Elderwood of Hinckley.

correction orders issued pursuant to the August 27, 2025 . The Department of Health concludes the licensee is in substantial compliance. State law requires the facility must take action to correct the state 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. In accordance with Minn. Stat. § 144G.31 Subd. 4 (a), state correction orders issued pursuant to the last survey, completed on August 27, 2025, found not corrected at the time of the December 3, 2025, follow-up survey and/ or subject to penalty assessment are as follows: 0775-Fire Protection And Physical Environment- 144g.45 Subd. 2. (a) - $500.00 The details of the violations noted at the time of this follow-up survey completed on December 3, 2025 (listed above) , are on the attached State Form. Brackets around the ID Prefix Tag in the left hand column, e.g., {2 ----} will identify the uncorrected tags. 500.00Also, at the time of this follow-up survey completed on December 3, 2025, we identified the following violation(s): 0830-Local Laws Apply-144g.45 Subd. 3 The details of the violation(s) noted at the time of this follow-up survey are delineated on the attached State Form. Only the ID Prefix Tag in the left hand column without brackets will identify these state correction orders. It is not necessary to develop a plan of correction. The refor e, in accor danc e wit h Minn. Sta t. §§ 144G.01 to 144G.999 9, the total amount you are An equal opportunity employer. Letter ID: 8GKP Revised 04/14/2023 Elderwood of Hinckley December 22, 2025 Page 2 assessed is $500.00. You will be invoiced approximately 30 days after receipt of this notice, subject to appeal . DOCUMENTATIO ONF ACTION TO COMPLY In accorda nce with Min n. Stat. § 144G.30, Sub d. 5(c), th e lic ens ee mus t docum ent ac tions taken t o comply with the correction orders outlined on the state form; however, plans of correction are not required to be submitted for approval. IMPOSITION OF FINES In accordance with Minn. Stat. § 144G.31, Subd. 4, fines and enforcement actions may be imposed based on the level and scope of the violations and may be imposed immediately with no opportunity to correct the violation first as follows: Level 1: no fines or enforcement; Level 2: a fine of $500 per violation, in addition to any enforcement mechanism authorized in § 144G.20; Level 3: a fine of $1,000 per incident, in addition to any enforcement mechanism authorized in § 144G.20; Level 4: a fine of $3,000 per incident, in addition to any enforcement mechanism authorized in § 144G.20; Level 5: a fine of $5,000 per violation, in addition to any enforcement mechanism authorized in § 144G.20. CORRECTIO NORDER RECONSIDERATIO PNROCESS In accordance with Minn. Stat. § 144G.32, Subd. 2, you may challenge the correction order( s) issued, including the level and scope, and any fine assessed through the correction order reconsideration process. The request for reconsideration must be in writing and received by MDH within 15 calendar days of the correction order receipt date. To submit a reconsideration request, please visit: https: / / forms. web. health. state. mn.us/ form/ HRDAppealsForm REQUESTIN GA HEARING Alternatively, in accordance with Minn. Stat. § 144G.31, Subd. 5(d), an assisted living provider that has been assessed a fine under this subdivision has a right to a reconsideration or a hearing under this section and chapter 14. Pursuant to Minn. Stat. § 144G.20, Subd. 14 and Subd. 18, a request for a hearing must be in writing and received by the Department of Health within 15 business days of the correction order receipt date. The request must contain a brief and plain statement describing each matter or issue contested and any new information you believe constitutes a defense or mitigating factor. To submit a hearing request, please visit: https: / / forms. web. health. state. mn. us/ form/ HRDAppealsForm Elderwood of Hinckley December 22, 2025 Page 3 To appe al fi nes via re cons iderat ion , pl ease follow the procedu r e outl ined abo ve. Plea se no te tha t you may re que st a rec onside rati on or a hearing, bu t not bot h. If you wish to cont est ta gs with out fine s in a reconsideration and tags with the fines at a hearing, please submit two separate appeals forms at the website listed above. We urge you to review these orders carefully. If you have questions, please contact Stephanie Jones de Palma at 651-201-4320. 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, Stephanie Jones de Palma, Supervisor State Engineering Services Section Email: stephanie. jones. de. palma@state. mn.us Telephone: 651-201-4320 Fax: 1-866-890-9290 HHH PRINTED: 12/ 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: ______________________ R B. WING _____________________________ 23986 12/ 03/ 2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 710 SPRING LANE ELDERWOOD OF HINCKLEY HINCKLEY, MN 55037 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 FOLLOW UP using federal software. Tag numbers have SURVEY WITH RE- ISSUE AND ISSUE OF been assigned to Minnesota State ORDERS Statutes for Assisted Living Facilities. The assigned tag number appears in the INITIAL COMMENTS far-left column entitled "ID Prefix Tag. " The state Statute number and the SL23986016- 1 corresponding text of the state Statute out of compliance is listed in the "Summary From November 24, 2025, through December 3, Statement of Deficiencies" column. This 202 , the Minnesota Department of Health column also includes the findings which conducted a follow-up survey at the above are in violation of the state requirement provider to follow-up on orders issued pursuant to after the statement, "This Minnesota a survey completed on August 27, 2025. At the requirement is not met as evidenced by." time of the survey, there were 35 residents; 35 Following the evaluators ' findings is the receiving services under the Assisted Living with Time Period for Correction. Dementia Care license. As a result of the follow-up survey, the following orders were issued PLEASE DISREGARD THE HEADING OF and reissued. THE FOURTH COLUMN WHICH STATES, "PROVIDER' S PLAN OF CORRECTION. " THIS APPLIES TO 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. {0 470} 144G. 41 Subdivision 1 Minimum requirements {0 470} SS= F (11) develop and implement a staffing plan for LABORATORY DIRECTOR' S OR PROVIDER/ SUPPLIER REPRESENTATIVE' S SIGNATURE TITLE (X6) DATE STATE FORM 6899 YR1S12 If continuation sheet 1 of 17 PRINTED: 12/ 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: ______________________ R B.

Finding: Not Substantiated Nature of Investigation: The Minnesota Department of Health investigated an allegation of maltreatment, in accordance with the Minnesota Reporting of Maltreatment of Vulnerable Adults Act, Minn. Stat. 626.557, and to evaluate compliance with applicable licensing standards for the provider type. Initial Investigation Allegation(s): Facility staff neglected a resident when staff failed to ensure the resident received oxygen as prescribed for two days causing the resident to become unresponsive and require hospitalization for low oxygen levels. In addition, staff failed to ensure the resident received her prescribed medications; failed to ensure the resident received physical and occupational therapy as prescribed; and failed to provide appropriate supervision to prevent the resident from eloping from the facility. Unknown facility staff abused the resident when the staff person grabbed the resident’s arm and yelled at her. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. Facility staff noticed a change in the resident’s condition, assessed the resident, and arranged for the resident to be evaluated at a hospital. The resident’s medication order included Methadone An equal opportunity employer. (opioid narcotic pain medication) three times a day. Although there was a delay with the pharmacy obtaining the medication, facility staff provided another as needed (Oxycodone) opioid pain medication for the resident. The resident’s record indicated the resident received physical and occupational therapy as ordered. There was no evidence the resident eloped from the facility. The Minnesota Department of Health determined abuse was not substantiated. There was no evidence an unknown alleged perpetrator yelled and/or grabbed the arm of the resident. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted the resident’s care coordinator and family member. The investigation included review of the resident’s medical record, hospital records, medication records, facility narcotic count record, facility schedules, death certificate, incident reports, and policies and procedures. Also, the investigator made an onsite visit to the facility. The resident resided in an assisted living memory care unit. The resident’s diagnoses included spasmodic torticollis (a painful condition where the neck muscles contract involuntarily, causing the head to twist or turn to one side), schizoaffective disorder, and chronic obstructive pulmonary disease (COPD). The resident’s service plan included assistance with medication management and oxygen management. The resident’s assessment indicated the resident required continuous oxygen, had difficulty with eating and swallowing due to spasmodic torticollis, used a wheeled walker for walking, and had chronic pain. The resident’s assessment indicated the resident was alert and oriented and made her own decisions. The residents care plan directed staff to check the resident’s oxygen saturation daily and to report to a nurse an oxygen saturation lower than 90%. A progress note indicated one day over a two-hour period, the resident continued to shut off her oxygen concentrator and liquid oxygen tank despite staff checking on the resident every 10 to 15 minutes and providing the oxygen. Early the same afternoon after completing the resident’s nebulizer (breathing) treatment the resident’s oxygen saturation was low at 71%, the resident was confused, and short of breath. Facility staff arranged for the resident to be evaluated at a hospital. The hospital record indicated the resident arrived at the emergency room with confusion, rapid heart rate, and rapid breathing. The resident required eight liters of oxygen and the resident’s laboratory values indicated oxygen saturation was 75% (normal range 95-100%). The resident was transferred to a hospital that provided a higher level and care. The resident’s diagnoses included COPD exacerbation (a sudden worsening of respiratory symptoms.) Nine days later the resident passed away. During an interview, unlicensed staff member (ULP) stated the day the resident was sent to the hospital the facility staff found the resident’s concentrator shut off three separate times over the course of 20 minutes. Leadership was notified, and the resident was sent to the hospital because her oxygen saturation was low. During an interview, another ULP stated the day the resident was sent to the hospital, the resident kept shutting off her oxygen. The resident was drooling and pale. The ULP stated staff checked on the resident frequently. During an interview, the nurse stated the resident was at risk for pneumonia because of the anatomy of the resident’s neck and the way her head tipped off to one side. The resident used oxygen continuously and had both an oxygen concentrator (took air from your surroundings, extract oxygen and filter it into purified oxygen for you to breathe) and portable oxygen tanks. The nurse stated the resident missed two days of the Methadone because the pharmacy needed a new prescription from the physician. The nurse also stated the resident worked with an outside therapy agency for physical and occupational therapy. The nurse stated the resident did not report concerns of abuse. During an interview, leadership stated the resident was alert and oriented. The resident had a history of adjusting the oxygen concentrator on her own. The resident was not a wander risk and liked to be outside by the garden. Leadership stated they routinely checked with the resident and no concerns with medication management, wandering, or abuse was reported. Review of the resident’s certificate of death indicated the resident passed away due to respiratory failure due to COPD. In conclusion, the Minnesota Department of Health determined abuse and 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. Abuse: Minnesota Statutes section 626.5572, subdivision 2. "Abuse" means: (a) An act against a vulnerable adult that constitutes a violation of, an attempt to violate, or aiding and abetting a violation of: (1) assault in the first through fifth degrees as defined in sections 609.221 to 609.224; (2) the use of drugs to injure or facilitate crime as defined in section 609.235; (3) the solicitation, inducement, and promotion of prostitution as defined in section 609.322; and (4) criminal sexual conduct in the first through fifth degrees as defined in sections 609.342 to 609.3451. A violation includes any action that meets the elements of the crime, regardless of whether there is a criminal proceeding or conviction. (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. The resident was deceased. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Not Applicable. Action taken by facility: The resident was sent to the hospital. 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: 12/26/2023 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 _____________________________ 23986 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 710 SPRING LANE ELDERWOOD OF HINCKLEY HINCKLEY, MN 55037 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 September 20, 2023, the Minnesota Department of Health initiated an investigation of complaint HL239867524M/ HL239864075C and HL239868285M/HL239865464C . No correction orders are issued.