Global Pointe Senior Living.

Finding: Not Substantiated Nature of Investigation: The Minnesota Department of Health investigated an allegation of maltreatment, in accordance with the Minnesota Reporting of Maltreatment of Vulnerable Adults Act, Minn. Stat. 626.557, and to evaluate compliance with applicable licensing standards for the provider type. Initial Investigation Allegation(s): The alleged perpetrator (AP), a facility staff member, abused resident #1 when the AP grabbed and attempted to restrain resident #1 during a physical altercation while in resident #2’s apartment. The facility neglected resident #1 when resident #1 was found with bruising on his lower arms and untreated skin tears on his hand. Investigative Findings and Conclusion: The Minnesota Department of Health determined abuse and neglect were not substantiated. Although an altercation occurred the incident did not rise to the level of abuse. When resident #1’s entered resident #2’s apartment the AP grabbed resident #1’s arm to keep resident #2 safe. The next day when resident #1’s wounds were observed, facility staff cleansed and applied a dressing. The facility nurse assessed and updated the medical provider. The investigator conducted interviews with facility staff members, nursing staff and a family member of resident #1. The investigation included review of resident #1’s records, facility internal investigation documentation, as well as related facility policies and procedures. The investigator toured the facility, observed staff interacting with residents and completing scheduled care activities at the time of the onsite visit. Resident #1 resided in an assisted living facility memory care unit. Resident #1’s diagnoses included dementia, major depressive disorder and a history of skin cancer. Resident #1’s service plan included assistance safety checks and medication administration. Resident #1’s assessment indicated that resident #1 had a history of behavior issues previously controlled with medication regimen. Resident #1 had fragile skin was not cognitively intact and needed redirection from staff. The resident was able to ambulate independently without the use of assistive devices, although in the past physical therapy has recommended the use of walking poles/sticks to aid in falls prevention. A nursing assessment of body systems completed prior to the alleged incident indicated the resident’s skin was classified by nursing staff as fragile, although at that time no wounds were on his skin. Documents reviewed indicate that while visiting the resident at the facility over a holiday weekend, a family member reported to facility staff that they could see bruising on both forearms and wounds on the hand of the resident. They had not been previously informed of these injuries and wanted staff to report these concerns to the nursing staff. Facility documents indicated the AP was assisting resident #2 with a shower. Resident #1 entered the apartment seemingly upset and attempted to hit the AP multiple times while also trying to remove resident #2 from the shower. The AP attempted to redirect resident #1 and protect himself while another facility staff was able to remove resident #1 from the bathroom. A facility document indicated the resident did not have injuries after the incident. Facility documents reviewed also indicated the following afternoon the AP found resident #1 cleaning his hands in his apartment with a wet towel. The AP observed what was described as skin tears on the back of resident #1 hand, he cleansed the wounds and applied a bandage. When asked Resident #1 was not able to recall how they had occurred. The medical record indicated the facility nurse assessed the wound and updated the medical provider. Resident #1 was treated with antibiotics and the wounds healed. During an interview, the AP stated that while assisting resident #2 with bathing cares, resident #1 entered resident #2’s apartment and was upset and began yelling at the AP. During the encounter, resident #1 attempted to pull resident #2 out of the shower and away from the AP. The AP repeatedly asked resident #1 to leave, and eventually a physical altercation ensued with resident #1 repeatedly striking at the AP. The AP called out for assistance as he positioned himself between resident #1 and resident #2 who continued to aggressively confront the facility staff members. Resident #1 was removed from the apartment by another staff person. The AP stated that after the altercation he did not observe any physical injuries on resident #1. The AP went on to state that the next afternoon when he entered resident #1’s room to administer medication as scheduled, he observed resident #1 at the sink. The AP stated he saw wounds on the back of resident #1’s hands at that time. During an interview, a facility staff person stated the night of the incident she heard yelling coming from the resident #2’s room. Upon entering the room, she observed resident #1 in the bathroom yelling at the AP and repeatedly attempting to strike the AP with both hands. The facility staff person was able to redirect resident #1 out of the bathroom and out of the apartment into a common area of the memory care unit where she was able to calm resident #1 down. The staff member stated she did not see any visible injuries, bleeding or open wounds on resident #1’s arms or hands on the day of the incident. During an interview, a facility nursing staff member stated that memory care staff were familiar with the resident #1’s behaviors and occasional outbursts and had all received training specific to memory care, related diagnosis and appropriate de-escalation techniques. In addition, it was noted that the resident had weeks earlier discontinued an antipsychotic medication, which was restarted days after this episode. During an interview, a family member stated that he was not aware of any other altercations involving his family member and other residents or staff members at the facility. The resident continued to reside at the facility for months after the reported incident, and once a suitable facility was secured, the family chose to relocate the resident to another facility by their own choosing. 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. 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, Unavailable for interview. Family/Responsible Party interviewed: Yes Alleged Perpetrator interviewed: Yes Action taken by facility: Reeducation was provided to facility staff. The facility contacted the residents primary care provider to re-assess the need for medication changes and updated care orders. 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: 11/12/2025 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 _____________________________ 35621 10/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5200 WAYZATA BOULEVARD GLOBAL POINTE SENIOR LIVING GOLDEN VALLEY, MN 55416 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE PREFIX PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 000 Initial Comments 0 000 On October 16, 2025, the Minnesota Department of Health initiated an investigation of complaint #HL356219910C/ #HL356214722M.

correction orders and document the actions taken to comply in the facility's records. The Department reserves the right to return to the facility at any time should the Department receive a complaint or deem it necessary to ensure the health, safety, and welfare of residents in your care. STATE CORRECTION ORDERS The enclosed State Form documents the state correction orders. MDH documents state licensing correction orders using federal software. Tag numbers are assigned to Minnesota state statutes for Assisted Living Facilities. The assigned tag number appears in the far left column entitled "ID Prefix Tag." The state statute number and the corresponding text of the state statute out of compliance are listed in the "Summary Statement of Deficiencies" column. This column also includes the findings that are in violation of the state statute after the statement, "This MN Requirement is not met as evidenced by . . ." IMPOSITION OF FINES In accordance with Minn. Stat. § 144G.31, Subd. 4, fines and enforcement actions may be imposed based on the level and scope of the violations and may be imposed immediately with no opportunity to correct the violation first as follows: Level 1: no fines or enforcement. Level 2: a fine of $500 per violation, in addition to any enforcement mechanism authorized in § 144G.20 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 An equal opportunity employer. Letter ID: IS7N REVISED 09/13/2021 Global Pointe Senior Living April 22, 2025 Page 2 § 144G.20. Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, the following fines are assessed pursuant to this survey: 0510 - 144g.41 Subd. 3 - Infection Control Program - $500.00 Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, t he total amount you are assessed is $500.00. You will be invoiced approximately 30 days after receipt of this notice, subject to appeal. DOCUMENTATION OF ACTION TO COMPLY In accordance with Minn. Stat. § 144G.30, Subd. 5(c), the licensee must document actions taken to comply with the correction orders within the time period outlined on the state form; however, plans of correction are not required to be submitted for approval. The correction order documentation should include the following: Identify how the area(s) of noncompliance was corrected related to the resident(s)/employee(s) identified in the correction order. Identify how the area(s) of noncompliance was corrected for all of the provider’s resident(s)/employees that may be affected by the noncompliance. Identify what changes to your systems and practices were made to ensure compliance with the specific statute(s). CORRECTION ORDER RECONSIDERATION PROCESS In accordance with Minn. Stat. § 144G.32, Subd. 2, you may challenge the correction order(s) issued, including the level and scope, and any fine assessed through the correction order reconsideration process. The request for reconsideration must be in writing and received by MDH within 15 calendar days of the correction order receipt date. To submit a reconsideration request, please visit: https://forms.web.health.state.mn.us/form/HRDAppealsForm REQUESTING A HEARING Alternatively, in accordance with Minn. Stat. § 144G.31, Subd. 5(d), an assisted living provider that has been assessed a fine under this subdivision has a right to a reconsideration or a hearing under this section and chapter 14. Pursuant to Minn. Stat. § 144G.20, Subd. 14 and Subd. 18, a request for a hearing must be in writing and received by the Department of Health within 15 business days of the correction order receipt date. The request must contain a brief and plain statement describing each matter or issue contested and any new information you believe constitutes a defense or mitigating factor. Global Pointe Senior Living April 22, 2025 Page 3 To submit a hearing request, please visit: https://forms.web.health.state.mn.us/form/HRDAppealsForm To appeal fines via reconsideration, please follow the procedure outlined above. P lease note that you may request a reconsideration o r a hearing, but not both. If you wish to contest tags without fines in a reconsideration and tags with the fines at a hearing, please submit two separate appeals forms at the website listed above. The MDH Health Regulation Division (HRD) values your feedback about your experience during the survey and/or investigation process. Please fill out this anonymous provider feedback questionnaire at your convenience at this link: h ttps://forms.office.com/g/Bm5uQEpHVa. Your input is important to us and will enable MDH to improve its processes and communication with providers. If you have any questions regarding the questionnaire, please contact Susan Winkelmann at susan.winkelmann@state.mn.us or call 651-201-5952. You are encouraged to retain this document for your records. It is your responsibility to share the information contained in the letter and state form with your organization’s Governing Body. If you have any questions, please contact me. Sincerely, Jess Schoenecker, Supervisor State Evaluation Team Email: jess.schoenecker@state.mn.us Telephone: 651-201-3789 Fax: 1 -866-890-9290 JMD PRINTED: 04/22/2025 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 _____________________________ 35621 03/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5200 WAYZATA BOULEVARD GLOBAL POINTE SENIOR LIVING GOLDEN VALLEY, MN 55416 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 SL35621016-0 Time Period for Correction. On March 10, 2025, through March 13, 2025, the PLEASE DISREGARD THE HEADING OF survey at the above provider. At the time of the STATES,"PROVIDER'S PLAN OF survey, there were 101 residents; 65 receiving CORRECTION." THIS APPLIES TO services under the Assisted Living Facility with FEDERAL DEFICIENCIES ONLY. THIS Dementia Care license. 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. 0 510 144G.41 Subd. 3 Infection control program 0 510 SS=F (a) All assisted living facilities must establish and LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 9FL711 If continuation sheet 1 of 16 PRINTED: 04/22/2025 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 _____________________________ 35621 03/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5200 WAYZATA BOULEVARD GLOBAL POINTE SENIOR LIVING GOLDEN VALLEY, MN 55416 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.

STATE LICENSING COMPLIANCE REPORT Report #: Date Concluded: September 26, 2024 HL356216233C Name, Address, and County of Facility Investigated: Global Pointe Senior Living 5200 Wayzata Boulevard Golden Valley, MN 55416 Hennepin County Facility Type: Assisted Living Facility with Evaluator’s Name: Erin Johnson-Crosby, RN Dementia Care (ALFDC) Special 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: 10/01/2024 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 _____________________________ 35621 08/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5200 WAYZATA BOULEVARD GLOBAL POINTE SENIOR LIVING GOLDEN VALLEY, MN 55416 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 August 20, 2024, the Minnesota Department of Health initiated an investigation of complaint #HL356216233C. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 WQ1K11 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 resident had been sick for four days and asked to see a doctor multiple times before presenting to the emergency department. Additionally, the resident had a large pressure ulcer present on her coccyx. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. Although the facility held the resident’s medication, the resident and family made the decision to remain off anticoagulation. Additionally, evidence did not indicate the resident had a change of condition days prior to presenting to the emergency department (ED). Regarding the pressure ulcer, the facility had arrangements with a home health group who provided regular treatments and wound monitoring. The facility staff monitored skin during showers and toileting. An equal opportunity employer. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted the provider. The investigation included review of the resident’s medical record, facility policies, facility grievances, staffing schedules, and pharmacy invoices. The investigation also included review of the resident’s hospital record, home health visit notes, and provider notes. Also, the investigator observed resident cares and interactions with facility staff. The resident resided in an assisted living facility. The resident’s diagnoses included heart failure and atrial fibrillation (an irregular heartbeat). The resident’s service plan included assistance with toileting, dressing, medication administration, and transfers. The resident’s assessment indicated the resident used a wheelchair and identified her as alert and oriented. A nursing note indicated staff contacted the on call registered nurse due to the resident experiencing nausea, vomiting, and an elevated pulse. The registered nurse encouraged fluids and a recheck of the pulse. A second progress note, less then one hour later, indicated staff reported the resident had no more episodes of vomiting, but had not been responding to questions and had difficulty breathing. The resident had an oxygen level of 85%. The registered nurse instructed staff to call 911 and have the resident sent to the hospital. The resident presented to the ED with weakness and atrial fibrillation. Additionally, the hospital records indicated the resident reported not feeling well for three days and had a non-blanchable pressure ulcer on the coccyx. While in the ED, the resident stated she stopped taking her Eliquis (a medication used to prevent blood clot formation due to irregular heartbeat) due to insurance issues. The hospital record indicated the resident experienced low blood pressures, low oxygen levels and identified the concern that atrial fibrillation caused acute chronic heart failure. The resident died in the ED. The death certificate identified the resident’s cause of death as atrial fibrillation, heart failure, and aortic stenosis (a narrowing of the aortic valve). Approximately one month prior to the resident presenting to the ED, the resident’s medication administration record indicated the facility held the resident’s Eliquis. This medication had been held for three weeks before the provider became aware of the hold. The provider’s visit note indicated she learned the resident’s Eliquis had been on hold due to cost at the time of her visit. She informed the resident who had not been made aware. The provider reviewed the risks and benefits of anticoagulation with the resident’s family member. The family member planned to speak with the resident about staying off anticoagulation or starting a new medication and would get back to the provider with the decision. The home health notes indicated they assessed the resident three days prior and the day of the resident’s ED visit. There were no concerns voiced by the resident and no change to the resident’s health noted during the visits. Both notes indicated skin assessments were completed. During an interview, the provider stated she became aware the resident had not been taking Eliquis while reviewing the resident’s medical record during a visit. The provider contacted the family and discussed the risks and benefits of this medication. Family discussed the Eliquis with the resident, and they decided to not resume it. Regarding the pressure ulcer, the provider stated it had been a chronic issue but had been improving the month the resident passed away. During an interview, the nurse stated the medication had not been available from the pharmacy, so she followed the facility process of holding the Eliquis until family paid for it, or it became available. The facility also received notification from the pharmacy regarding the high cost of Eliquis. The nurse stated addressing the medication issue would have been a coordination between the provider, the family and resident, and there had been multiple communications between them. The family and resident were going to decide whether to resume the Eliquis or not. During an interview, the family member stated he had not been aware of the medication being held until he reviewed a pharmacy invoice, which did not include Eliquis. Over the course of four days, he emailed facility staff multiple times, seeking clarification on the Eliquis before a nurse finally responded. The family member believed he should have been contacted sooner. The family member spoke to the resident the day before she went to the emergency department. He thought she seemed very tired but did not recall anything being wrong. Regarding the pressure ulcer, the family member stated she had been getting treated for a while. 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 sent the resident to the emergency department in a timely manner. 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: 08/14/2023 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 _____________________________ 35621 06/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5200 WAYZATA BOULEVARD GLOBAL POINTE SENIOR LIVING GOLDEN VALLEY, MN 55416 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 CORRECTION using federal software. Tag numbers have ORDER been assigned to Minnesota State Statutes for Assisted Living Facilities. The In accordance with Minnesota Statutes, section assigned tag number appears in the far 144G.08 to 144G.95, these correction orders are left column entitled "ID Prefix Tag." The issued pursuant to a complaint investigation. state Statute number and the Determination of whether a violation is corrected corresponding text of the state Statute out requires compliance with all requirements of compliance is listedin the "Summary provided at the statute number indicated below. Statement of Deficiencies" column.

correction orders issued pursuant to the July 7, 2023 survey. In accordance with Minn. Stat. § 144G.31 Subd. 4 (a), state correction orders issued pursuant to the last survey completed on July 7, 2023, found not corrected at the time of the September 6, 2023, follow-up survey and/or subject to penalty assessment are as follows: 1290 - Background Studies Required - 144g.60 Subdivision 1 - $3,000.00 2310 - Appropriate Care And Services - 144g.91 Subd. 4 (a) - $3,000.00 Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, t he total amount you are assessed is $6,000.00. 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. IMPOSITION OF FINES: 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 §144 G.20. An equal opportunity employer. Letter ID: 8GKP Revised 04/14/2023 Globa lPointe Senior Living Septembe r8, 2023 Page 2 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 the MDH within 15 calendar days of the correction order receipt date. A state correction order under Minn. Stat. § 144G.91, Subd. 8, Free from Maltreatment is associated with a maltreatment determination by the Office of Health Facility Complaints. If maltreatment is substantiated, you will receive a separate letter with the reconsideration process under Minn. Stat. § 626.557. Please email reconsideration requests to: Health.HRD.Appeals@state.mn.us. Please attach this letter as part of your reconsideration request. Please clearly indicate which tag(s) you are contesting and submit information supporting your position(s). Please address your cover letter for reconsideration requests to: Reconsideration Unit 85 East Seventh Place St. Paul, MN 55164-0970 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 MDH 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. Requests for hearing may be emailed to: Health.HRD.Appeals@state.mn.us. 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. We urge you to review these orders carefully. If you have questions, please contact Casey DeVries at Globa lPointe Senior Living Septembe r8, 2023 Page 3 You are encouraged to retain this document for your records. It is your responsibility to share the information contained in the letter and/or state form with your organization’s Governing Body. Sincerely, Casey DeVries, Supervisor State Evaluation Team Email: casey.devries@state.mn.us Telephone: 651-201-5917 Fax: 6 51-281-9796 JMD PRINTED: 09/08/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ R B. WING _____________________________ 35621 09/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5200 WAYZATA BOULEVARD GLOBAL POINTE SENIOR LIVING GOLDEN VALLEY, MN 55416 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 been assigned to Minnesota State Statutes for Assisted Living License In accordance with Minnesota Statutes, section Providers. The assigned tag number 144G.08 to 144G.95 this correction order(s) has appears in the far-left column entitled "ID been issued pursuant to a survey. Prefix Tag." The state Statute number and the corresponding text of the state Statute Determination of whether a violation has been out of compliance is listed in the corrected requires compliance with all "Summary Statement of Deficiencies" requirements provided at the Statute number column. This column also includes the indicated below. When Minnesota Statute findings which are in violation of the state contains several items, failure to comply with any requirement after the statement, "This of the items will be considered lack of Minnesota requirement is not met as compliance. evidenced by." Following the surveyors' findings is the Time Period for Correction. INITIAL COMMENTS: SL35621015-1 PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On September 5, 2023, to September 6, 2023, STATES,"PROVIDER'S PLAN OF the Minnesota Department of Health conducted a CORRECTION." THIS APPLIES TO revisit at the above provider to follow-up on FEDERAL DEFICIENCIES ONLY. THIS orders issued pursuant to a survey completed on WILL APPEAR ON EACH PAGE. June 7, 2023. At the time of the survey, there were 91 residents: 53 of whom were receiving THERE IS NO REQUIREMENT TO services under the Assisted Living (with Dementia SUBMIT A PLAN OF CORRECTION FOR Care) license. As a result of the revisit, the VIOLATIONS OF MINNESOTA STATE following orders were reissued and/or issued. STATUTES. The letter in the left column is used for tracking purposes and reflects the scope and level issued pursuant to 144G.31 subd. 1, 2, and 3. {0 650} 144G.42 Subd. 8 Employee records {0 650} SS=F (a) The facility must maintain current records of each paid employee, each regularly scheduled LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 UREL12 If continuation sheet 1 of 17 PRINTED: 09/08/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ R B. WING _____________________________ 35621 09/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5200 WAYZATA BOULEVARD GLOBAL POINTE SENIOR LIVING GOLDEN VALLEY, MN 55416 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) {0 650} Continued From page 1 {0 650} volunteer providing services, and each individual contractor providing services. The records must include the following information: (1) evidence of current professional licensure, registration, or certification if licensure, registration, or certification is required by this chapter or rules; (2) records of orientation, required annual training and infection control training, and competency evaluations; (3) current job description, including qualifications, responsibilities, and identification of staff persons providing supervision; (4) documentation of annual performance reviews that identify areas of improvement needed and training needs; (5) for individuals providing assisted living services, verification that required health screenings under subdivision 9 have taken place and the dates of those screenings; and (6) documentation of the background study as required under section 144.057. This MN Requirement is not met as evidenced by: No further action required. {0 660} 144G.42 Subd. 9 Tuberculosis prevention and {0 660} SS=F control (a) The facility must establish and maintain a comprehensive tuberculosis infection control program according to the most current tuberculosis infection control guidelines issued by the United States Centers for Disease Control and Prevention (CDC), Division of Tuberculosis Elimination, as published in the CDC's Morbidity and Mortality Weekly Report. The program must include a tuberculosis infection control plan that STATE FORM 6899 UREL12 If continuation sheet 2 of 17 PRINTED: 09/08/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ R B.