Broadwell Plymouth Senior Livi.

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 for widespread violations; Level 3: a fine of $3,000 per violation per incident, in addition to any enforcement mechanism authorized in § 144G.20. Level 4: a fine of $5,000 per incident, in addition to any enforcement mechanism authorized in An equal opportunity employer. Letter ID: IS7N REVISED 09/13/2021 Broadwell Plymouth Senior Living July 23, 2025 Pa ge 2 § 144G.20. Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, the following fines are assessed pursuant to this survey: St - 0 - 0510 - 144g.41 Subd. 3 - Infection Control Program - $500.00 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, the total amount you are assessed is $1,000.00. You will be invoiced approximately 30 days after receipt of this notice, subject to appeal. DOCUMENTATION OF ACTION TO COMPLY In accordance with Minn. Stat. § 144G.30, Subd. 5( c), the licensee must document actions taken to comply with the correction orders within the time period outlined on the state form; however, plans of correction are not required to be submitted for approval. The correction order documentation should include the following: Identify how the area(s) of noncompliance was corrected related to the • resident(s)/employee(s) identified in the correction order. Identify how the area(s) of noncompliance was corrected for all of the provider’s • resident(s)/employees that may be affected by the noncompliance. Identify what changes to your systems and practices were made to ensure compliance with • the specific statute(s). CORRECTION ORDER RECONSIDERATION PROCESS In accordance with Minn. Stat. § 144G.32, Subd. 2, you may challenge the correction order(s) issued, including the level and scope, and any fine assessed through the correction order reconsideration process. The request for reconsideration must be in writing and received by MDH within 15 calendar days of the correction order receipt date. To submit a reconsideration request, please visit: https://forms.web.health.state.mn.us/form/HRDAppealsForm REQUESTING A HEARING Alternatively, in accordance with Minn. Stat. § 144G.31, Subd. 5(d), an assisted living provider that has been assessed a fine under this subdivision has a right to a reconsideration or a hearing under this section and chapter 14. Pursuant to Minn. Stat. § 144G.20, Subd. 14 and Subd. 18, a request for a hearing must be in writing and received by the Department of Health within 15 business days of the correction order receipt date. The request must contain a brief and plain statement describing each matter or issue contested and any new information you believe constitutes a defense or mitigating factor. Broadwell Plymouth Senior Living July 23, 2025 Pa ge 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. Please 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/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, Casey DeVries, Supervisor State Evaluation Team Email: Casey.DeVries@state.mn.us Telephone: 651-201-5917 Fax: 1-800-337-9238 HHH PRINTED: 07/23/2025 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 _____________________________ 37869 05/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3025 NORTH HARBOR LANE BROADWELL PLYMOUTH SENIOR LIVING PLYMOUTH, MN 55447 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 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. SL37869016-0 PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On May 19, 2025, through May 21, 2025, the STATES,"PROVIDER'S PLAN OF survey at the above provider and the following FEDERAL DEFICIENCIES ONLY. THIS correction orders are issued. At the time of the WILL APPEAR ON EACH PAGE. survey, there were 100 residents; 48 receiving services under the Assisted Living Facility with THERE IS NO REQUIREMENT TO Dementia Care license. SUBMIT A PLAN OF CORRECTION FOR VIOLATIONS OF MINNESOTA STATE STATUTES. The letter in the left column is used for tracking purposes and reflects the scope and level issued pursuant to 144G.31 subd. 1, 2, and 3. 0 430 144G.40 Subd. 2 Uniform checklist disclosure of 0 430 SS=C services (a) All assisted living facilities must provide to LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 9LO611 If continuation sheet 1 of 31 PRINTED: 07/23/2025 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 alleged perpetrator financially exploited resident #1 and resident #2 when she stole their money. Investigative Findings and Conclusion: The Minnesota Department of Health determined financial exploitation was inconclusive. The investigation found there was insufficient evidence to determine if the financial exploitation occurred. The investigator conducted interviews with family member. The investigation included review of the resident’s record, internal investigation documentation, incident reports, personnel files, staff schedules, policies, and procedures. Resident #1 resided in an independent living facility. Resident #1 did not receive nursing services. He opted out of bi-weekly housekeeping and had meals at the facility daily. Resident #2 resided in an independent living facility. Resident #1 did not receive nursing services. He received bi-weekly housekeeping and ate some meals at the facility. Resident #1 reported during an interview with the manager that he noticed $1,800 in cash was missing at the end of January. He discovered the money was gone when he went to access his safe to pay his personal housekeeper. According to Resident #1, he always left his apartment door unlocked and kept his safe key hidden in a white bowl. He stated that while he was in the hallway, he saw the AP (a facility housekeeper), who asked if she could take out his trash. He agreed and gave her the key. She was the last person in his apartment before he realized the money was missing. Resident #2 also reported to staff that $600 in cash was missing from his apartment. He could not recall the exact date it went missing. He stated that, to his knowledge, the only person who had been in his apartment around the time of the loss was AP, the same facility housekeeper. The AP’s employment was terminated by the facility due to unrelated reasons in middle of January. There were no surveillance cameras near the apartments of Resident #1 and Resident #2 nor in the adjacent hallways. A police report indicated Resident #1 told an officer that the lock on his safe required a key, which he typically kept in a bowl above one of his cabinets. On the day he discovered the theft, he found the key lying on the counter and realized that $1,800–$1,900 in $100 bills was missing from the safe and he was unsure of the exact amount. The same document indicated he said last time he saw the money was in mid-January. He also said that his personal housekeeper, who had worked for him twice a month for the past two years, was the last person inside his apartment, followed by AP. He recalled the AP had asked to take out his trash sometime in early January, and he gave her the key. The police report also indicated that Resident #2 was interviewed and indicated he said he kept two wallets, one containing $1,000 and another with $600. He noticed that $600 in $100 bills was missing. The same document inodiated he said he received housekeeping services from the AP every other week and remembered that approximately two to three weeks ago, he was out for over an hour on a walk while AP was cleaning his apartment. He could not provide a specific period for when the money went missing. During an interview, resident #1’s family member stated that she was unsure of the exact amount of money stolen but she became aware of the incident after it had occurred and noted the police were unable to take further action due to a lack of evidence, resulting in the case being closed. During an interview, the AP stated she could not recall the exact date of her last shift at the facility. She stated she was not R1’s regular housekeeper and had only filled in once to clean his room. She had not seen the safe in R1’s room and did not know where it was located. Regarding resident #2, she said she was his regular housekeeper; however, since he was new to the facility, she had only cleaned his room twice. She stated resident #2 did not allow her to clean his room unless he was present, and she had never seen his wallet. The AP denied taking money from either resident. In conclusion, the Minnesota Department of Health determined financial exploitation 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. Financial exploitation: Minnesota Statutes, section 626.5572, subdivision 9 "Financial exploitation" means: (b) In the absence of legal authority, a person: (1) willfully uses, withholds, or disposes of funds or property of a vulnerable adult; (2) obtains for the actor or another the performance of services by a third person for the wrongful profit or advantage of the actor or another to the detriment of the vulnerable adult; (3) acquires possession or control of, or an interest in, funds or property of a vulnerable adult through the use of undue influence, harassment, duress, deception, or fraud; or (4) forces, compels, coerces, or entices a vulnerable adult against the vulnerable adult's will to perform services for the profit or advantage of another. Vulnerable Adult interviewed: No. Family/Responsible Party interviewed: Yes Alleged Perpetrator interviewed: Yes Action taken by facility: The facility started internal investigation and called law enforcement. 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: 04/17/2025 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 _____________________________ 37869 03/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3025 NORTH HARBOR LANE BROADWELL PLYMOUTH SENIOR LIVING PLYMOUTH, MN 55447 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 March 27th, 2025, the Minnesota Department of Health initiated an investigation of complaints #HL378699122M/HL378697462C . No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 YR1811 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 staff failed to appropriately supervise residents to protect their health and safety. A resident-to-resident altercation occurred (between the resident and a peer). The resident was hospitalized and diagnosed with subdural hematoma and a hip fracture. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. The resident and the resident’s peer argued when the resident wandered near her peer’s room. Neither resident had a history of physical aggression toward each other or toward other residents of the facility, and their plan of care was being followed. Facility staff could not have foreseen the incident would occur. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted family. The investigation included review of the resident record, death record, hospital records, facility internal investigation, facility incident reports, personnel files, staff schedules, and related facility policies and procedures. Also, the investigator observed resident interactions with staff. The resident resided in an assisted living memory care unit. The resident’s diagnoses included dementia. The resident’s services included help with mobility, ambulation, meals, medication administration, housekeeping, laundry, and activities of daily living. The resident’s assessment indicated the resident was susceptible to physical abuse, lacked community orientation skills, and was unable to deal with verbally/physically aggressive residents. The facility sentinel event document indicated the resident was found on the floor in the memory care hallway. The incident was initially determined to be an unwitnessed fall. Staff called 911 and the resident was admitted to the hospital. A computed tomography (CT) scan indicated the resident had a subdural hematoma. The resident complained of left hip pain, and an x-ray was initially negative for fractures. After three days, the resident continued to complain of left hip pain, and a CT scan revealed a left femoral neck fracture. The resident was discharged from the hospital 13 days after admission to a transitional care unit. Facility leadership viewed recorded camera footage of the night the resident fell and discovered the resident appeared to have been pushed by a peer outside the peer’s room. As a result, the resident fell to the floor. Staff found the resident lying on the floor four minutes later. The recorded camera footage showed the resident in the memory care unit hallway standing outside her peer’s door. The resident’s peer was standing just inside the door, with her left hand holding the resident’s right hand. The resident’s peer stepped out of her room and took hold of the resident’s lower right arm with her right hand. The resident’s peer ungripped her left hand from the resident’s lower right arm and moved her left hand to the resident’s right upper arm. At that point, the resident lost her balance and began to fall. As the resident fell to the floor, the resident’s peer lost her balance, falling forward nearly onto the floor. The resident’s peer was able to place both her hands on the floor to steady herself and stand back up. The resident’s peer turned around and walked back into her room as the resident lay on the floor. Progress notes and incident reports indicated the resident, and her peer had no known aggressive interactions prior to this incident, and neither had displayed physical aggression toward other residents. The resident’s peer had no memory of the interaction with the resident. Physical therapy (PT) progress notes documented during the resident’s TCU stay indicated the resident wandered in the hallway, looking in another patient’s room and required redirection to return to her room. PT facilitated gait training without an assistive device to increase the resident’s ambulation tolerance. The resident ambulated 300 feet but was easily distracted. A sentinel event document indicated three days after the resident returned from the TCU the resident was sitting in her wheelchair in the memory care dining room. She got out of the wheelchair and began to walk across the dining room. The resident tried to navigate around a pillar, lost her balance, and fell onto her right side, hitting her head on the wall. The resident said her head hurt. Camera footage revealed the resident sitting in the lower right corner of the screen. The resident was sitting in her wheelchair and wheeled herself a short distance before she stood up. The resident was wearing slip-on sneakers. The resident walked along the cafeteria with a slow, shuffling gate, hands in her pockets. The resident walked past a pillar at the entrance of the cafeteria. A second pillar was a short distance away, but there was a walker parked near it. When walking between the second pillar and the walker, the resident got tripped up on her feet and fell to the floor onto her right side. It appeared the resident hit her head on the wall as she fell. As the resident lay on the floor, two staff members immediately ran to her side. The two staff members briefly assessed her before the first staff member walked away and the second staff member went to get the resident’s wheelchair. The first staff member returned, wheeling another resident into the living room area. Both staff members appeared to try to manage the scene as residents gathered in the area. The first staff member then stayed with the resident, while the second staff member left the memory care unit. The video clip ended. Progress notes indicated staff assessed the resident and called 911. The resident was admitted to the hospital and received surgery on her right hip. The resident passed away in the hospital three days after admission. The resident’s hospital record indicated she was diagnosed with a scattered subarachnoid hemorrhage, subdural hematoma, and closed fracture of right hip. The resident underwent a surgical hip repair. After the surgery, the resident’s blood pressure lowered, and a family member elected to transition the resident to comfort cares. The medical examiner report indicated the resident died from complications of multiple blunt force injuries due to falls. The manner of death was documented as homicide. When interviewed, multiple staff members stated both the resident and her peer were pleasant and prone to wandering. The resident’s peer would verbally express frustration, but neither resident had displayed physical aggression toward each other or other residents prior to the incident. When the resident first fell, facility staff thought it was an unwitnessed fall and triaged it accordingly. Staff found the resident minutes after she fell and called 911. When the hospital informed the facility of the extent of the resident’s injuries, the facility leaders reviewed camera footage and discovered the resident’s fall was precipitated by the confrontation between the resident and her peer. The resident appeared to wander toward her peer’s room, and the peer attempted to push her away. As a result, the resident fell to the floor, and her peer nearly fell as well. This came as a surprise to staff, as neither resident had been known to interact with each other prior to this incident, nor had either expressed physical aggression. 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, deceased. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Not Applicable. the Action taken by facility: The facility provided supplemental staff training on how to intervene and recognize potential aggressive behavior. Staff continued to supervise resident-to-resident interactions and intervene when needed.

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 a resident when they failed to monitor the resident when eating. The resident choked on food and passed away. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. The facility ensured all staff working in the memory care unit were aware of the resident’s tendency to overfill his mouth with food and directed staff to monitor the resident at mealtime. The resident began choking, then collapsed on the staff, who made efforts to get the food out of his airway and called 911 when the resident became unresponsive. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted family. The investigation included review of the resident record, death record, medical examiner records, facility incident reports, personnel files, staff schedules, related facility policy and procedures. Also, the investigator observed staff/resident interactions during mealtime. The resident lived in an assisted living memory care unit for less than a year. The resident’s diagnoses included Alzheimer’s disease. The resident’s service plan included assistance with reminders for meals, getting to, and returning from meals. The resident’s assessment indicated the resident received a normal diet, was motivated by snacks, and although often overfilled his mouth with food, had no history of choking. An incident report indicated a staff realized the resident was choking on a mouthful of food, so she tried, but was unable to remove the food. When the resident became unresponsive, the staff called 911. During an interview, a staff member stated the resident loved food and would often fill his mouth and then chew it. The staff stated on the day of the incident, she asked the resident to come over to the cart for his medication. As the resident approached her the staff noticed his mouth was full of food. The staff stated she grabbed a garbage can and told the resident to spit it out. The staff stated the resident shook his head “no”. The staff said she looked down to pop out a pill, and when she looked up the resident was moving toward her. The staff stated she thought maybe he was choking, although he had no throat grabbing and made no sounds, she patted him on the back. The staff stated the resident then began to fall and she lowered him to the floor. The staff stated he looked blue, and she could tell he was not breathing so she yelled for her co-workers and tried to remove the food from his mouth. The staff stated she began abdominal thrusts, but nothing came out of his mouth. The staff stated she then called 911. An investigative report indicated law enforcement and emergency responders arrived at the facility and began cardiopulmonary resuscitation (CPR). The report indicated the resident had received chicken and rice for lunch, finished, staff cleared the table, and the resident walked to get his medications. The report indicated staff had no choking concerns, no concern for injury, and the resident had no recent illnesses, or head strikes. The report indicated emergency responders stopped CPR when staff provided valid do not resuscitated (DNR) paperwork. During investigative interviews, multiple staff members stated the resident had put non-food items in his mouth, but never choked before. During an interview, a family member stated she did not believe the facility could have done anything different to change the outcome of the incident. 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, deceased Family/Responsible Party interviewed: Yes Alleged Perpetrator interviewed: Not Applicable the Action taken by facility: The facility conducted an investigation, provided additional training to staff on responding to emergencies and monitoring residents at mealtime. 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: 08/05/2024 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 _____________________________ 37869 07/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3025 NORTH HARBOR LANE BROADWELL PLYMOUTH SENIOR LIVING PLYMOUTH, MN 55447 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 July 25, 2024, the Minnesota Department of Health initiated an investigation of complaint #HL378693725C/#HL378693462M. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 D1RH11 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): An unknown alleged perpetrator (AP) abused a resident when they yelled and repeatedly hit the resident’s low back. Investigative Findings and Conclusion: The Minnesota Department of Health determined abuse was not substantiated. There was no evidence abuse occurred. There were no witnesses to the alleged abuse. The resident was unable to recall the day or time the alleged abuse occurred and was unable to name a specific staff member. Staff members denied abusing the resident. The resident’s family member stated the resident had a history of hallucinations and delusions. An equal opportunity employer. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted a family member. The investigation included review of the resident’s medical record, facility incident and investigation reports, employee files, and facility policies. Also, 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 dementia and chronic pain. The resident’s service plan included assistance with transfers, toileting, mobility, dressing and medication administration. The resident’s nursing assessment indicated the resident was alert and oriented to self and had issues with hallucinations, delusions, and paranoia. The resident used a walker and wheelchair for mobility. The resident’s incident report indicated one day the resident reported to a staff member he was poked on his left side multiple times by a staff member who wanted the resident to move faster. The resident complained of pain on his left side. The resident was assessed and the nurse did not find any bruising or redness on the resident’s left side. Staff members who worked on the days and times the alleged abuse occurred were removed from the schedule until the internal investigation was completed. The internal investigation included interviews with the resident and several staff members who provided cares to the resident on days the alleged abuse occurred. When interviewed by facility administration, the resident was unsure when it happened and could not provide a name of the alleged staff member who abused him. Three staff members who were interviewed denied abusing the resident. At the end of the investigation, the facility concluded there was not enough evidence to suspend or reprimand a specific staff member. During interviews, multiple staff members denied they abused the resident and stated the resident was a sweet, gentle man. During an interview, a nurse stated she did not find any injuries or tender areas on the resident’s body when she assessed him. The nurse stated the residents never complained about staff members being abusive. During an interview, a family member stated the resident had a history of making delusional statements, and stated the resident suffered from chronic pain with movement. The family member stated he was happy with the cares the resident received from staff members. In conclusion, the Minnesota Department of Health determined abuse 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. Abuse: Minnesota Statutes section 626.5572, subdivision 2. "Abuse" means: (b) Conduct which is not an accident or therapeutic conduct as defined in this section, which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to, the following: (1) hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult; Vulnerable Adult interviewed: No, unable to interview due to cognitive status. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Unknown AP. Action taken by facility: The facility immediately conducted an internal investigation. Staff members who worked on days when the abuse may have occurred were removed from the schedule pending the results of the investigation. The facility retrained staff members on resident cares and rights. 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: 09/11/2023 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 _____________________________ 37869 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3025 NORTH HARBOR LANE BROADWELL PLYMOUTH SENIOR LIVING PLYMOUTH, MN 55447 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 July 27th, 2023, the Minnesota Department of Health initiated an investigation of complaint #HL378692242C/#HL378696524M. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 5I9U11 If continuation sheet 1 of 1