Eagan Pointe Senior Living Llc.

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 CORRECTIO NORDERS 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 t he violati ons ; however, no immediate fines are assessed for this survey of your facility. 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: An equal opportunity employer. Letter ID: IS7N REVISE D09/13/2021 Eagan Pointe Senior Living LLC December 24, 2025 Page 2 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 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, Jodi Johnson, Supervisor State Evaluation Team Email: Jodi.Johnson@state. mn.us Telephone: 507-344-2730 Fax: 1-866-890-9290 KKM PRINTED: 12/ 24/ 2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/ SUPPLIER/ CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 31786 12/ 03/ 2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4232 BLACK HAWK ROAD EAGAN POINTE SENIOR LIVING LLC EAGAN, MN 55122 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. SL31786016- 0 PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On December 1, 2025, through December 3, STATES, "PROVIDER' S PLAN OF 2025, the Minnesota Department of Health CORRECTION. " THIS APPLIES TO conducted a full survey at the above provider and FEDERAL DEFICIENCIES ONLY. THIS the following correction orders are issued. At the WILL APPEAR ON EACH PAGE. time of the survey, there were 149 residents; 80 receiving services under the Assisted Living THERE IS NO REQUIREMENT TO Facility with 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. 01760 144G. 71 Subd. 8 Documentation of 01760 SS= D administration of medication LABORATORY DIRECTOR' S OR PROVIDER/ SUPPLIER REPRESENTATIVE' S SIGNATURE TITLE (X6) DATE STATE FORM 6899 OWBL11 If continuation sheet 1 of 6 PRINTED: 12/ 24/ 2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/ SUPPLIER/ CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 31786 12/ 03/ 2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4232 BLACK HAWK ROAD EAGAN POINTE SENIOR LIVING LLC EAGAN, MN 55122 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) 01760 Continued From page 1 01760 Each medication administered by the assisted living facility staff must be documented in the resident' s record. The documentation must include the signature and title of the person who administered the medication. The documentation must include the medication name, dosage, date and time administered, and method and route of administration. The staff must document the reason why medication administration was not completed as prescribed and document any follow-up procedures that were provided to meet the resident' s needs when medication was not administered as prescribed and in compliance with the resident' s medication management plan. This MN Requirement is not met as evidenced by: Based on observation, interview, and record review, the licensee failed to ensure medications were administered as ordered for one of one resident (R7). This practice resulted in a level two violation (a violation that did not harm a resident' s health or safety but had the potential to have harmed a resident' s health or safety, but was not likely to cause serious injury, impairment, or death) , and was issued at an isolated scope (when one or a limited number of residents are affected or one or a limited number of staff are involved or the situation has occurred only occasionally) . The findings include: On December 2, 2025, at 8:15 a. m. , the surveyor observed unlicensed personnel (ULP)-G administering morning medication to R7. Voltaren cream located in the resident' s locked medication cabinet did not include a measuring strip for the cream. The surveyor observed STATE FORM 6899 OWBL11 If continuation sheet 2 of 6 PRINTED: 12/ 24/ 2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/ SUPPLIER/ CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B.

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 the facility over-medicated the resident with an opioid pain medication, oxycodone. The resident became unresponsive and naloxone, a medication that rapidly reverses opioid effects, was administered. The resident’s last days were shortened due to the incident. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was inconclusive. The resident became more sedated and unresponsive after the administration of pain medication and there was an error in medication administration that caused the resident to receive an additional 5mg of Oxycodone. However, it could not be determined if the additional 5 mg of oxycodone caused the resident to become unresponsive. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted providers that were caring for the resident during the time in question. The investigation included review of the resident medical records, death record, pharmacy records, facility internal investigation, facility incident reports, staff schedules, and related facility policy and procedures. The resident resided in an assisted living memory care unit. The resident’s diagnoses included cancer. The resident’s service plan included care goals to promote comfort and assist in the achievement of a comfortable, peaceful death. The resident’s assessment indicated the resident was on hospice care due to a terminal cancer diagnosis. Review of resident’s facility medical record and the facility internal review indicated the resident moved to the memory care unit two days before the time in question and experienced increased pain and vomiting. At that time, a one-time 15mg oxycodone dose was administered for pain and a provider gave orders for 10mg oxycodone every four hours and hourly as needed for pain; and lorazepam, an antianxiety medication, 1mg every four hours and every two hours as needed for nausea. The day before the time in question, the resident reported to be without pain and nausea but was tired and sedated. The residents Oxycodone was decreased to 5mg every six hours and hourly as needed for pain; and lorazepam 1mg every six hours for nausea. During the early morning hours of the day in question, the staff member caring for the resident administered 10mg oxycodone rather than the scheduled 5mg oxycodone in error. That afternoon the resident was unresponsive with shallow breathing and blue tinged skin. The resident’s state was a drastic change from the two days prior and naloxone was administered. Four hours later, the resident was unable to stay awake but could open her eyes intermittently, answer yes and no questions, and move her arms and legs. The resident’s pain and nausea medications were discontinued and later reordered. The resident continued to receive hospice care and died eleven days later. During interview, a nurse stated the resident lived independently prior to moving to the memory care unit. The resident moved due to increased need for assistance, especially assistance with medication management. The nurse stated she saw the resident the day the resident moved to the memory care unit, the resident had a change of condition and was very ill in the bathroom, retching and vomiting profusely. The resident’s vomiting was so forceful it was causing pain and pain medication orders were increased. The nurse saw the resident again on the day in question and the resident was lying in bed, ashen in color, unresponsive to voice and touch, and did not withdraw from pain stimulation applied to fingertips. A family member of the resident expressed concern of possible over-medication, the provider was contacted and ordered naloxone. The nurse administered the naloxone and after a few minutes the resident opened her eyes and coughed. The nurse stayed with the resident and facility staff informed the nurse a medication error occurred the night before. The nurse stated the resident became more conversational over the next few days, but declined quickly and did not walk or leave her room like she did prior to moving to the memory care unit. During interview, a second nurse indicated she conducted an internal facility review of the medication error including speaking with staff and reviewing medication orders, documentation, and bubble packs. The second nurse stated it was determined one medication error occurred when a staff member administered 10mg rather than 5mg of oxycodone during the early morning hours. During interview, a medical provider stated a concern was voiced regarding the resident experiencing a medication error at the facility. The provider stated it was not possible to know if an extra dose of oxycodone caused the resident’s sedation. 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: No, deceased. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Not Applicable. Action taken by facility: Internal facility review of the incident and re-education of staff. 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: 03/19/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ C B. WING _____________________________ 31786 02/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4232 BLACK HAWK ROAD EAGAN POINTE SENIOR LIVING LLC EAGAN, MN 55122 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 12, 2025, the Minnesota Department of Health initiated an investigation of complaint #HL317869642C/#HL317866333M. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 CZFH11 If continuation sheet 1 of 1