Stoney River Ramsey.

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 unknown alleged perpetrator (AP) abused the resident when the resident was sent to the hospital after a reported fall with multiple fractures and extensive bruising inconsistent from a fall. Investigative Findings and Conclusion: The Minnesota Department of Health determined abuse was not substantiated. The AP completed safety checks on the resident per the resident’s care plan. The resident was observed twice during the night in the dining room and was assisted back to his room. The resident’s primary care provider said the resident’s injuries could have been sustained from a fall. The resident had a history of fractures and most likely had undiagnosed osteoporosis. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator interviewed a family member and other residents who lived at the facility. The investigation included review of the resident’s record, hospital records, facility internal investigation, facility incident reports, personnel files, staff schedules, and related facility policy and procedures. Also, the investigator toured the facility and observed staff providing care to residents. The resident resided in an assisted living facility The resident’s diagnoses included dementia, dizziness, weakness, and fainting. The resident’s service plan included assistance with medication management, safety checks once per shift, bathing, and housekeeping. The resident’s assessment indicated the resident wore hearing aids and glasses but was not wearing these items when he was found on the floor. The resident’s memory was declining and recently the facility and family had discussed moving him to memory care. The internal investigation indicated the resident was found on his bedroom floor lying on his right side. He was alert but confused and was unable to report what happened. He had an abrasion on the right side of his face, a bump on the back of his head and complained of pain in his right arm. His family was notified, and they transported him to the hospital. The hospital record indicated the resident was diagnosed with multiple fractures including ribs, sternum (middle vertical chest bone that ribs connect to), pelvis, and elbow. The resident sustained a subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain), and abrasion (rug burn) on right side of face. The resident had recently become more unsteady on his feet but had documented no recent falls. He was recently seen at the hospital for fainting. Due to the extent of the resident’s injuries, the hospital suspected possible abuse from the facility. The resident was discharged to a transitional care unit. During an interview, a member of management said she conducted the internal investigation. She said the resident had several fractures and injuries related to his fall. The incident was reported based on the injuries sustained but she had no concerns of abuse after investigating the incident. She said staff followed the resident’s care plan. The resident had a recent decline mentally and physically and family planned to move him to memory care. The resident was kind and well-liked by staff. During an interview, an unlicensed personnel said she found the resident lying on the floor when she went to administer his morning medication. He was confused and when asked what happened he said something about steps or stairs. Family was contacted and several staff assisted the resident off the floor and the resident was sent to the hospital. During an interview, a member of management said he responded to the call for assistance after the resident was found on the floor. The resident was observed close to the bathroom with his head facing the bathroom door. It appeared he tried to walk to the bathroom. He said the resident tried to get up several times while staff assessed him, and he needed to be redirected to relax and not get up. He said from the restlessness the resident exhibited while on the ground, the resident most likely fell, got up, and fell again possibly several times. During an interview, the AP said the resident received safety checks once per shift. She observed the resident twice during her shift. She said he recently had become more confused and wandered down to the dining room for breakfast during the night. The first time she observed him in the dining room she gave him a snack and helped him back to his room. The second time he declined a snack, and she helped him back to his apartment. She never observed the resident on the floor, never harmed the resident, and never witnessed anyone else harm the resident. During an interview, a family member said the resident sustained his injuries from a fall. She had no concerns about the facility. She said the facility provided excellent care and denied any similar incidents. During an interview, the resident’s primary care provider said the resident sustained his injuries from a reported fall. She said the resident most likely had undiagnosed osteoporosis (weak, brittle bones) and although his injuries were extensive, it was not uncommon for someone his age to sustain these injuries from a fall. During an interview, resident-2 said the staff were kind and helpful. She had no concerns with the care she received. She said she never observed a staff member verbally or physically abuse her or another resident. During an interview, residnet-3 said staff were “very good.” He said he had never observed a staff member verbally or physically abuse him or another resident. The resident had no concerns about the way staff treat him. 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. Physical Abuse: Minnesota Statutes, section 260E.03, Subd. 18 "Physical abuse" means any physical injury, mental injury under subdivision 13, or threatened injury under subdivision 23, inflicted by a person responsible for the child's care on a child other than by accidental means, or any physical or mental injury that cannot reasonably be explained by the child's history of injuries, or any aversive or deprivation procedures, or regulated interventions, that have not been authorized under section 125A.0942 or 245.825. Vulnerable Adult interviewed: No, due to cognitive deficit. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Yes. Action taken by facility: The facility assessed the resident, called family to report the incident, and sent the resident to the hospital. The facility completed an internal investigation. The facility installed a fall system in resident rooms that detects when a resident falls. The family member and/or residents decide if they want the system activated. 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: 05/15/2025 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 _____________________________ 31334 04/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 14401 NOWTHEN BOULEVARD NW STONEY RIVER RAMSEY RAMSEY, MN 55303 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 25, 2025, the Minnesota Department of Health initiated an investigation of complaint #HL313347864C/#HL313349283M. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 DUTE11 If continuation sheet 1 of 1

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 § 144G.20. Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, the following fines are assessed pursuant to this survey: An equal opportunity employer. Letter ID: IS7N REVISED 09/13/2021 Stoney River Ramsey February 11, 2025 Page 2 0510 - 144g.41 Subd. 3 - Infection Control Program - $500.00 2310 - 144g.91 Subd. 4 (a) - Appropriate Care And Services - $3,000.00 Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, t he total amount you are assessed is $3,500.00. 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. 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 Stoney River Ramsey February 11, 2025 Page 3 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 JMD 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 _____________________________ 31334 12/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 14401 NOWTHEN BOULEVARD NW STONEY RIVER RAMSEY RAMSEY, MN 55303 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 far 144G.08 to 144G.95, these correction orders are 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. SL31334016-0 PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On December 16, 2024, through December 20, STATES,"PROVIDER'S PLAN OF 2024, the Minnesota Department of Health CORRECTION." THIS APPLIES TO conducted a full survey at the above provider, and FEDERAL DEFICIENCIES ONLY. THIS the following correction orders are issued. At the WILL APPEAR ON EACH PAGE. time of the survey, there were 75 residents; 55 receiving services under the provider's Assisted THERE IS NO REQUIREMENT TO Living with Dementia Care license. SUBMIT A PLAN OF CORRECTION FOR VIOLATIONS OF MINNESOTA STATE An immediate correction order was identified on STATUTES. December 18, 2024, issued for SL31334016-0, tag identification 2310. 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. 0 510 144G.41 Subd. 3 Infection control program 0 510 SS=F (a) All assisted living facilities must establish and LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 WGRO11 If continuation sheet 1 of 74 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 _____________________________ 31334 12/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 14401 NOWTHEN BOULEVARD NW STONEY RIVER RAMSEY RAMSEY, MN 55303 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) 0 510 Continued From page 1 0 510 maintain an infection control program that complies with accepted health care, medical, and nursing standards for infection control. (b)The facility's infection control program must be consistent with current guidelines from the national Centers for Disease Control and Prevention (CDC) for infection prevention and control in long-term care facilities and, as applicable, for infection prevention and control in assisted living facilities. (c) The facility must maintain written evidence of compliance with this subdivision.

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 (AP) financially exploited a resident when two 30-day supplies of narcotic medications went missing after the AP received them from the pharmacy. Investigative Findings and Conclusion: The Minnesota Department of Health determined financial exploitation was inconclusive. The facility never recovered the controlled substances, and the AP denied taking the controlled substances although she signed for them during a medication delivery. Additionally, multiple staff stated the facility did not have a set protocol for receiving medications from the pharmacy at the time of the incident, and all nursing staff had access to the medication rooms. The investigator conducted interviews with facility staff members, including nursing staff and unlicensed staff. The investigator contacted law enforcement. The investigation included review of the resident’s medical record, facility information including policies related to the allegation, An equal opportunity employer. and incident reports. Also, the investigator observed medication rooms, as well as controlled substance storage and logs. The resident resided in an assisted living facility. The resident’s diagnoses included cancer and chronic pain. The resident’s service plan included assistance with medication management. The resident admitted to the facility on hospice. The resident’s admission orders included lorazepam 0.5 milligrams (mg) by mouth every four hours as needed for agitation, restlessness, anxiety, or shortness of breath, and hydromorphone 1 mg by mouth every four hours as needed for pain or shortness of breath. The resident’s medical record included progress notes indicating the resident would not receive medication administration the day of admission. A pharmacy delivery receipt indicated the AP signed for 30 tablets of lorazepam and 30 tablets of hydromorphone. During an interview, the AP stated she did not take the resident’s controlled substances. That evening, the AP signed the pharmacy invoice receipt and accepted medications for facility residents from the pharmacy delivery driver. She did not review the medications to ensure the pharmacy invoices matched which the delivered medications. The AP brought the medications back to the medication room of her unit and left the bags there while she completed tasks and assisted residents. Later when the evening slowed down, the AP brought the medication bags to the appropriate units throughout the building. The AP delivered the resident’s bag of medications to the appropriate medication room and informed the unlicensed personnel (ULP 1) passing medications for that unit. At no point during the shift did the AP open any of the medication bags. The AP stated although the medication rooms were secured with codes, all nurses and aides had access to the rooms. During an interview, ULP 1 stated all the nursing staff had access to the medication rooms. Throughout ULP 1’s time at the facility, there had been many nursing and management changes. At the time of the incident, staff did not have clear direction for medication deliveries, so unlicensed staff would often just receive the medications, look to see who the medications were for, then place the bag in the appropriate medication cart or medication room until a nurse arrived to take care of the medications. During the middle of a medication pass, the pharmacy delivery driver arrived. ULP 1 witnessed the AP receiving medications. Later in the shift, ULP 1 found a medication bag on the medication cart she had been working out of. ULP 1 left the bag in the medication cart since the facility had not started administering medications to the resident yet. During shift change the next morning, ULP 1 informed ULP 2 about the medication bag. During an interview, ULP 2 stated she started her shift the next morning and received report from ULP 1 who reported there had been a medication delivery the night before, and the bag was on the table in the medication room. ULP 2 completed her morning medication pass, then brought the bag to the nurse to open together. The nurse then realized the controlled substances, lorazepam and hydromorphone, were supposed to be in the delivery. ULP 2 stated the facility did not teach her how to accept medications from the pharmacy delivery driver until after this incident occurred. During an interview, a nurse stated it had not been uncommon during that time for staff to leave delivered medications for the nurses the next day, but it was her first time seeing it occur for delivered controlled substances. The nurse stated they completed an investigation after opening the medication bag and not finding the hydromorphone. The nurse stated there had been a second bag containing the lorazepam, but the hydromorphone was missing. They checked throughout the facility, including in the medication carts and resident apartments but did not recover the controlled substance. The facility completed an in-service training with staff regarding the proper protocol for controlled substances. During an interview, a family member stated they had extra medication from prior to the resident’s admission they were able to administer the resident until the new medications arrived, so she did not have to go without medication. During an onsite visit, the investigator observed the facility’s controlled substances were stored according to their policy. Additionally, staff accurately verbalized the current pharmacy delivery process which included only accepting medications after staff have compared the pharmacy receipt and delivered medications to ensure all medications were delivered. Then staff deliver medications to each appropriate medication cart, and enter controlled substances into the narcotic book before placing them in the narcotic box. 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; Vulnerable Adult interviewed: No; The resident is deceased. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Yes. Action taken by facility: The facility completed an internal investigation and training with staff. Additionally, 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: 02/16/2024 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 _____________________________ 31334 12/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 14401 NOWTHEN BOULEVARD NW STONEY RIVER RAMSEY RAMSEY, MN 55303 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 20, 2023, the Minnesota Department of Health initiated an investigation of complaint #HL313344721C/#HL313347865M. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 GRPP11 If continuation sheet 1 of 1