Maple Hill Senior Living 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), a facility staff member neglected the resident when the AP failed to provide care and supervision during an incident when the resident fell. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. At the time of the incident, the AP was following the resident’s plan of care. The resident sustained a fall and was transported to the hospital. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted the resident’s family member. The investigation included review of the resident records, death record, hospital records, facility internal investigation, personnel files, staff schedules, and related facility policy and procedures. Also, the investigator observed staff interactions with residents. The resident resided in an assisted living memory care unit. The resident’s diagnoses included a history of falling, dementia, and Alzheimer’s disease. The resident’s service plan included assistance with day and evening safety checks. The resident’s assessment indicated the resident was independent with transferring, walking and toileting. The resident had not had a fall for the past three months. The facility investigation indicated one day the resident had a fall in the early morning hours. Another resident heard the resident yelling out for help. The other resident notified emergency services, met the emergency services at the front door of the facility, and escorted emergency services to the resident’s room. Emergency services transported the resident to the hospital for an evaluation. The emergency service report indicated the resident was found in her apartment. The resident reported her legs gave out and that she fell. The emergency service report indicated the resident was found with no signs of a hip fracture. The resident was transferred to the hospital for further evaluation. The hospital record indicated the resident reported she fell and landed on her left hip. The resident sustained a left hip fracture, was hospitalized for nine days, and transferred to a higher level of care. The resident records indicated the resident did not have scheduled activities of daily living services or safety checks at the time of the incident. During an interview, leadership stated camera footage was reviewed and that the AP entered the nurse’s station and remained in the nurse’s station for approximately four hours. During the time the AP was in the nurse’s station, the other resident was seen on the camera footage, meeting the emergency services at the front door, and escorting the emergency services down to the resident room and within minutes, the resident was assisted out of the facility by the emergency services. Facility staff can be seen on camera footage completing rounds approximately one hour after the resident was taken to the hospital. Leadership stated the other resident did not notify facility staff that emergency services was called, and that the resident left the facility until later that morning when the resident family member came to the facility looking for her. Leadership stated during the times the AP was in the nurse’s station, the resident did not have any scheduled services to be completed. During an interview, the AP did not recall working the morning of the incident. During an interview, the family member stated facility staff assisted the resident with medications in the morning and evening. The family member stated the resident walked independently in the apartment. The family member stated the morning of the incident, they arrived at the facility when the other resident approached them and stated they had called emergency services because the resident fell earlier that morning and was transported to the hospital. 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. Resident was deceased. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Yes. the Action taken by facility: Once the facility learned the resident was no longer at the facility, the facility began an investigation. The facility installed additional cameras. The AP is no longer employed by the facility. 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: 04/10/2025 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 _____________________________ 31968 12/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3030 SOUTHLAWN DRIVE MAPLE HILL SENIOR LIVING LLC MAPLEWOOD, MN 55109 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 December 30, 2024, the Minnesota Department of Health initiated an investigation of complaint #HL319686642M/#HL319689884C. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 3V5C11 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: An equal opportunity employer. Letter ID: IS7N REVISED 09/13/2021 Maple Hill Senior Living LLC February 11, 2025 Page 2 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 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, Renee L. Anderson, Supervisor State Evaluation Team Email: Renee.L.Anderson@state.mn.us Telephone: 651-201-5871 Fax: 1-866-890-9290 HHH PRINTED: 02/11/2025 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 _____________________________ 31968 12/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3030 SOUTHLAWN DRIVE MAPLE HILL SENIOR LIVING LLC MAPLEWOOD, MN 55109 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 Licensing Correction Orders using federal software. In accordance with Minnesota Statutes, section Tag numbers have been assigned to 144G.08 to 144G.95, these correction orders are Minnesota State Statutes for Assisted issued pursuant to a survey. Living License Providers. The assigned tag number appears in the far left column Determination of whether violations are corrected entitled "ID Prefix Tag." The state Statute requires compliance with all requirements number and the corresponding text of the provided at the Statute number indicated below. state Statute out of compliance is listed in When Minnesota Statute contains several items, the "Summary Statement of Deficiencies" failure to comply with any of the items will be column. This column also includes the considered lack of compliance. findings which are in violation of the state requirement after the statement, "This INITIAL COMMENTS: Minnesota requirement is not met as evidenced by." Following the surveyors' SL31968016-0 findings is the Time Period for Correction. On December 16, 2024, through December 20, PLEASE DISREGARD THE HEADING OF 2024, the Minnesota Department of Health THE FOURTH COLUMN WHICH conducted a full survey at the above provider. At STATES,"PROVIDER'S PLAN OF the time of the survey, there were 73 residents; CORRECTION." THIS APPLIES TO 73 receiving services under the Assisted Living FEDERAL DEFICIENCIES ONLY. THIS Facility with 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 pursuant to 144G.31 Subd. 1, 2 and 3. 0 480 144G.41 Subdivision 1 Subd. 1a (a-b) Minimum 0 480 SS=F requirements; required food services (a) Except as provided in paragraph (b), food must be prepared and served according to the Minnesota Food Code, Minnesota Rules, chapter LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 PX9K11 If continuation sheet 1 of 10 PRINTED: 02/11/2025 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 _____________________________ 31968 12/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3030 SOUTHLAWN DRIVE MAPLE HILL SENIOR LIVING LLC MAPLEWOOD, MN 55109 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 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 allowed provided the facility keeps them clean and in good condition; (6) notwithstanding Minnesota Rules, part STATE FORM 6899 PX9K11 If continuation sheet 2 of 10 PRINTED: 02/11/2025 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 _____________________________ 31968 12/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3030 SOUTHLAWN DRIVE MAPLE HILL SENIOR LIVING LLC MAPLEWOOD, MN 55109 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 4626.

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 fell, requested to go to the hospital, and facility staff refused to send her. She was bedridden for two days and facility staff did not respond her pendent calls for help. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. Although the resident fell, facility nursing staff assessed the resident, completed safety checks, and updated the medical provider. The resident was sent to the ER three days after the fall. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigation included review of the resident’s records, hospital records, facility incident reports, personnel files, staff schedules, and related facility policies and procedures. Also, the investigator observed interactions between staff and residents. The resident resided in an assisted living facility. The resident’s diagnoses included adult failure to thrive and bipolar disorder. The resident’s service plan included assistance with bed making, housekeeping, and medication management. The resident’s assessment indicated the resident was cognitively intact with occasional need for redirection and reassurance. The resident’s assessment indicated the resident had a history of falls. Facility documentation indicated the resident was found on the ground near her door. The resident reported she got up to go to the bathroom, got dizzy, fell backwards, and hit her head. Unlicensed staff obtained vital signs and notified the facility nurse of the fall and that the resident reported she hit her head. A facility nurse assessed the resident the day of the fall. The resident was reassessed by another facility nurse two days after the fall. During the reassessment, the resident reported a bump on the back of her head that caused discomfort and the medical provider was updated. Three days after the fall, the resident complained of being dehydrated and a facility nurse sent the resident to the emergency room (ER). Hospital records indicated the resident was diagnosed with recurrent falls and anemia (a condition of low red blood cells or hemoglobin, which can cause tiredness, weakness, and shortness of breath). The resident was discharged to a transitional care unit and later returned to the facility. During an interview, a facility staff member stated the resident pressed her pendent and when she responded to the resident’s light, she found the resident on the ground near her apartment door. The resident reported that she hit her head, so the staff member called the facility nurse. The nurse came into the facility and assessed the resident. At the time of the assessment the nurse asked the resident if she wanted to go to the ER and the resident declined. The nurse advised the resident to push her pendent if she needed help. The facility staff member stated that she checked on the resident several times throughout the next two days and the resident did not report any additional concerns. During an interview, the resident stated her mind wasn’t clear at the time of the fall and the days were all “clumped” together. The resident denied pushing her pendent for help in the days after the fall. The resident stated that facility staff came into her room and brought her food but not consistently. The resident did not report any concerns to facility staff because she thought she could just lay in bed and get better but realized she wasn’t getting better and was sent to the hospital. During investigative interviews, facility nursing staff stated the resident was assessed after the fall and initially declined transport to the ER. Nursing staff continued to monitor and assess the resident and when the resident reported she had a bump on her head, the medical provider was updated. Three days after the fall, the resident reported concerns and staff noted a change in condition and the resident was sent to the emergency room. 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: No, attempts to interview were unsuccessful. Alleged Perpetrator interviewed: Not Applicable. Action taken by facility: The facility assessed the resident, administered pain medication, updated the provider, and sent the resident to the emergency room when a change in condition occurred. 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: 06/26/2024 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 _____________________________ 31968 04/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3030 SOUTHLAWN DRIVE MAPLE HILL SENIOR LIVING LLC MAPLEWOOD, MN 55109 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 April 16, 2024, the Minnesota Department of Health initiated an investigation of complaint #HL319688155C /#HL319689949M. No correction orders are issued LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 BNCU11 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 alleged perpetrator (AP) neglected a resident when she administered medication to the resident that was not ordered for the resident by the provider. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. The AP administered insulin to the resident. The insulin was meant for another resident with a similar name. Although the wrong medication was given, the error was an isolated incident. The resident sustained nausea and vomiting, received increased monitoring, anti-nausea medication and returned to their baseline health condition. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, unlicensed staff, and a family member. The investigation included review of the resident’s medical record, the medical provider’s orders, facility incident report and personnel An equal opportunity employer. files. Also, the investigator toured the facility and observed staff interactions with residents and medication administration. The resident resided in an assisted living memory care unit. The resident’s diagnoses included psychotic disorder with delusions and dementia with behavioral disturbance. The resident’s service plan included assistance with bathing, toileting, and dressing. The resident’s medication administration record (MAR) indicated she received assist with medication administration. The resident’s assessment indicated she was oriented to person only and required stand by assist with walking. The facility internal investigation indicated the AP took a syringe from the nurse, that was identified by the nurse as Trulicity (a diabetes medication) and administered it to the resident. The medication was ordered for a different resident with a similar name. The resident’s progress notes indicated the provider was notified of the error and of the resident developing increased anxiety and nausea with vomiting. The facility received orders from the provider for Ativan (a medication used to reduce anxiety) as needed and Zofran (an anti-nausea medication). Progress notes indicated the resident had returned to her baseline health status three days after the medication error was made. The AP’s personnel record indicated the AP received retraining after the incident and demonstrated competency with insulin administration. During an interview, the AP stated she did not follow the five rights of medication administration (ensuring right medication, right resident, right time, right dose, right route) prior to giving the injection, because the nurse had already had the medication prepared and she thought the nurse had gone through all the steps already. The AP stated she should not have given the medication. The AP stated she had a feeling to double check the resident’s MAR after giving her the insulin and found the medication was not listed on her MAR. The AP stated once the error was discovered, she called the provider, received new orders, and implemented them. The AP stated she called the family but did not get an answer at that time. During an interview, the nurse stated she told the AP she did not feel comfortable giving the resident her insulin injection because she heard from other staff, she can be resistive at times. The AP stated she would do it and took the syringe from LPN-B. LPN-B followed the AP to the resident’s room. The AP administered the medication. LPN-B stated later, while still doing the medication pass, another resident with a similar name notified LPN-B she needed her injection. At that time, LPN-B realized the medication error made. LPN-B and the AP went to the medication refrigerator where the medication was stored, and discovered the medication was given to the wrong resident. During an interview, the licensed assisted living director (LALD) stated she was notified by the AP of the error the same day. The LALD later stated in an email communication to the investigator that she was out of state when the error occurred and was notified of the error upon her return to the facility. The LALD stated the internal investigation concluded staff were going too fast during medication pass and both made assumptions the other made the safety checks already. The LALD stated LPN-B and the AP received retraining after the incident. During an interview, a family member stated he was told by staff different versions of the incident. The family member stated he did not feel the resident was safe in the facility. 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. (c) For purposes of this section, a vulnerable adult is not neglected for the sole reason that: (5) an individual makes an error in the provision of therapeutic conduct to a vulnerable adult that results in injury or harm, which reasonably requires the care of a physician, and: (i) the necessary care is provided in a timely fashion as dictated by the condition of the vulnerable adult; (ii) if after receiving care, the health status of the vulnerable adult can be reasonably expected, as determined by the attending physician, to be restored to the vulnerable adult's preexisting condition; (iii) the error is not part of a pattern of errors by the individual; (iv) if in a facility, the error is immediately reported as required under section 626.557, and recorded Vulnerable Adult interviewed: No, due to cognitive deficits. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Yes. Action taken by facility: The facility immediately reported the incident to the provider and provided the follow up medical care as ordered by the provider. The facility provided retraining to staff. 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: 11/30/2023 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 _____________________________ 31968 10/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3030 SOUTHLAWN DRIVE MAPLE HILL SENIOR LIVING LLC MAPLEWOOD, MN 55109 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 corresponding text of the state Statute out Determination of whether a violation is 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 a Minnesota Statute contains several are in violation of the state requirement items, failure to comply with any of the items will after the statement, "This Minnesota be considered lack of compliance. requirement is not met as evidenced by." Following the evaluators' findings is the INITIAL COMMENTS: Time Period for Correction.

Finding: Inconclusive 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 provide incontinent care, leading to open wounds. Facility staff also failed to administer medication according to hospital discharge orders, requiring rehospitalization. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was inconclusive. Due to lack of documentation and conflicting information, it is unable to be determined if the resident sustained open wounds due to a lack of incontinence care. When staff observed a change in the resident’s condition, the resident was assessed and sent to the hospital for further evaluation. The resident admitted to the intensive care unit (ICU) and discharged back to the facility. No documentation was available to identify the resident’s condition or care provided following her return to the facility. Three days later, the resident was readmitted to the hospital. It is unable to be determined if the cause of the rehospitalization was directly related to the facility not administering the resident’s medications. An equal opportunity employer. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator also contacted the resident’s case manager. The investigation included review of resident medical records, personnel files, and facility policies and procedures. At the time of the onsite visit, the investigator toured the facility and observed interactions between staff and residents. The resident resided in an assisted living memory care unit. The resident’s diagnoses included vascular dementia, type 2 diabetes, and atrial fibrillation. The resident’s service plan included assistance with medication administration, dressing, toileting, and safety checks. The resident’s assessment indicated the resident was forgetful and orientated to self, due to dementia. Review of the resident’s medical record indicated the resident had a history of refusals of incontinent care. The resident’s medical record included no documentation or evidence of open wounds or skin integrity concerns. The resident’s progress notes identified one day the resident was vomiting and having loose stools. The facility nurse assessed the resident and crackles were noted in the resident’s lungs. The resident was sent to the hospital for evaluation. The resident’s hospital records indicated the resident was diagnosed with septic shock from pneumonia, admitted to the intensive care unit (ICU) for six days, and discharged back to the facility. Facility records lacked documentation of the resident’s return to the facility. Documentation identified the resident received services upon her readmission but did not identify which services were provided. The resident’s medical record did not contain assessment of the resident’s condition upon her return to the facility. The medical record did not identify new monitoring, medications, or treatments required or provided following the resident’s hospital stay and subsequent return to the facility. There was no record of medication administered to the resident, but the record indicated medications were not delivered to the facility upon her return. Pharmacy records reviewed included no record of the resident’s hospital discharge orders, change in medication orders, or delivery of medication to the facility. Hospital records identified the resident returned to the hospital three days after her previous discharge. There was no facility documentation identifying the resident’s condition or reason for transfer to the hospital. The resident’s hospital record indicated the resident returned to the hospital with complaints of nausea and vomiting. The resident was admitted and hospitalized for nine days for chronic heart failure, cardiomyopathy (a heart muscle disease), diabetes, and a heel pressure injury. Hospital records indicated lack of medication administration could not be directly correlated to the resident’s re-hospitalization. The resident’s status improved, and the resident discharged to another facility at the family member’s request. During an interview, facility unlicensed staff recalled the resident returned for a short time in between hospital admissions, but could not recall the resident’s condition, what care was provided, or if medications were administered. During an interview, a facility nurse confirmed the resident returned to the facility for three days before she was sent back to the hospital but could not recall any additional details surrounding the incident. During an interview, the case manager stated the resident discharged to a facility that could provide a higher level of care after the resident’s second hospitalization. In conclusion, the Minnesota Department of Health determined neglect was inconclusive. Inconclusive: Minnesota Statutes, section 626.5572, Subdivision 11. "Inconclusive" means there is less than a preponderance of evidence to show that maltreatment did or 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, due to cognitive status Family/Responsible Party interviewed: Attempts to contact were unsuccessful Alleged Perpetrator interviewed: Not applicable the Action taken by facility: None 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: 06/16/2023 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 _____________________________ 31968 05/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3030 SOUTHLAWN DRIVE MAPLE HILL SENIOR LIVING LLC MAPLEWOOD, MN 55109 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 corresponding text of the state Statute out Determination of whether a violation is 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 a Minnesota Statute contains several are in violation of the state requirement items, failure to comply with any of the items will after the statement, "This Minnesota be considered lack of compliance. requirement is not met as evidenced by." Following the evaluators ' findings is the INITIAL COMMENTS: Time Period for Correction. #HL319684662C/#HL319682764M #HL319684663C/#HL319682765M PLEASE DISREGARD THE HEADING OF On May 4, 2023, the Minnesota Department of THE FOURTH COLUMN WHICH Health conducted a complaint investigation at the STATES,"PROVIDER'S PLAN OF above provider, and the following correction CORRECTION." THIS APPLIES TO orders are issued. At the time of the complaint FEDERAL DEFICIENCIES ONLY. THIS investigation, there were 74 residents receiving WILL APPEAR ON EACH PAGE. services under the provider's Assisted Living with Dementia Care license. The following correction order is issued for #HL319684662C/#HL319682764M, tag THERE IS NO REQUIREMENT TO identification 2320. SUBMIT A PLAN OF CORRECTION FOR VIOLATIONS OF MINNESOTA STATE No correction orders were issued for, STATUTES. #HL319684663C/#HL319682765M. THE LETTER IN THE LEFT COLUMN IS USED FOR TRACKING PURPOSES AND REFLECTS THE SCOPE AND LEVEL LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 NFAS11 If continuation sheet 1 of 7 PRINTED: 06/16/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.