): The facility neglected the resident when facility staff failed to provide supervision and prevent the resident’s elopements. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. The resident had a history of aggressive behavior and walking away from medical facilities prior to elopements that occurred at the assisted living facility. The facility coordinated with behavioral health providers, family and law enforcement to manage the resident’s elopements. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted law enforcement and a family member. The investigation included review of the resident record(s), hospital records, pharmacy records, facility internal investigation, facility incident reports, personnel files, staff schedules, law enforcement report, related facility policy and procedures. Also, the investigator observed facility staff provide direct cares. The resident resided in an assisted living memory care unit. The resident’s diagnoses included moderate dementia and psychotic disturbance. The resident’s service plan included assistance with behavior management, safety checks and supervision. The resident’s assessment indicated the resident was independent with activities of daily living, walked frequently, was impulsive and had poor judgement. The assessment indicated the resident had a history of substance abuse, was an elopement risk and had successfully eloped from facilities. The resident’s record indicated the facility was aware of the resident’s risk for elopements and incident reports outlined how the resident eloped. The resident eloped seven times from the facility’s secure unit and made several unsuccessful attempts. The facility requested behavioral health assistance, and a provider adjusted behavioral health medications. Facility staff allowed the resident to spend time in an area of the facility secured by an eight-foot fence when the resident was not displaying exit seeking behaviors. Facility staff were aware the resident could climb the fence and planned the resident’s time outside to be monitored by facility staff. Two of the elopements occurred when facility staff were present and unsuccessfully attempted to redirect the resident away from the fence. Facility staff alerted authorities when the resident left facility grounds. The resident’s family had installed a Life360 location application on the resident’s cell phone and family had the ability to locate the resident when he eloped. Each time the resident eloped he was returned to the facility by law enforcement or family unharmed. The resident’s incident reports indicated the resident had witnessed and unwitnessed elopements. The resident had a history of aggression with facility staff and family when he wanted to leave, and the resident had used furniture to climb a fence in a secured outside area. The facility held a care conference with family, a resident representative and consulted with law enforcement to develop a safety plan for the resident. The facility and law enforcement coordinated with the family to monitor, locate and return the resident to the facility with a Life360 cell phone application installed on the resident’s phone. Law enforcement reports indicated the resident had walked away from medical facilities prior to placement in the facility. Officers had been called to assist in locating and returning the resident to the facility four times in two months. Facility staff and management were in contact with law enforcement officers throughout the resident’s elopements and at times facility staff had eyes on the resident while waiting for officer assistance. During an interview, a licensed staff stated the resident resided in a secured area of the facility and like to spend time outside. Licensed staff stated the resident had eloped from the facility and would go to a place he was familiar with in his younger years. Licensed staff stated coordination with the resident’s family and law enforcement was put in place to keep the resident safe when he eloped. Licensed staff stated the resident was difficult for staff to redirect until the facility reached out to behavioral health for assistance. Licensed staff stated behavioral health assessed the resident for the best interventions to manage the resident’s behaviors and a neuropsychic evaluation was scheduled. Licensed staff stated since behavioral health became involved, and facility staff became familiar with the resident’s preferences the resident was more content and one to one supervision was provided when the resident was outside in the secured area. During an interview, a resident representative stated the resident could scale a secured fence in the outside area and facility staff “can’t physically pull him off the fence” or stop the resident when he made up his mind to leave. A resident representative stated interventions were implemented and family was involved. A resident representative stated the resident likes it there and was settling in. During an interview, a family member stated the resident could be very difficult, however, thought the facility was trying their best to manage and prevent the resident’s elopements. A family member stated the resident could scale an eight-foot secured fence when he wanted to leave the facility and liked to be outside. A family member stated the facility, and family had attempted to have the resident transferred to a specialized behavioral facility for evaluation, but the behavioral facility would not accept the resident due to medical concerns. 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 Family/Responsible Party interviewed: Yes Alleged Perpetrator interviewed: Not Applicable the Action taken by facility: The facility implemented a variety of interventions and coordinated with outside agencies to provide a safety plan for 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: 07/28/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ C B. WING _____________________________ 33975 07/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 33310 STATE HIGHWAY 6 MAPLE WOODS ASSISTED LIVING DEER RIVER, MN 56636 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 ORDER Minnesota Department of Health is documenting the State Correction Orders In accordance with Minnesota Statutes, section using federal software. Tag numbers have 144G.08 to 144G.95, these correction orders are been assigned to Minnesota State issued pursuant to a complaint investigation. Statutes for Assisted Living Facilities. The assigned tag number appears in the Determination of whether a violation is corrected far-left column entitled "ID Prefix Tag." The requires compliance with all requirements state Statute number and the provided at the statute number indicated below. corresponding text of the state Statute out When a Minnesota Statute contains several of compliance is listed in the "Summary items, failure to comply with any of the items will Statement of Deficiencies" column. This be considered lack of compliance. column also includes the findings which are in violation of the state requirement INITIAL COMMENTS: after the statement, "This Minnesota requirement is not met as evidenced by." #HL339753665M/ #HL339757051C Following the evaluators' findings is the #HL339753702M /#HL339757148C Time Period for Correction.

Finding: Inconclusive Nature of Investigation: The Minnesota Department of Health investigated an allegation of maltreatment, in accordance with the Minnesota Reporting of Maltreatment of Vulnerable Adults Act, Minn. Stat. 626.557, and to evaluate compliance with applicable licensing standards for the provider type. Initial Investigation Allegation(s): The facility neglected the resident when they failed to provide wound care in accordance with physician orders. The facility discontinued the resident’s wound care services after the resident returned from the hospital with new orders, stating they were not able to provide the wound care due to staffing. The resident later admitted to the hospital with cellulitis. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was inconclusive. Although wound care was not consistently documented as provided in accordance with physician’s orders, there was not a preponderance of evidence the actions, or inactions, of facility staff led to the resident being hospitalized with cellulitis. The facility discontinued wound care provided by unlicensed staff; however, continued providing wound care by a licensed nurse. Hospital records related to the hospitalization were not able to be obtained. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted law enforcement, the case worker, hospital staff, and the resident’s primary care provider. The investigation included review of the resident records, hospital records, facility incident reports, staff schedules, law enforcement report, and related facility policies and procedures. Also, the investigator observed the resident’s wounds and wound care provided by the facility. The resident resided in an assisted living facility. The resident’s diagnoses included paraplegia and type two diabetes. The resident’s service plan included assistance with wound care two times per day. The resident’s assessment indicated the resident had two stage 3 (extending into the fatty tissue) pressure ulcers and a stage 4 (extending into the muscles, tendons, and ligaments) pressure ulcer to his buttocks. The resident was paralyzed from the chest down and required two people and a mechanical hoyer lift for all transfers. The resident was cognitively intact, managed his medications and directed his care. The resident had a history of pressure ulcers and skin breakdown to his coccyx and buttocks. The resident’s record indicated wound care to his three wounds was to be completed twice per day. Unlicensed personnel (ULP) initially performed the wound care, however facility management decided to not allow ULP to complete wound care as a delegated task and changed its policy to only allow licensed nurses to complete wound cares. As a result, wound care documentation was removed from the resident’s service recap summary. Licensed nurses began documenting sporadically in progress notes when wound care was completed. In the two weeks leading up to his hospitalization, documentation of wound cares being completed was inconsistent. Six days lacked documentation of wound cares being completed. The resident’s progress notes indicated staff observed swelling to the resident’s groin area and his legs were firm with increased redness. Staff called 911 and the resident was admitted to the hospital and diagnosed with cellulitis. The resident spent six days in the hospital and was treated with IV antibiotics. Hospital records related to the resident’s hospitalization for cellulitis were requested, but only partial records were provided. Documentation related to the resident’s reason for admission or condition of the wounds were not provided by the hospital. The facility was also unable to obtain documentation related to the resident’s hospital admission. During an interview, a facility nurse stated due to staffing constraints, the decision was made to not allow ULP to complete wound care and the nurses took over the task. The nurse stated she or one of the other nurses did his twice daily dressing changes but the service had been removed from his medical record so they documented in a progress note when it was completed. The nurse stated the resident’s wound care was always completed. During an interview the registered nurse (RN) stated when she began serving as the interim supervisor, she didn’t feel the ULP were completing the dressing changes appropriately, so they transitioned the task to be completed by the licensed nurse only. The RN stated to her knowledge, all wound cares were completed as ordered and none were missed. The RN stated she wasn’t as familiar with the facility’s electronic medical record and was not sure why some documentation was missing. In conclusion, the Minnesota Department of Health determined neglect was inconclusive. Inconclusive: Minnesota Statutes, section 626.5572, Subdivision 11. "Inconclusive" means there is less than a preponderance of evidence to show that maltreatment did or did not occur. 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: No action taken. 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: 11/18/2024 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 _____________________________ 33975 10/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 33310 STATE HIGHWAY 6 MAPLE WOODS ASSISTED LIVING DEER RIVER, MN 56636 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. On October 7, 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 20 residents receiving services under the provider's Assisted Living with Dementia Care license. The following correction orders are issued for #HL339755501M/#HL339757721C, tag identification 0430, 0450, 0470, 1070, 1940, 1960. 0 430 144G.40 Subd. 2 Uniform checklist disclosure of 0 430 SS=F services (a) All assisted living facilities must provide to prospective residents: (1) a disclosure of the categories of assisted living licenses available and the category of license held by the facility; (2) a written checklist listing all services permitted under the facility's license, identifying all services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 CXH411 If continuation sheet 1 of 34 PRINTED: 11/18/2024 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 _____________________________ 33975 10/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 33310 STATE HIGHWAY 6 MAPLE WOODS ASSISTED LIVING DEER RIVER, MN 56636 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) 0 430 Continued From page 1 0 430 the facility offers to provide under the assisted living facility contract, and identifying all services allowed under the license that the facility does not provide; and (3) an oral explanation of the services offered under the contract.