Volante of Hanover.

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 a resident when they failed to provide health care, medications, and services to address the resident’s changing health status. As a result, the resident had multiple falls. One fall resulted in the resident laying on the floor for five hours. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was inconclusive. The resident developed a systemic rash (whole body) and physician’s discontinued various medications to determine the cause of the rash. Although the facility failed to discontinue medications accurately, it was not likely these medication errors contributed to the resident falling. The resident had multiple chronic medical diagnoses which effected the resident’s gait (walking) and balance. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigation included review of the resident records, pharmacy records, facility internal investigation, facility incident reports, personnel files, and related facility policy and procedures. Also, the investigator toured the facility and observed medication administration. The resident resided in an assisted living memory care unit. The resident’s diagnoses included Alzheimer’s disease, meningioma (brain tumor), kidney failure, and diabetes. The resident’s service plan included assistance with medication management. The resident’s nursing assessment indicated the resident had severe memory loss and required frequent redirection from staff members. The nursing assessment indicated the resident was at risk for falling because she had a history of falling and her diagnoses included seizures and a brain tumor. Progress notes indicated the resident’s neck and chest was “red” when she admitted into the facility because she received radiation treatment for a brain tumor. Progress notes indicated the resident began to scratch at her skin and had a few open wounds. Approximately one week later, progress notes indicated the resident’s rash was all over her body. The resident had blisters, and swelling of her lower limbs. Progress notes indicated the resident went to the emergency room (ER) and returned to the facility with physician orders for new medications and an order to discontinue (stop) taking the medication Lexapro (medication used to treat depression and anxiety). Physician visit records indicated the resident’s family contacted them through a message portal system six days later because the resident’s rash had not improved since the physicians discontinued the Lexapro. The records indicated the physician wanted to discontinue another medication called Depakote (used to prevent seizures and treat mood disorders). Medication administration records (MAR) indicated the facility did not discontinue medications Lexapro and Depakote when ordered by the physician; the resident remained on those medications. Facility Incident reports indicated the resident fell five times within the same month. The resident fell twice in one day which resulted in hospitalization. Progress notes written by the nurse indicated staff members found the resident on the floor in her room around 7:30 a.m. The progress notes indicated staff members who worked the night shift offered the resident help to get to the bathroom, however she declined. They went back into the room to check on her and saw a “scrape” on her nose. The resident denied falling. The progress notes indicated the nurse observed the resident “crossing over” her feet as she walked which caused her to be unsteady. The progress notes indicated this behavior had occurred before, so the nurse told staff members to walk with the resident The progress notes lacked indication between the time staff members offered the resident assistance to the bathroom to the time they found her. There were no further progress notes regarding the resident’s fall in the evening, however the nurse completed an incident report, the same day, later in the evening. Facility incident report indicated the resident fell in the evening at 6:30 p.m., in her bathroom and sustained a cut to the back of her head. Staff members sent the resident to the ER. The incident report indicated the resident had improper shoes on at the time of the fall. Hospital records indicated physicians diagnosed the resident with major neurocognitive disorder due to Alzheimer disease, with behavior disturbance, acute delirium (sudden change in memory), and cognitive decline. Hospital records indicated the resident had a rapid mental decline and weakness of the right side of her body. The records indicated the resident’s brain tumor contributed to her memory decline and poor balance. Physicians ordered hospice care (end of life) for the resident due to her rapid cognitive decline, and weakness. Medical examiner records indicated the resident died approximately one month later from dementia (brain disease). During an interview, a nurse said the resident had multiple health issues including a brain tumor. The nurse said the resident had memory problems, psychosis (delusions/hallucinations), exit seeking behaviors, and aggression. The nurse said the resident’s behaviors occurred more frequently during the evening. The nurse said staff members who worked with the resident during the night called her and told her the resident fell so she went to the facility. The nurse said there was miscommunication between the two shifts of staff members about what occurred. The nurse said she interviewed the staff members when she arrived, called the resident’s family, and physician. The nurse said she no longer worked at the facility and could not remember details about the resident’s falls, but said her documentation about the falls was accurate. The nurse said there were multiple leadership team members who completed the investigation into the resident’s falls. Both staff members working at the time of the fall failed to respond to request for interviews. During an interview, a manager said the resident’s family member told him they were concerned the resident was on the floor for an extended period. The manger said both staff members who worked at the time told him they were in a room right next to the resident’s room, and they responded timely. The manager said there were no cameras in the resident’s room and cameras outside the resident’s room did not show anything significant. During an interview, a family member said a staff member called her in the morning and told her the resident fell. The family member said she arrived at the facility, prior to the nurse, and saw the resident on the floor with dried blood on her face. The family member said staff members were trying to get her into a chair. The family member said a staff member told her there was a pillow and blanket with the resident at the time they found her on the floor. The family member said she did not see the pillow and blanket at the time she arrived. The family member said once the resident was up, she stayed with her at the facility for the morning. The family member said later in the evening the facility called her and told her the resident fell again so they sent her to the ER. The family member said the resident admitted into the hospital for medical evaluation. The family member said the resident stayed in the hospital for approximately one week and discharged to a different facility. The family member said the resident was no longer able to walk when she discharged from the hospital. In conclusion, the Minnesota Department of Health determined neglect was inconclusive. “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. the Action taken by facility: The facility provided dementia training for staff members. Action taken by the Minnesota Department of Health: No further action taken at this time.

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 necessar yto ensure the health, safety, and welfare of residents in your care. STATE CORRECTIO ONRDERS The enclosed State Form documents the state correction orders. The Department of Health documents state correction orders using federal software. Tag numbers are assigned to Minnesota state statutes for Home Care Providers .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 Requiremen tis not met as evidenced by . . ." In accordance with Minn. Stat. § 144G3. 1 Subd .4, MDH may asses sfines based on the level and scope of the violations; however, no immediate fines are assesse dfor this survey of your facility. DOCUMENTATIO ONF ACTION TO COMPLY Per Minn. Stat. § 144G3. 0, Subd .5(c), the licens ee must document acti ons ta ken to comply with the An equal opportunity employer. Letter ID: 9GJX Revise d04/20/2023 Volante of Hanover Septembe r25, 2025 Page 2 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: x Identify how the area(s) of noncompliance was corrected related to the resident(s)/ employee(s) identified in the correction order. x Identify how the area(s) of noncompliance was corrected for all of the provider’s residents/employees that may be affected by the noncompliance. x Identify what changes to your systems and practices were made to ensure compliance with the specific statute(s). CORRECTIO ONRDER RECONSIDERATI OPRNOCESS In accordance with Minn. Stat. § 144G3. 2, Subd .2, you may challenge the correction order issued, including the level and scope ,and any fine assesse dthrough the correction order reconsideration process .The request for reconsideration must be in writing and received by the Department of Health 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: https:/ / forms.office.com/g/ Bm5uQEpHV.a Your input is important to us and will enable MDH to improve its processe sand communication with providers . If you have any questions regarding the questionnaire ,please contact Susan Winkelmann at susanw. inkelmann@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 organizations’ Governing Body. If you have any questions ,please contact me. Sincerely, Jess Schoenecke rS, upervisor State Evaluation Team Email: JessS. choenecker@state.mn.us Telephone :651-201-3789 Fax :1-866-890-9290 Volante of Hanover Septembe r25, 2025 Page 3 AH PRINTED: 09/25/2025 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 _____________________________ 40633 07/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 10875 SETTLERS LANE, BUILDING 2 VOLANTE OF HANOVER HANOVER, MN 55341 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 ***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." issued pursuant to a survey. The 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. SL40633015-0 PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On July 14, 2025, through July 15, 2025, the STATES,"PROVIDER'S PLAN OF 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 was one (1) resident receiving services under the Provisional Assisted Living THERE IS NO REQUIREMENT TO Facility 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. 01880 144G.71 Subd. 19 Storage of medications 01880 SS=D LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 Z2WW11 If continuation sheet 1 of 6 PRINTED: 09/25/2025 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 _____________________________ 40633 07/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 10875 SETTLERS LANE, BUILDING 2 VOLANTE OF HANOVER HANOVER, MN 55341 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) 01880 Continued From page 1 01880 An assisted living facility must store all prescription medications in securely locked and substantially constructed compartments according to the manufacturer's directions and permit only authorized personnel to have access. This MN Requirement is not met as evidenced by: Based on observation, interview, and record review, the licensee failed to ensure medications were stored securely for one of one resident (R2) with medication management service. 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 July 15, 2025, at 9:45 a.m., during a tour of R2's private bathroom with clinical nurse supervisor (CNS)-C, the following over the counter (OTC) medications were noted unsecured and accessible by R2: - Pain relief cream (4% lidocaine HCl); - Anti-diarrheal (loperamide 2 milligram (mg) capsules); - Anti-Itch cream (diphenhydramine HCl 2% / Zinc Acetate 0.1%); - Murine Tears (Polyvinyl alcohol 5 mg/mL (milliliter) / Povidone 6 mg/mL) eye drops; - Refresh Relieva PF (Carboxymethylcellulose sodium - 0.5 % / Glycerin - 0.9 %) eye drops; STATE FORM 6899 Z2WW11 If continuation sheet 2 of 6 PRINTED: 09/25/2025 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 _____________________________ 40633 07/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 10875 SETTLERS LANE, BUILDING 2 VOLANTE OF HANOVER HANOVER, MN 55341 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) 01880 Continued From page 2 01880 - Hemorrhoidal Cream (glycerin 14.4% / phenylephrine HCl 0.25% / pramoxine HCl 1% / white petrolatum 15%); and - Hydrocortisone cream (hydrocortisone 1%). R2 was admitted on February 4, 2025.

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 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 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 An equal opportunity employer. Letter ID: IS7N REVISED 09/13/2021 Volante Of Hanover September 12, 2025 Page 2 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 To appeal fines via reconsideration, please follow the procedure outlined above. Please 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. INFORMAL CONFERENCE In accordance with Minn. Stat. § 144A.475, Subd. 8 OR Minn. Stat. § 144G.20, Subd. 20, the Commissioner of Health is authorized to hold a conference to exchange information, clarify issues, or resolve issues. The Department of Health staff would like to schedule a conference call with Volante of Hanover. Please contact Kelly Thorson at 320-223-7336 on or before M arch 7, 2025, to schedule the conference call. 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, Kelly Thorson, Supervisor State Evaluation Team Email: Kelly.Thorson@state.mn.us Telephone: 320-223-7336 Fax: 1-866-890-9290 HHH P r o t e c t i n g , M a i n t a i n i n g a n d I m p r o v i n g t h e H e a l t h o f A l l M i n n e s o t a n s Electronically Delivered September 10, 2025 Licensee Volante of Hanover 10875 Settlers Lane Hanover, MN 55341 RE: Project Number(s) SL32913016 Dear Licensee: On June 30, 2025, the Minnesota Department of Health completed a follow-up survey of your facility to determine correction of orders from the survey completed on January 24, 2025. This follow-up survey verified that the facility is in substantial compliance. You are encouraged to retain this document for your records. It is your responsibility to share the information contained in the letter with your organization’s Governing Body. Please feel free to call me with any questions. Sincerely, Kelly Thorson, Supervisor State Evaluation Team Email: Kelly.Thorson@state.mn.us Telephone: 320-223-7336 Fax: 1-866-890-9290 HHH An equal opportunity employer. P 709 HC Orders Corrected REVISED 04/19/2023 P r o t e c t i n g , M a i n t a i n i n g a n d I m p r o v i n g t h e H e a l t h o f A l l M i n n e s o t a n s Electronically Delivered March 4, 2025 Licensee Volante of Hanover 10875 Settlers Lane Hanover, MN 55341 RE: Project Number(s) SL32913016 Dear Licensee: The Minnesota Department of Health (MDH) completed a survey on January 24, 2025, for the purpose of evaluating and assessing compliance with state licensing statutes. At the time of the survey, MDH noted violations of the laws pursuant to Minnesota Statute, Chapter 144G, Minnesota Food Code, Minnesota Rules Chapter 4626, Minnesota Statute 626.5572 and/or Minnesota Statute Chapter 260E. 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 § 144G.20. Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, the following fines are assessed pursuant to this survey: An equal opportunity employer. Letter ID: IS7N REVISED 09/13/2021 Volante of Hanover March 4, 2025 Page 2 St - 0 - 1290 - 144g.60 Subdivision 1 - Background Studies Required - $3,000.00 Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, t he total amount you are assessed is $3,000.00. You will be invoiced approximately 30 days after receipt of this notice, subject to appeal. DOCUMENTATION OF ACTION TO COMPLY In accordance with Minn. Stat. § 144G.30, Subd. 5(c), the licensee must document actions taken to comply with the correction orders within the time period outlined on the state form; however, plans of correction are not required to be submitted for approval. The correction order documentation should include the following: Identify how the area(s) of noncompliance was corrected related to the resident(s)/employee(s) identified in the correction order. Identify how the area(s) of noncompliance was corrected for all of the provider’s resident(s)/employees that may be affected by the noncompliance. Identify what changes to your systems and practices were made to ensure compliance with the specific statute(s). CORRECTION ORDER RECONSIDERATION PROCESS In accordance with Minn. Stat. § 144G.32, Subd. 2, you may challenge the correction order(s) issued, including the level and scope, and any fine assessed through the correction order reconsideration process. The request for reconsideration must be in writing and received by MDH within 15 calendar days of the correction order receipt date. To submit a reconsideration request, please visit: https://forms.web.health.state.mn.us/form/HRDAppealsForm REQUESTING A HEARING Alternatively, in accordance with Minn. Stat. § 144G.31, Subd. 5(d), an assisted living provider that has been assessed a fine under this subdivision has a right to a reconsideration or a hearing under this section and chapter 14.