Marywood.

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) abused the resident when the AP physically restrained the resident into her wheelchair using a transfer belt. Investigative Findings and Conclusion: The Minnesota Department of Health determined abuse was not substantiated. Although the AP restrained the resident to her wheelchair with a transfer belt, the error was an isolated incident, and no harm occurred to the resident. The resident was observed on facility video surveillance restrained to her wheelchair with the transfer belt for about one hour. During that time the resident had no signs or symptoms of distress observed. When staff noticed the resident was restrained, they removed the transfer belt and reported the incident. When interviewed the AP admitted restraining the resident to her wheelchair and denied any malicious intent but rather intended to keep the resident safe. All staff were re-educated on use of restraints. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted the resident’s family. The investigation included review of the resident record(s), facility internal investigation, personnel files, staff schedules, facility video surveillance, and related facility policy and procedures. Also, the investigator observed residents and staff at the facility. The resident resided in an assisted living facility memory care unit with diagnoses including dementia, Alzheimer’s disease late onset, and anxiety disorder. The resident’s assessment and plan of care indicated the resident was severely cognitively impaired. The assessment and plan of care indicated the resident was at risk of falls and required assistance from staff with transfers using a transfer belt. The facility investigation documentation indicated the AP applied a transfer belt to restrain the resident to her wheelchair. The investigation indicated when staff became aware the resident was restrained, the transfer belt was immediately removed, and the incident was reported to leadership. The investigation indicated when the AP was interviewed by facility leadership, the AP stated she was trying to keep the resident safe and prevent her from falling. The AP explained the resident had multiple self-transfers that morning and non-pharma logical interventions tried were ineffective. The investigation indicated the resident sustained no injuries and had no emotional distress noted as a result of the incident. A review of facility video surveillance from the common area during the time of the incident showed the resident walking out of her room without assistance then the AP rushed to prevent the resident from falling while another staff went to get the resident her wheelchair. The AP was observed assisting the resident into her wheelchair then secured the transfer belt around the wheelchair and the resident’s waist. The resident was observed propelling herself around the unit until staff noticed the transfer belt and removed it approximately one hour later. The resident appeared calm, with no signs of agitation or distress while the transfer belt was in place. When interviewed, facility leadership stated they had no concerns with the AP’s conduct prior to the incident and indicated the incident was isolated. Facility leadership stated the AP had no malicious intent and was trying to keep the resident safe. When interviewed, several unlicensed staff stated they had no concerns with the AP’s conduct prior to the incident. Staff stated they received re-education on restraints after the incident. When interviewed, the AP admitted applying the transfer belt to keep the resident in her wheelchair but indicated the resident was able to mobilize and she did not think it was a restraint. The AP stated she had never used a transfer belt to restrain the resident before and indicated the transfer belt was around the back of the chair and she thought it was there to help keep the resident in her wheelchair. The AP denied any intent to cause harm or distress to the resident and stated she was trying to keep the resident safe. In conclusion, the Minnesota Department of Health determined abuse 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. Abuse: Minnesota Statutes section 626.5572, subdivision 2. "Abuse" means: (b) Conduct which is not an accident or therapeutic conduct as defined in this section, which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to, the following: (3) use of any aversive or deprivation procedure, unreasonable confinement, or involuntary seclusion, including the forced separation of the vulnerable adult from other persons against the will of the vulnerable adult or the legal representative of the vulnerable adult unless authorized under applicable licensing requirements or Minnesota Rules, chapter 9544. Vulnerable Adult interviewed: Yes. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Yes. Action taken by facility: Facility staff removed the restraint, reported the incident and the AP was suspended pending investigation into the incident. All staff were re-educated on what constitutes a restraint, the prohibited use of restraints, and the resident’s right to be free from restraints. 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/ 28/ 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 _____________________________ 31068 02/ 17/ 2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 915 KENWOOD AVENUE MARYWOOD DULUTH, MN 55811 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 February 17, 2026, the Minnesota Department of Health initiated an investigation of complaint #HL310681040M/ #HL310685060C. No correction orders are issued. LABORATORY DIRECTOR' S OR PROVIDER/ SUPPLIER REPRESENTATIVE' S SIGNATURE TITLE (X6) DATE STATE FORM 6899 842711 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 the facility failed to ensure the resident had adequate pain management. As a result, the resident experienced unmanageable pain. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. While unlicensed personnel (ULP) had technical difficulty in how they viewed the resident’s electronic medication administration record (eMAR) throughout a weekend, the eMAR was still accessible, and records indicated the ULPs’ administered the resident’s pain medication as ordered. In addition, as the resident’s pain medication increased throughout the weekend, the facility implemented orders, and the resident received pain medications. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigation included review of the resident records, death record, facility internal investigation, narcotic and controlled medication records, hospice orders, facility incident reports, staff schedules, and related facility policy and procedures. Also, the investigator observed the resident’s unit and staff interactions with other residents. The resident resided in an assisted living memory care unit. The resident’s diagnoses included dementia, chronic pain, and anxiety. The resident’s service plan included assistance with medication administration. The resident’s assessment indicated the resident received hospice services. The resident’s records indicated during a four-day timeframe prior to the resident’s death, the resident had multiple medication changes for pain. The resident also had multiple medication changes for anxiety/restlessness/terminal agitation. The records indicated facility and on-call nurses communicated with hospice services regarding the changes. Records indicated the resident’s narcotic pain medication and controlled medication for anxiety/restlessness/terminal agitation both increased throughout this timeframe. The resident’s records indicated the facility implemented hospice orders. The resident’s eMAR indicated staff provided the resident pain medication and provided medication for the resident’s anxiety/restlessness/terminal agitation throughout this time frame. The eMAR indicated as orders changed, the resident received the increased doses of both medications. The resident’s progress notes indicated multiple ULP called the on-call nurses regarding issues viewing the resident’s eMAR with the resident medication changes. However, the resident’s narcotic and controlled medication logs reviewed in comparison with the resident’s eMAR indicated medications staff removed were administered to the resident. The facility’s internal investigation indicated ULP were able to view the medication orders in the resident’s eMAR after logging out and relogging into the eMAR a different way. During an interview, a nurse stated the resident was on hospice services, declined quickly and transitioned to the stage of dying. The nurse said the resident’s pain medications changed frequently, and the resident had medications for pain and terminal restlessness. During an interview, an ULP stated towards the end of the resident’s life, the resident’s medication doses increased and changed due to the resident feeling uncomfortable. Staff contacted and spoke with the on-call nurses throughout the weekend due to how the medications were showing up on the eMAR. The ULP stated staff were still able to access the eMAR just in a different way of logging in. During an interview, leadership stated the facility had designated ULP staff administering narcotic and controlled medications. There were technical issues with how the resident’s medication changes were not pulling up on the designated ULP eMAR flow sheet. However, leadership stated the resident’s eMAR was still accessible to the designated ULPs by logging into the system a different way. Leadership stated the designated ULP’s knew how to access the eMAR using the different way because the resident’s narcotic and controlled medications were administered. The facility implemented orders received for the medication changes. Leadership conducted an internal investigation and determined the resident missed one dose of pain medication during this timeframe. Other allegations of concern included the resident’s falls. Records indicated the facility nurses assessed and monitored the resident after falls. Hospice and the resident’s provider were updated. During investigative interviews, leadership and a nurse both stated the facility added interventions to reduce fall risk. Another concern identified was the facility failed to have a nurse physically present in the building during an identified weekend. The resident’s records indicated unlicensed staff had access to an on-call nurse, contacted and spoke to the on-call nurse numerous times. Another concern identified was a ULP fell asleep, and the resident did not receive any pain medication throughout shift. Prior to the resident’s death and during the timeframe in question, records indicated one dose of the resident’s pain medication was not administered. However, records indicated the resident received his next scheduled pain medication dose and ongoing doses after that. Leadership stated there was an occasion when one ULP did fall asleep while on break. Leadership stated during overnight shift there was a second ULP available on the adjoining unit as well as a float ULP. Review of schedules supported leadership’s stated staffing model. Leadership stated staff were expected to be awake. The facility conducted an internal investigation, and the staff member involved received discipline. 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 deceased. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Not Applicable. Action taken by facility: When unlicensed staff members contacted the on-call nurse throughout the weekend, on-call nurses spoke to the staff members and provided instruction. 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: 01/ 08/ 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 _____________________________ 31068 12/ 02/ 2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 915 KENWOOD AVENUE MARYWOOD DULUTH, MN 55811 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER' S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS- REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 000 Initial Comments 0 000 On December 2, 2025, the Minnesota Department of Health initiated an investigation of complaint #HL310685702C/ #HL310686582M. No correction orders are issued. LABORATORY DIRECTOR' S OR PROVIDER/ SUPPLIER REPRESENTATIVE' S SIGNATURE TITLE (X6) DATE STATE FORM 6899 PCQ811 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 . . ." In accordance with Minn. Stat. § 144G.31 Subd. 4, MDH may assess fines based on the level and scope of the violations; h owever, no immediate fines are assessed for this survey of your facility. 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 An equal opportunity employer. Letter ID: IS7N REVISED 09/13/2021 Marywood February 19, 2025 Page 2 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 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, Jessie Chenze, Supervisor State Evaluation Team Email: jessie.chenze@state.mn.us Telephone: 218-332-5175 Fax: 1 -866-890-9290 JMD PRINTED: 02/19/2025 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 _____________________________ 31068 01/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 915 KENWOOD AVENUE MARYWOOD DULUTH, MN 55811 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 SL31068016-0 Time Period for Correction. On January 6, 2025, through January 9, 2025, the survey at the above provider. At the time of the THE FOURTH COLUMN WHICH survey, there were 45 resident(s); 45 receiving STATES,"PROVIDER'S PLAN OF services under the Assisted Living Facility with CORRECTION." THIS APPLIES TO Dementia Care license. 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 290J11 If continuation sheet 1 of 21 PRINTED: 02/19/2025 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 _____________________________ 31068 01/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 915 KENWOOD AVENUE MARYWOOD DULUTH, MN 55811 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) 0 480 Continued From page 1 0 480 0 480 144G.41 Subdivision 1 Subd. 1a (a-b) Minimum 0 480 SS=F requirements; required food services (a) Except as provided in paragraph (b), food must be prepared and served according to the Minnesota Food Code, Minnesota Rules, chapter 4626. (b) For an assisted living facility with a licensed capacity of ten or fewer residents: (1) notwithstanding Minnesota Rules, part 4626.0033, item A, the facility may share a certified food protection manager (CFPM) with one other facility located within a 60-mile radius and under common management provided the CFPM is present at each facility frequently enough to effectively administer, manage, and supervise each facility's food service operation; (2) notwithstanding Minnesota Rules, part 4626.0545, item A, kick plates that are not removable or cannot be rotated open are allowed unless the facility has been issued repeated correction orders for violations of Minnesota Rules, part 4626.1565 or 4626.1570; (3) notwithstanding Minnesota Rules, part 4626.0685, item A, the facility is not required to provide integral drainboards, utensil racks, or tables large enough to accommodate soiled and clean items that may accumulate during hours of operation provided soiled items do not contaminate clean items, surfaces, or food, and clean equipment and dishes are air dried in a manner that prevents contamination before storage; (4) notwithstanding Minnesota Rules, part 4626.1070, item A, the facility is not required to install a dedicated handwashing sink in its existing kitchen provided it designates one well of a two-compartment sink for use only as a handwashing sink; STATE FORM 6899 290J11 If continuation sheet 2 of 21 PRINTED: 02/19/2025 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 _____________________________ 31068 01/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 915 KENWOOD AVENUE MARYWOOD DULUTH, MN 55811 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) 0 480 Continued From page 2 0 480 (5) notwithstanding Minnesota Rules, parts 4626.1325, 4626.1335, and 4626.1360, item A, existing floor, wall, and ceiling finishes are allowed provided the facility keeps them clean and in good condition; (6) notwithstanding Minnesota Rules, part 4626.1375, shielded or shatter-resistant lightbulbs are not required, but if a light bulb breaks, the facility must discard all exposed food and fully clean all equipment, dishes, and surfaces to remove any glass particles; and (7) notwithstanding Minnesota Rules, part 4626.

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) abused the resident when the resident was found to have a bruise on her right forearm. It was also alleged the AP was heard yelling at the resident in the same time frame. Investigative Findings and Conclusion: The Minnesota Department of Health determined abuse was not substantiated. There was not evidence of conduct by the AP that caused physical pain or injury. The resident had two small bruises on her forearm, spaced a part and red in color. The resident was on long term blood thinner use, causing increased risk for bruising. The AP reported she speaks in a loud tone, but there was not allegation the AP made verbal threats or used abusive language towards the resident. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator also contacted the resident’s emergency An equal opportunity employer. contact. The investigation included review of the resident’s medical record. Also, the investigator observed the resident. The bruise present at the time of the report had since healed but the resident had several small bruises on both forearms each about the size of a dime. The resident resided in an assisted living memory care unit. The resident’s diagnoses included weakness and history of pulmonary embolism which required anticoagulant (blood thinner) medication. The resident’s service plan indicated the resident required assistance with repositioning every two hours and used a ceiling mechanical lift for transfers. The resident’s assessment indicated the resident took blood thinners daily and received hospice services. The facility internal investigation indicated the nurse received an allegation an unlicensed personnel (ULP) heard the AP yell at the resident and the next morning the morning ULP reported a bruise on the resident’s forearm. The nurse interviewed the resident who said she “fought” with the AP and the bruise was from the AP being rough. The resident stated she was fearful of the AP and the nurse removed the AP from working with the resident. The nurse assessed the resident and noted two small bruises to the resident forearm, red in color and the resident denied pain. Interventions included the AP no longer providing care to the resident and retraining provided to the AP regarding reporting of abuse and the resident bill of rights. During an interview, the nurse stated she did not see any bruises that resembled fingerprints. The nurse stated when she talked with the resident, the resident said the AP was a little rough and talks loudly, but the AP did not try to hurt her. During an interview, the resident’s family member stated she was aware of the incident, and it was not unusual for the resident to have bruises due to being on a blood thinner. The family member stated she had no concerns about the resident’s care. In conclusion, the Minnesota Department of Health determined abuse 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. Abuse: Minnesota Statutes section 626.5572, subdivision 2. "Abuse" means: (b) Conduct which is not an accident or therapeutic conduct as defined in this section, which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to, the following: (1) hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult; (2) use of repeated or malicious oral, written, or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening; Vulnerable Adult interviewed: No. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: No. Action taken by facility: The facility completed an investigation, completed retraining with the AP and removed the AP from providing cares to 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: 10/19/2023 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 _____________________________ 31068 07/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 915 KENWOOD AVENUE MARYWOOD DULUTH, MN 55811 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 31, 2023, the Minnesota Department of Health initiated an investigation of complaint HL310683377C/HL310686969M. No correction orders are issued. HL310687535C/HL310684463M was not the jursidication of MDH and referral was made to the appropriate agency. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 URPI11 If continuation sheet 1 of 1