Lindstrom Senior Living.

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; 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. An equal opportunity employer. Letter ID: IS7N REVISED 09/13/2021 Lindstrom Senior Living September 22, 2025 Page 2 Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, the following fines are assessed pursuant to this survey: St - 0 - 0775 - 144g.45 Subd. 2. (a) - Fire Protection And Physical Environment - $500.00 St - 0 - 1290 - 144g.60 Subdivision 1 - Background Studies Required - $1,000.00 Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, t he total amount you are assessed is $1,500.00. 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. To submit a hearing request, please visit: https://forms.web.health.state.mn.us/form/HRDAppealsForm Lindstrom Senior Living September 22, 2025 Page 3 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, Kelly Thorson, Supervisor State Evaluation Team Email: Kelly.Thorson@state.mn.us Telephone: 320-223-7336 Fax: 1-866-890-9290 AH PRINTED: 09/22/2025 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 _____________________________ 37816 08/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 30455 LEHIGH AVENUE LINDSTROM SENIOR LIVING LINDSTROM, MN 55045 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 Licensing ASSISTED LIVING PROVIDER LICENSING Correction Orders using federal software. CORRECTION ORDER(S) Tag numbers have been assigned to Minnesota State Statutes for Assisted In accordance with Minnesota Statutes, section Living License Providers. The assigned 144G.08 to 144G.95, these correction orders are tag number appears in the far-left column issued pursuant to a survey. entitled "ID Prefix Tag." The state Statute number and the corresponding text of the Determination of whether violations are corrected state Statute out of compliance is listed in requires compliance with all requirements the "Summary Statement of Deficiencies" provided at the Statute number indicated below. column. This column also includes the When Minnesota Statute contains several items, findings which are in violation of the state failure to comply with any of the items will be requirement after the statement, "This considered lack of compliance. Minnesota requirement is not met as evidenced by." Following the surveyors' INITIAL COMMENTS: findings is the Time Period for Correction. SL37816016 PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On August 4, 2025, through August 6, 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 were 87 residents; 82 receiving services under the Assisted Living Facility with THERE IS NO REQUIREMENT TO 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 subd. 1, 2, and 3. 0 630 144G.42 Subd. 6 (b) Compliance with 0 630 SS=D requirements for reporting ma (b) The facility must develop and implement an LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 GMGY11 If continuation sheet 1 of 17 PRINTED: 09/22/2025 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 _____________________________ 37816 08/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 30455 LEHIGH AVENUE LINDSTROM SENIOR LIVING LINDSTROM, MN 55045 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) 0 630 Continued From page 1 0 630 individual abuse prevention plan for each vulnerable adult. The plan shall contain an individualized review or assessment of the person's susceptibility to abuse by another individual, including other vulnerable adults; the person's risk of abusing other vulnerable adults; and statements of the specific measures to be taken to minimize the risk of abuse to that person and other vulnerable adults. For purposes of the abuse prevention plan, abuse includes self-abuse.

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 staff failed to administer the resident’s pain medication according to the physician orders resulting in unrelieved pain. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. Although the facility ran out of Morphine (opioid narcotic) for the resident, the contracted hospice services was responsible for the supply of the resident’s Morphine. Facility staff requested a refill of the resident’s Morphine from hospice approximately 10 hours prior to running out of the medication, however, there was confusion between pharmacies leaving the resident without Morphine for approximately 11 to 12 hours. Hospice arranged for the resident to receive hydromorphone (opioid narcotic) approximately four hours after running out of the Morphine supply. During that time, the resident was calm, unresponsive, and displayed no signs of pain. The investigator conducted interviews with facility staff members, including nursing staff, and unlicensed staff. The investigator contacted the resident’s family member and a hospice nurse. The investigation included review of the resident records, death record, hospice records, pharmacy records, staff schedules, and related facility policy and procedures. Also, the investigator observed staff interactions with residents at the facility. The resident resided in an assisted living memory care unit. The resident’s diagnoses included Alzheimer’s disease and osteomyelitis (bone infection) of the right ankle and foot. The resident’s service plan included assistance with dressing, assistance with repositioning in bed, and medication administration. The resident’s assessment indicated the resident needed one staff member to assist with activities of daily living and had severe cognitive impairment. The resident received hospice for end of life and comfort care. The resident’s assessment indicated the resident denied having pain. Review of the resident’s medication administration record indicated on the day of the incident, the resident was to receive Morphine 5 milligrams (four tablets for a total of 20 milligrams) every hour, sublingual (under the tongue) and four tablets every one hour as needed for pain and shortness of breath. In addition, the resident received Fentanyl (opioid narcotic for severe pain) patch 100 micrograms, apply two patches every 72 hours, and Lorazepam (anti-anxiety medication) 0.5 milligrams sublingual, two tablets every hour and two tablets every hour as needed for terminal agitation. The medication administration record indicated the resident did not receive Morphine for approximately 11 to 12 hours after the facility ran out of Morphine. Hospice coordination notes indicated a facility staff member notified the hospice triage nurse to request a refill of Morphine, the night before the resident’s Morphine medication ran out. The next morning a different facility staff member notified hospice triage that the resident’s Morphine medication needed to be refilled. Hospice triage made the refill request to a pharmacy that was unable to fill the prescription. The hospice coordination notes indicated the hospice triage contacted a different pharmacy to refill the Morphine medication and that the refill would take two to four hours to be delivered to the facility. The hospice triage nurse then contacted a third pharmacy to have Dilaudid (opioid narcotic) eight milligrams every hour for pain, an alternate medication for Morphine, filled for the resident’s pain. Because of time required to deliver the Dilaudid to the facility from the pharmacy, hospice staff arranged for the resident’s family member to pick up the Dilaudid from the pharmacy. Approximately four hours after running out of Morphine medication, the resident received a dose of Dilaudid. During an interview, unlicensed staff member stated the night prior to the resident passing away, licensed staff contacted hospice to have the resident’s Morphine medication refilled. The following evening, the unlicensed staff member stated when they arrived at the facility, they were told the Morphine medication had not arrived from the pharmacy. The unlicensed staff member stated the family received a different medication from a pharmacy and was administering it to the resident. The unlicensed staff member stated a call to hospice was placed again to check on the delivery of the Morphine medication. The Morphine medication arrived two hours after calling, and the resident received two doses prior to passing away. During an interview, another unlicensed staff member stated the day the resident passed away, the resident ran out of Morphine. The unlicensed staff member stated facility licensed staff notified hospice of the resident not having any available Morphine. The hospice agency stated they were attempting to get more Morphine delivered for the resident. The unlicensed staff member stated the resident had other medications for pain control and comfort. The resident appeared to be comfortable and would only moan out when repositioned but calmed immediately after care was completed. During an interview, a hospice nurse stated the resident received hospice cares for end-of-life comfort and wound care. The resident used Morphine every one hour for pain. The hospice nurse stated to refill a medication the order would be sent to a physician, the physician signed for it, the order was then sent to the pharmacy, and the pharmacy filled and delivered the medication. The hospice nurse stated the evening the resident passed away, the resident was comfortable and unresponsive to facility staff. During an interview, a facility nurse stated the facility collaborated when hospice ordered medications between the facility, hospice, and pharmacy to ensure the resident received the right medication. The day the resident ran out of Morphine, facility staff had contacted hospice to have the Morphine refilled. The facility nurse stated usually medications arrived from pharmacy within four hours. The Dilaudid medication was ordered for the resident until the Morphine medication arrived at the facility. The resident had other pain medications and the resident’s Fentanyl patch was increased the day prior to passing away. During an interview, a family member stated the day the resident ran out of Morphine medication, they went to a pharmacy and picked up the Dilaudid medication that was ordered. The family member stated the Morphine medication arrived at the facility shortly before the resident passed away. In conclusion, the Minnesota Department of Health determined neglect was not substantiated. “Not Substantiated” means: An investigatory conclusion indicating the preponderance of evidence shows that an act meeting the definition of maltreatment did not occur. Neglect: Minnesota Statutes, section 626.5572, subdivision 17 “Neglect” means neglect by a caregiver or self-neglect. (a) "Caregiver neglect" means the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to, food, clothing, shelter, health care, or supervision which is: (1) reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult; and (2) which is not the result of an accident or therapeutic conduct. Vulnerable Adult interviewed: No. The resident was deceased. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Not Applicable. the Action taken by facility: The facility staff contacted the hospice agency for the Morphine medication to be refilled. 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: 12/09/2024 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 _____________________________ 37816 11/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 30455 LEHIGH AVENUE LINDSTROM SENIOR LIVING LINDSTROM, MN 55045 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 November 4, 2024, the Minnesota Department of Health initiated an investigation of complaint #HL378166404M / #HL378169554C. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 Z2X311 If continuation sheet 1 of 1

STATE LICENSING COMPLIANCE REPORT Report #: HL378167521C Date Concluded: October 15, 2024 Name, Address, and County of Facility Investigated: Lindstrom Senior Living 30455 Lehigh Ave Lindstrom, MN 55045 Chisago county Facility Type: Assisted Living Facility with Evaluator’s Name: Deb Schillinger RN BSN, 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, 144G (ALL). 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 651-201-4201 to be provided a copy via mail or email. If you are viewing this report on the MDH website, please see the attached state form. PRINTED: 10/16/2024 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 _____________________________ 37816 10/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 30455 LEHIGH AVENUE LINDSTROM SENIOR LIVING LINDSTROM, MN 55045 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 October 10, 2024, the Minnesota Department of Health initiated an investigation of complaint #HL378167521C. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 JELL11 If continuation sheet 1 of 1