Lino Lakes Gw Llc.

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) neglected the resident when the resident did not receive medication according to physician orders and the resident was hospitalized. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. Although the resident received a different resident’s medications, the error was an isolated incident and the facility provided timely care in response to the error. The resident’s blood pressure and pulse decreased, and the resident was sent to the hospital. The resident required placement of a pacemaker, (a medical device that uses electrical pulses to regulate the heart's rhythm, correcting slow, fast, or irregular heartbeats by prompting the heart to contract and pump blood effectively). A physician stated the resident had a history of atrial fibrillation (an irregular heartbeat) and would have needed a pacemaker placed to ensure the heart rate was within normal range of 60 to 100 beats per minute. The investigator conducted interviews with facility staff members, including administrative staff, and unlicensed staff. The investigator contacted the physician. The investigation included review of the resident records, hospital records, facility internal investigation, facility incident reports, personnel files, staff schedules, and related facility policy and procedures. Also, the investigator made an unannounced visit and observed administration of medication. The resident resided in an assisted living memory care unit. The resident’s diagnoses included Alzheimer’s disease, dementia, atrial fibrillation, and bradycardia sinus (a slower than normal heartbeat, resulting in a heart rate below 60 beats per minute). The resident’s service plan included assistance with medication administration. The resident’s assessment indicated the resident had intact cognition and but was determined unable to safely self-administer medication because of dementia. The resident’s medical record indicated one evening the AP gave the resident another resident’s medications. After realizing the resident received the wrong medications, the AP obtained the resident’s vital signs. The AP called the on-call nurse and instructed to take the resident’s vital signs again after 30 minutes. The resident’s blood pressure and pulse decreased. The resident’s blood pressure was taken a third time. The resident’s blood pressure and pulse had decreased again and was no longer within normal range. The AP called emergency medical services and the resident was taken to the hospital. Hospital records indicated the resident had a slow heart rate and medications were adjusted. The resident was hospitalized for three days and sent back to the facility. That same day the resident was sent back to the hospital because of tachy-brady syndrome (a heart rhythm disorder where the heart alternates between beating too fast and too slow). The resident had a pacemaker placed and returned to the facility after three days. During an interview, a physician stated the resident had a history of atrial fibrillation and was on medications that slowed his heart rate down. During the medication error the resident received three medications that lowered his blood pressure, which may have affected the resident’s heart rate. The physician stated the resident did not receive the pacemaker because of the wrong medications. The resident was likely going to need a pacemaker placed because of atrial fibrillation. During an interview, the AP stated there was confusion between two residents when the error occurred. The AP identified the error as the resident swallowed the medications. The on-call nurse, leadership, and the resident were alerted of the medication error. The AP stated she never had made a medication error before. During an interview, leadership stated the AP was educated on the medication error and was removed from administering medications. The AP would receive medication administration training if she administered medications again. During an interview, a family member stated the facility assisted with medication administration along with other activities of daily living. The family member was notified of the medication error and stated the resident had a heart problem prior to the medication error and had been seen by a cardiologist. 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: Yes. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Yes. Action taken by facility: Following the medication error, the resident’s vital signs were monitored, and the resident was sent to the hospital. The AP was educated on the medication error and the facility’s medication administration policy and was removed from medication administration. 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: 01/ 21/ 2026 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 _____________________________ 31761 01/ 06/ 2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 675 MARKET PLACE DRIVE LINO LAKES GW LLC LINO LAKES, MN 55014 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 January 6, 2026, the Minnesota Department of Health initiated an investigation of complaint HL317617202M/ HL317616762C. No correction orders are issued. LABORATORY DIRECTOR' S OR PROVIDER/ SUPPLIER REPRESENTATIVE' S SIGNATURE TITLE (X6) DATE STATE FORM 6899 TJ0F11 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, after multiple falls and injuries, the facility did not develop interventions to prevent future falls. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. Although the resident had multiple falls, facility staff reported, assessed, monitored, treated and developed post-fall preventative measures after each fall reviewed. The resident’s providers and family were notified of each fall. The investigator conducted interviews with facility staff members, including administrative, nursing and unlicensed staff. The investigator contacted the resident’s hospice agency. The investigation included review of the resident record(s), death record, hospice records, facility incident reports, personnel files, related facility policy and procedures. Also, the investigator observed the facility physical plant, medication administrations, treatment administrations, cares given to the residents and staff interactions. The resident resided in assisted living memory care unit. The resident’s diagnoses included Parkinson’s Disease, vascular dementia, orthostatic hypotension and chronic kidney disease. The resident’s service plan included daily assistance with transfers, mobility, safety checks, toileting. The resident’s assessment indicated the resident was alert and orient to person only, with forgetfulness, confusion, memory loss including poor decision-making skills. The resident’s assessment indicated the resident had a history of behaviors that included resistance to cares, taking medication and physical aggression. The assessment also indicated the resident had a history of falls. The resident’s medical records indicted the resident had several falls in a six-month period reviewed. Following each fall facility staff assessed the resident then report their findings to the nurse, who instructed staff on a plan to monitor and treat the resident. Subsequently, facility administrative staff completed a post-fall review for each fall then developed and initiated updated fall prevention interventions. The resident’s medical records indicated a couple of the resident’s falls resulted in a head strike, but the resident’s family decided not to transport the resident to the hospital for evaluation. The resident’s medical records indicated facility staff assessed, monitored and treated the resident’s head injury per family request. The resident’s medical records indicated the resident received hospice services during the time reviewed for the multiple falls. The resident’s hospice agency provided additional assessment, monitoring, treatment and input on updated post-fall preventions. The resident’s medical records indicated the resident had a last unwitnessed fall that resulted in the resident reopening an old wound on the right eyebrow, a new skin tear on the left elbow, both of which were reported, assessed and treated. The next four days the resident’s condition declined when the resident did not eat, became lethargic, had increased pain, restlessness and a slight fever. The hospice agency nurse adjusted the resident’s comfort medications throughout the four days and instructed facility staff to monitor the resident’s temperature every shift. The fifth day after the resident’s fall, the resident died. During an interview, an unlicensed staff stated the resident fell a lot after he would attempt to transfer by himself. The unlicensed staff recalled it being difficult to prevent the falls as the resident walked around a lot and staff could not observe the resident one hundred percent of the time. During an interview, facility nurse #1 stated the resident’s provider would be notified of any post fall abnormal assessments, including abnormal vital signs. Facility nurse #2 stated the resident’s behaviors were taken into consideration as they related to falls and staff were educated to offer as needed behavior medications as fall preventative. During an interview, a hospice, agency, administrative, nurse, who reviewed the resident’s medical records, stated there were several falls, follow-up visits provided by hospice agency nurses. The hospice, agency, administrative nurse stated assessments, treatment, medication review and post-fall intervention recommendations were routinely made at each visit. During an interview, the resident’s family members stated the resident wanted to remain independent and would attempt to transfer and ambulate by himself to the bathroom. The resident’s family members stated the facility did everything they could to prevent the falls and both the facility and the resident’s hospice agency effectively communicated updates regarding the resident’s condition. The family members stated they believed facility staff “loved” the resident and the family members were happy with the care provided. 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. he Action taken by facility: The facility completed facility incident reports. The facility reported all falls to the resident’s provider, family and hospice agency. The facility completed post-fall reviews and initiated fall prevention interventions after each fall. The resident was assessed, monitored and treated after each fall. The facility completed assessments after falls and changes in condition when applicable. 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/ 10/ 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 _____________________________ 31761 11/06/ 2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 675 MARKET PLACE DRIVE LINO LAKES GW LLC LINO LAKES, MN 55014 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 6, 2025, the Minnesota Department of Health initiated an investigation of complaint #HL317616083C/ #HL317616704M. No correction orders are issued. LABORATORY DIRECTOR' S OR PROVIDER/ SUPPLIER REPRESENTATIVE' S SIGNATURE TITLE (X6) DATE STATE FORM 6899 P4ZZ11 If continuation sheet 1 of 1

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 . . ." 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 survey 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 An equal opportunity employer. Letter ID: IS7N REVISED 09/13/2021 Lino Lakes Gracewood May 16, 2025 Page 2 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 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 PRINTED: 05/16/2025 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 _____________________________ 31761 04/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 675 MARKET PLACE DRIVE LINO LAKES GRACEWOOD LINO LAKES, MN 55014 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 SL31761016-0 Time Period for Correction. On April 14, 2025, through April 16, 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 34 residents; 34 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. 0 480 144G.41 Subdivision 1 Subd. 1a (a-b) Minimum 0 480 SS=F requirements; required food services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 G33511 If continuation sheet 1 of 17 PRINTED: 05/16/2025 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 _____________________________ 31761 04/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 675 MARKET PLACE DRIVE LINO LAKES GRACEWOOD LINO LAKES, MN 55014 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) 0 480 Continued From page 1 0 480 (a) Except as provided in paragraph (b), food must be prepared and served according to the Minnesota Food Code, Minnesota Rules, chapter 4626. (b) For an assisted living facility with a licensed capacity of ten or fewer residents: (1) notwithstanding Minnesota Rules, part 4626.0033, item A, the facility may share a certified food protection manager (CFPM) with one other facility located within a 60-mile radius and under common management provided the CFPM is present at each facility frequently enough to effectively administer, manage, and supervise each facility's food service operation; (2) notwithstanding Minnesota Rules, part 4626.0545, item A, kick plates that are not removable or cannot be rotated open are allowed unless the facility has been issued repeated correction orders for violations of Minnesota Rules, part 4626.1565 or 4626.1570; (3) notwithstanding Minnesota Rules, part 4626.0685, item A, the facility is not required to provide integral drainboards, utensil racks, or tables large enough to accommodate soiled and clean items that may accumulate during hours of operation provided soiled items do not contaminate clean items, surfaces, or food, and clean equipment and dishes are air dried in a manner that prevents contamination before storage; (4) notwithstanding Minnesota Rules, part 4626.1070, item A, the facility is not required to install a dedicated handwashing sink in its existing kitchen provided it designates one well of a two-compartment sink for use only as a handwashing sink; (5) notwithstanding Minnesota Rules, parts 4626.1325, 4626.1335, and 4626.1360, item A, existing floor, wall, and ceiling finishes are STATE FORM 6899 G33511 If continuation sheet 2 of 17 PRINTED: 05/16/2025 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 _____________________________ 31761 04/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 675 MARKET PLACE DRIVE LINO LAKES GRACEWOOD LINO LAKES, MN 55014 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) 0 480 Continued From page 2 0 480 allowed provided the facility keeps them clean and in good condition; (6) notwithstanding Minnesota Rules, part 4626.

STATE LICENSING COMPLIANCE REPORT Report #: HL317616286C Date Concluded: February 28, 2025 Name, Address, and County of Facility Investigated: Lino Lakes Gracewood 675 Market Place Dr 30 Lino Lakes, MN 55014-2454 Anoka County Facility Type: Assisted Living Facility with Evaluator’s Name: Lori Pokela R.N. 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 (for 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 MDH website, please see the attached state form. PRINTED: 03/24/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ C B. WING _____________________________ 31761 02/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 675 MARKET PLACE DRIVE LINO LAKES GRACEWOOD LINO LAKES, MN 55014 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 000 Initial Comments 0 000 On February 26, 2025, the Minnesota Department of Health initiated an investigation of complaint #HL317616286C. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 4UD211 If continuation sheet 1 of 1