Brookside Senior Living.

correction orders and document the actions taken to comply in the facility's records. The Department reserves the right to return to the facility at any time should the Department receive a complaint or deem it necessar yto ensure the health, safety, and welfare of residents in your care. STATE CORRECTIO ONRDERS The enclosed State Form documents the state correction orders. 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 Statemen tof Deficiencies "column. This column also includes the findings that are in violation of the state statute after the statement, "This MN Requiremen tis not met as evidenced by . . ." IMPOSITION OF FINES In accordance with Minn. Stat. § 144G3. 1, 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: Leve l1: no fines or enforcement; Leve l2: a fine of $500 per violation, in addition to any enforcement mechanism authorized in § 144G2. 0; Leve l3: a fine of $1,000 per incident, in addition to any enforcement mechanism authorized in § 144G2. 0; An equal opportunity employer . Letter ID: IS7N REVISE 0D9/13/2021 Brookside Senior Living Novembe r12, 2025 Page 2 Leve l4: a fine of $3,000 per incident, in addition to any enforcement mechanism authorized in § 144G2. 0; Leve l5: a fine of $5,000 per violation, in addition to any enforcement mechanism authorized in § 144G2. 0. Therefore ,in accordance with Minn. Stat. §§ 144G0. 1 to 144G9. 999, the following fines are assessed pursuant to this survey: St - 0 - 0775 - 144g.45 Subd. 2. (a) - Fire Protection And Physica lEnvironment - $500.00 St - 0 - 0780 - 144g.45 Subd. 2 (a) (1) - Fire Protection And Physica lEnvironment - $500.00 Therefore ,in accordance with Minn. Stat. §§ 144G0. 1 to 144G9. 999, the total amount you are assesse dis $1,000.00. You will be invoiced approximately 30 days after receipt of this notice, subject . to appeal DOCUMENTATIO ONF ACTION TO COMPLY In accordance with Minn. Stat. § 144G3. 0, Subd .5(c), the licensee must docum ent 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: x Identify how the area(s) of noncompliance was corrected related to the resident(s)/ employees( ) identified in the correction order. x 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. x Identify what changes to your systems and practices were made to ensure compliance with the specific statute(s). CORRECTIO ONRDER RECONSIDERATI OPRNOCESS In accordance with Minn. Stat. § 144G3. 2, Subd .2, you may challenge the correction order(s) issued, including the level and scope ,and any fine assesse dthrough the correction order reconsideration process .The request for reconsideration must be in writing and received by 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 AG HEARING Alternatively ,in accordance with Minn. Stat. § 144G3. 1, Subd .5(d), an assisted living provider that has been assesse da fine under this subdivision has a right to a reconsideration or a hearing under this section and chapter 14. Pursuan tto Minn. Stat. § 144G2. 0, 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 Brookside Senior Living Novembe r12, 2025 Page 3 factor. To submit a hearing request, please visit: https:/ / forms.web.health.state.mn.us/form/ HRDAppealsForm To appea lfines via reconside ration, please follow the pr ocedur e outlined above. Plea se note that you may request a reconsideration or 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: https:/ / forms.office.com/g/ Bm5uQEpHV.a Your input is important to us and will enable MDH to improve its processe sand communication with providers . If you have any questions regarding the questionnaire ,please contact Susan Winkelmann at susanw. inkelmann@state.mn.us or call 651-201-5952. You are encouraged to retain this document for your records . It is your responsibility to share the information contained in the letter and state form with your organizations’ Governing Body. If you have any questions ,please contact me. Sincerely, Kelly Thorson ,Supervisor State Evaluation Team Email: Kelly.Thorson@state.mn.us Telephone :320-223-7336 Fax :1-866-890-9290 CLN PRINTED: 11/12/2025 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 _____________________________ 21803 10/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 804 BENSON ROAD BROOKSIDE SENIOR LIVING MONTEVIDEO, MN 56265 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE PREFIX PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 000 Initial Comments 0 000 *****ATTENTION***** Minnesota Department of Health is documenting the State Correction Orders ASSISTED LIVING PROVIDER LICENSING using federal software. Tag numbers have CORRECTION ORDER(S) been assigned to Minnesota State Statutes for Assisted Living License In accordance with Minnesota Statutes, section Providers. The assigned tag number 144G.08 to 144G.95, these correction orders are appears in the far-left column entitled "ID issued pursuant to a survey. Prefix Tag." The state Statute number and the corresponding text of the state Statute Determination of whether violations are corrected out of compliance is listed in the requires compliance with all requirements "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. SL21803016-0 PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On October 20, 2025, through October 22, 2025, STATES,"PROVIDER'S PLAN OF the Minnesota Department of Health conducted a CORRECTION." THIS APPLIES TO full survey at the above provider and the FEDERAL DEFICIENCIES ONLY. THIS following correction orders are issued. At the time WILL APPEAR ON EACH PAGE. of the survey, there were 57 residents; 53 receiving services under the Assisted Living THERE IS NO REQUIREMENT TO Facility with 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 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 92DH11 If continuation sheet 1 of 16 PRINTED: 11/12/2025 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.

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, required hospitalization, where a fracture was identified along with severe constipation. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. While the resident did fall in her room, the facility fell and was found on the floor, however the facility sought appropriate care in response to the fall. At the hospital, the resident was found to have severe constipation which was treated there. The resident did have medications prescribed for her on an as-needed basis at the facility, however the facility had not observed any recent symptoms nor had the resident requested these medications. The investigator conducted interviews with facility staff members, including administrative staff, and unlicensed staff. The investigation included review of the resident’s records, incident reports, staff schedules, policies, and procedures. The resident resided in an assisted living facility. The resident’s diagnoses include dementia and diverticulosis. The resident’s service plan indicated resident needed assistance with medication administration, morning and bedtime care, including grooming and dressing. The service plan at the time of the fall did not include any over night cares or safety checks. A fall incident report indicated the facility caregiver(s) heard a faint call from the resident’s apartment one night at approximately 2 AM. The same document indicated the resident was found near her bed in pain, so she was transferred to the hospital via 911. The hospital records indicated the resident admitted for a lumbar compression fracture, which was described as mild and stable, and altered mental status. The hospital also diagnosed the resident with severe constipation. To address the fracture and fall, physical and occupational therapy were scheduled for follow-up. During the hospitalization, the resident’s medications were reviewed, and several medications were discontinued due to their potential to cause fatigue or confusion. For chronic constipation, the records noted that Lactulose might be causing nausea before bowel movements, so it should be used as needed. Senokot and daily MiraLAX are to be continued as prescribed. Prior to the fall, the resident’s medications as prescribed at the facility included docusate capsules once daily as needed, glycerin suppositories once daily as needed, and Polyethylene Glycol powder as needed, which were medications to help prevent constipation. Also, prior to the fall, the medication administration record indicated the docusate capsule were administrated once two weeks prior the incident happened. During an interview, the family member stated that the resident fell and was sent to the hospital. She said that the resident complained of abdominal pain at the hospital, where it was discovered that she was severely constipated. A review of the resident’s facility progress notes prior to the fall, there was no indication that the resident had complained of symptoms of constipation such as abdominal discomfort. During an interview, the unlicensed caregiver #1 stated that the resident was alert but became more confused prior to the incident. She said the resident had a laxative prescribed on an as-needed basis, and she would administer the medication if the resident expressed a need for it or complained about constipation. She said the resident rarely complained about constipation and did not say anything about it before the incident. During an interview, the unlicensed caregiver #2 stated that the resident did not complain about constipation to her before the incident. During an interview, unlicensed caregiver #3 stated that she did not remember whether the resident complained about constipation. She said that she knew the resident had laxative powder for it but, to her knowledge, had not requested it. During an interview, a manager stated the facility tracking bowel movements was not on all resident’s service plans as it was an extra service and had to be added, which had not been added to the resident’s service plan. Since it was not part of her plan, the facility relied on the resident’s reports since the laxatives were prescribed “as needed” and not a scheduled medication. 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 in transitional care unit. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Not Applicable. he Action taken by facility: The facility followed protocol and sent the resident 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: 12/31/2024 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 _____________________________ 21803 12/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 804 BENSON ROAD BROOKSIDE SENIOR LIVING MONTEVIDEO, MN 56265 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 18, 2025, the Minnesota Department of Health initiated an investigation of complaint HL218036583M/HL218039864C. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 12EG11 If continuation sheet 1 of 1

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 resident was sexually abused when an unlicensed staff/alleged perpetrator (AP) was witnessed engage in kissing and close inappropriate intimate contact with a resident. Investigative Findings and Conclusion: The Minnesota Department of Health determined abuse was inconclusive. The AP was observed in the resident’s bathroom embracing the resident while kissing him on the lips. The observed contact between the resident and the AP did not rise to the level of abuse. However, it could not be determined if the AP engaged in sexual contact with the resident prior to being observed kissing the resident. Although the resident repeatedly asked for the AP after the incident occurred, the resident has not shown any signs of emotional distress from the incident. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted the resident’s family. The investigation included review of the resident record(s), facility internal investigation, facility incident reports, personnel files, staff schedules, and related facility policy and procedures. Also, the investigator observed resident’s and staff at the facility. The resident resided in an assisted living facility memory care unit with diagnoses including post-traumatic stress disorder, neurocognitive disorder with Lewy Bodies Dementia (a progressive form of dementia that leads to a decline in thinking, reasoning, and independent function), anxiety disorder, and depression. The resident’s assessment and plan of care indicated the resident was ambulatory, and independent with toileting and incontinence care. The assessment indicated the resident could easily get confused during conversations, was mildly disoriented, and required reminders and verbal cues from staff. The resident’s individual abuse prevention plan indicated the resident had poor safety awareness and could become agitated when he does not get what he wants. A faxed communication to the resident’s provider 45 days prior to the incident indicated the resident was having hypersexual behaviors over the past 3 months with staff and other residents. The AP’s personnel file included a performance improvement form 12 days prior to the incident which indicated the AP received a warning that working under the influence would not be tolerated and would result in corrective action leading up to termination of her employment. The day of the incident a staff member texted leadership and reported at 12:50 p.m. the AP was observed in the resident’s bathroom making out with the resident which made her feel very uncomfortable, and the staff did not want the AP working with the residents. The text communication indicated the AP was observed kissing the resident while the resident had his hands on the AP’s body and the AP had her hands on the resident’s face and neck area. When the staff saw the AP, the AP slammed the bathroom door shut. A facility investigation indicated when leadership called the AP to the office, the AP denied kissing the resident, and stated the resident was always trying to put his arms around her and kiss her. The AP stated she had helped the resident get ready for the day and indicated she was assisting the resident with toileting when the staff saw them. The resident’s service delivery of care record indicated another staff, not the AP, assisted the resident to get ready for the day. The delivery record indicated during the time of the incident the AP had not provided toileting or incontinence care for the resident at the time she was witnessed kissing the resident in his bathroom. When interviewed the staff who witnessed the incident stated the resident needed assistance to get up and ready for the day but was independent with toileting and incontinence care. The staff witness stated she had not seen the AP for 10-15 minutes and needed assistance with another resident, so she went to look for the AP. The witness stated the resident’s bathroom door was open slightly and she saw movement, then pushed the door open wide and saw the AP standing in the middle of the bathroom with her arms up and hands on the resident’s face and neck, while the resident had his hands on the AP’s waist and hip area and the two were kissing each other. The witness stated as soon as she opened the door the AP quickly slammed the bathroom door shut in the witness’s face. The witness stated she was shocked and disgusted by what she had seen. The witness stated afterwards the AP came to her and asked if she had seen the resident trying to kiss her. The witness stated the AP told her the resident forced himself on her and was trying to “do things” with her but the AP would not let him. The witness stated the AP was embracing the resident and kissing the resident on the lips. The witness stated after the incident the AP appeared agitated and nervous. The witness stated the resident persistently asked about the AP, described the AP’s appearance, and stated he needed to talk to her. The witness stated the resident does not ask about other staff at the facility just the AP. The resident’s psychiatric provider progress note 2 days after the incident occurred indicated staff reported the resident had sexual behaviors described as trying to kiss and inappropriately touch other resident’s and staff, and indicated he was sad because he was “locked up” in the facility. About one month after the incident occurred a provider progress note indicated the resident was seen for medication management and behavioral concerns. The resident continued to have sexual behaviors such as masturbating in front of staff. The note indicated the resident asked where the AP was several times before he was able to be redirected by staff. Staff reported the resident often brought up the AP by name. A nurse’s note about one month after the incident indicated the resident was repeatedly asking for the AP’s phone number. Another month later a progress note indicated the resident was talking about and described the AP. When interviewed several unlicensed personnel (ULP) staff stated the resident made inappropriate comments, and would try to touch, grab, or kiss them but he was easily redirectable. The staff stated the resident needed assistance to get up and ready for the day, reminders/ques throughout the day, but was independent with toileting and incontinence care. Staff indicated there was no reason for the AP to be in the resident’s bathroom at the time the incident occurred. One ULP staff stated the day of the incident when the AP reported for her shift she was mumbling, had extremely exaggerated reactions, statements, head, and body movements, with very odd behavior. The ULP stated she received a text message from leadership staff who indicated they wanted the AP to report to the office. The ULP stated the AP leaned in to look at the message, and her leg swung way out, like the AP was off balance. The ULP stated the AP responded, “OH that’s me!” and the ULP got a strong smell of alcohol on the AP’s breath. The ULP stated the AP appeared to be under the influence and she did not feel comfortable leaving the residents in the AP’s care. The ULP stated she was relieved when leadership stated another staff would be covering the AP’s shift. Another ULP stated she had not worked with the AP much, but reported the AP was vaping, acting weird, and appeared to be under the influence of something 12 days prior to the incident with the resident. When asked to describe “acting weird” the ULP stated the AP had touched a hospice resident inappropriately by running her hands up and down the resident’s bare legs while mumbling incoherently and kissed the resident’s bare feet with blisters on them. The ULP stated she told the AP to “STOP”, but the AP just smiled and laughed at the ULP, then the ULP told the AP to leave the resident’s room. The ULP stated the AP had inappropriate conduct toward the ULP, was overly friendly, and offered the ULP money, shoes, and clothing to engage in a relationship with the AP. The ULP stated she reported her concerns to leadership.