Shiloh Assisted 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 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 . . ." IMPOSITION OF FINES In accordance with Minn. Stat. § 144G.31, Subd. 4, fines and enforcement actions may be imposed based on the level and scope of the violations and may be imposed immediately with no opportunity to correct the violation first as follows: Level 1: no fines or enforcement; Level 2: a fine of $500 per violation, in addition to any enforcement mechanism authorized in § 144G.20; Level 3: a fine of $1,000 per incident, in addition to any enforcement mechanism authorized in § 144G.20; Level 4: a fine of $3,000 per incident, in addition to any enforcement mechanism authorized in An equal opportunity employer. Letter ID: IS7N REVISED 09/13/2021 Shiloh Assisted Living August 22, 2025 Page 2 § 144G.20; Level 5: a fine of $5,000 per violation, in addtion to any enforcement mechanism authorized in § 144G.20. Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, the following fines are assessed pursuant to this survey: St - 0 - 0775 - 144g.45 Subd. 2. (a) - Fire Protection And Physical Environment - $500.00 Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, t he total amount you are assessed is $. You will be invoiced approximately 30 days after receipt of this notice, subject to appeal. DOCUMENTATION OF ACTION TO COMPLY In accordance with Minn. Stat. § 144G.30, Subd. 5(c), the licensee must document actions taken to comply with the correction orders within the time period outlined on the state form; however, plans of correction are not required to be submitted for approval. The correction order documentation should include the following: Identify how the area(s) of noncompliance was corrected related to the resident(s)/employee(s) identified in the correction order. Identify how the area(s) of noncompliance was corrected for all of the provider’s resident(s)/employees that may be affected by the noncompliance. Identify what changes to your systems and practices were made to ensure compliance with the specific statute(s). CORRECTION ORDER RECONSIDERATION PROCESS In accordance with Minn. Stat. § 144G.32, Subd. 2, you may challenge the correction order(s) issued, including the level and scope, and any fine assessed through the correction order reconsideration process. The request for reconsideration must be in writing and received by MDH within 15 calendar days of the correction order receipt date. To submit a reconsideration request, please visit: https://forms.web.health.state.mn.us/form/HRDAppealsForm REQUESTING A HEARING Alternatively, in accordance with Minn. Stat. § 144G.31, Subd. 5(d), an assisted living provider that has been assessed a fine under this subdivision has a right to a reconsideration or a hearing under this section and chapter 14. Pursuant to Minn. Stat. § 144G.20, Subd. 14 and Subd. 18, a request for a hearing must be in writing and received by the Department of Health within 15 business days of the correction order receipt date. The request must contain a brief and plain statement describing each matter or issue contested and any new information you believe constitutes a defense or mitigating factor. Shiloh Assisted Living August 22, 2025 Page 3 To submit a hearing request, please visit: https://forms.web.health.state.mn.us/form/HRDAppealsForm To appeal fines via reconsideration, please follow the procedure outlined above. P lease note that you may request a reconsideration o r a hearing, but not both. If you wish to contest tags without fines in a reconsideration and tags with the fines at a hearing, please submit two separate appeals forms at the website listed above. The MDH Health Regulation Division (HRD) values your feedback about your experience during the survey and/or investigation process. Please fill out this anonymous provider feedback questionnaire at your convenience at this link: h ttps://forms.office.com/g/Bm5uQEpHVa. Your input is important to us and will enable MDH to improve its processes and communication with providers. If you have any questions regarding the questionnaire, please contact Susan Winkelmann at susan.winkelmann@state.mn.us or call 651-201-5952. You are encouraged to retain this document for your records. It is your responsibility to share the information contained in the letter and state form with your organization’s Governing Body. If you have any questions, please contact me. Sincerely, Jessie Chenze, Supervisor State Evaluation Team Email: Jessie.Chenze@state.mn.us Telephone: 218-332-5175 Fax: 1-866-890-9290 AH PRINTED: 08/22/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 34980 07/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5384 COUNTRY CARE LANE SHILOH ASSISTED LIVING PEQUOT LAKES, MN 56472 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 LICENSING using federal software. Tag numbers have CORRECTION ORDER(S) been assigned to Minnesota State Statutes for Assisted Living Facilities. The In accordance with Minnesota Statutes, section assigned tag number appears in the 144G.08 to 144G.95, these correction orders are far-left column entitled "ID Prefix Tag." The issued pursuant to a survey. state Statute number and the corresponding text of the state Statute out Determination of whether violations are 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 Minnesota Statute contains several items, are in violation of the state requirement failure to comply with any of the items will be after the statement, "This Minnesota considered lack of compliance. requirement is not met as evidenced by." Following the evaluators ' findings is the INITIAL COMMENTS: Time Period for Correction. SL34980016 PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH STATES,"PROVIDER'S PLAN OF On June 30, 2025, through July 2, 2025, the CORRECTION." THIS APPLIES TO survey at the above provider and the following WILL APPEAR ON EACH PAGE. correction orders are issued. At the time of the survey, there were 50 residents; 50 receiving THERE IS NO REQUIREMENT TO services under the Assisted Living Facility with SUBMIT A PLAN OF CORRECTION FOR Dementia Care license. VIOLATIONS OF MINNESOTA STATE STATUTES. THE LETTER IN THE LEFT COLUMN IS USED FOR TRACKING PURPOSES AND REFLECTS THE SCOPE AND LEVEL ISSUED PURSUANT TO 144G.31 SUBDIVISION 1-3. 0 470 144G.41 Subdivision 1 Minimum requirements 0 470 SS=F (11) develop and implement a staffing plan for LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 JVFP11 If continuation sheet 1 of 35 PRINTED: 08/22/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B.

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 the resident fell and injured his head, resulting in a brain bleed. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was inconclusive. The resident fell several times in the weeks leading up to his death and the facility failed to develop additional fall prevention interventions. However, when a fall with significant injury occurred the resident’s primary care provider and hospice agency were updated appropriately, and the resident received timely medical care. It is unable to be determined if staff’s failure to develop additional fall interventions would have prevented the resident’s last fall with injury. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted hospice and the primary care provider. The investigation included review of hospice records, emergency room records, and An equal opportunity employer. facility records including progress notes, assessments, service plan, and incident reports. Also, the investigator observed resident cares in the facility. The resident resided in an assisted living memory care unit. The resident’s diagnoses included end stage liver disease, hepatic encephalopathy (an altered level of consciousness as a result of liver failure leading to confusion and forgetfulness), and chronic obstructive pulmonary disease (a progressive lung disease that can cause shortness of breath.) The resident’s service plan included assistance with toileting, transferring, behavior management, and hourly safety checks. The resident’s most recent assessment, completed two months prior to his death, identified the resident as at risk for falls. The assessment indicated the resident had sustained several falls and included fall interventions. The resident also received hospice services. Hospice records indicated nurse and home health aide visits were increased to daily visits, due to a change in condition, a few days before the resident was sent to the hospital. At that time, the resident was noted to have labored breathing and difficulty swallowing medications. Around three weeks prior to the resident’s death, the hospice physician documented the resident was experiencing more frequent hallucinations and delusions with two-to-three-day periods of unresponsiveness. Facility records indicated the resident fell many times in the weeks leading up to his death, however incident reports were not completed after every fall. For the falls which were documented, the primary care provider (PCP) and hospice were updated within a reasonable timeframe. However, the last fifteen documented falls did not include any new or additional fall prevention interventions. Hospital records indicated the resident was sent to the emergency room following a fall at the facility. The resident was diagnosed with a “closed head injury and left forehead abrasion/laceration.” The emergency room physician wrote “was able to speak with the hospice nurse and we will go ahead with head CT knowing that if there is bleeding, patient would not be a candidate for any intervention…” The CT scan confirmed the resident had a right sided subarachnoid hemorrhage (brain bleed). The resident discharged back to the facility after it was agreed no aggressive treatment would be done. The resident died two days later. The resident’s death record identified the cause of death as closed head trauma due to fall. During an interview, a former facility registered nurse (RN) stated she implemented various interventions including the use of headphones, increased toileting times, frequent safety checks, and anticipation of needs, but the resident continued to fall. The former RN indicated she quit working at the facility approximately two months before the resident died. The former RN was not sure why the RN who replaced her did not implement new interventions. During investigative interviews, multiple unlicensed personnel (ULP) stated the resident fell frequently and falls occurred on an almost daily basis. ULP stated the new RN did not ask them for feedback on fall interventions and did not talk to staff about new interventions after repeated falls. Multiple ULP said they would try to keep the resident busy and checked on him frequently, but sometimes he fell minutes after they last checked on him. ULP stated no matter what they seemed to do; they couldn’t prevent the resident from falling. During an interview, the resident’s PCP stated the resident fell frequently but could also go weeks without any falls. The PCP stated the resident had encephalopathy due to liver failure (symptoms include difficulty thinking, confusion, forgetfulness, and poor judgment) and thought he could still do things on his own. The PCP stated staff notified her of falls and she had tried to brainstorm ideas to keep him from falling but didn’t know what else they could have done. The PCP indicated staff would check on him and two minutes later, he’d be on the floor. 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, deceased. Family/Responsible Party interviewed: Yes Alleged Perpetrator interviewed: Not Applicable Action taken by facility: No action taken. 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: 06/28/2023 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 _____________________________ 34980 05/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5384 COUNTRY CARE LANE SHILOH ASSISTED LIVING PEQUOT LAKES, MN 56472 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 000 Initial Comments 0 000 ******ATTENTION****** Minnesota Department of Health is documenting the State Licensing ASSISTED LIVING PROVIDER LICENSING Correction Orders using federal software. CORRECTION ORDER Tag numbers have been assigned to Minnesota State Statutes for Assisted In accordance with Minnesota Statutes, section Living License Providers. The assigned 144G.08 to 144G.95, these correction orders are tag number appears in the far left column issued pursuant to a complaint investigation. entitled "ID Prefix Tag." The state Statute number and the corresponding text of the Determination of whether a violation is corrected state Statute out of compliance is listed in requires compliance with all requirements the "Summary Statement of Deficiencies" provided at the statute number indicated below. column. This column also includes the When a Minnesota Statute contains several findings which are in violation of the state items, failure to comply with any of the items will requirement after the statement, "This be considered lack of compliance. Minnesota requirement is not met as evidenced by." Following the surveyors' INITIAL COMMENTS: findings is the Time Period for Correction. #HL349805343M/ HL349809103C. PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On May 3, 2023, the Minnesota Department of STATES,"PROVIDER'S PLAN OF Health conducted a complaint investigation at the CORRECTION." THIS APPLIES TO above provider, and the following correction order FEDERAL DEFICIENCIES ONLY. THIS is issued. At the time of the complaint WILL APPEAR ON EACH PAGE. investigation, there were 38 residents receiving services under the provider's Assisted Living with THERE IS NO REQUIREMENT TO Dementia Care license.