Hayden Grove of St Anthony.

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) abused the resident when she crushed the resident’s medication, mixed them in milk, and forced the resident to drink it while co-workers held him. Investigative Findings and Conclusion: The Minnesota Department of Health determined abuse was inconclusive. The AP did crush the medications, even though the residents service plan stated do not crush the medications, and the AP mixed the medications in milk for administration. However, there was conflicting and/or a lack of evidence the resident was physically forced to drink the milk and medications. While the technique use during the medication pass may have been poor, it was unclear if abuse occurred. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff and family members. The investigation included review of the resident records, facility internal investigation, facility incident reports, personnel files, staff schedules, related facility policy and procedures. Also, the investigator observed staff interactions with other staff, residents and visitors. The resident resided in an assisted living memory care unit. The resident’s diagnoses included Alzheimer’s dementia, anxiety, and insomnia. The resident’s service plan included assistance with ambulation, medication management and eating prompts. The resident’s assessment indicated the resident could be resistant to cares and taking medications. An internal investigation document indicated one evening the AP crushed the residents evening medications, mixed that with milk and had the resident drink the milk. When asked why the AP did that, the report indicated the AP said the resident had previously refused his medications but liked milk so AP thought that if she crushed the medication and put them in milk, he would drink it. The internal investigation document indicated there was no force used to make the resident drink the milk and medications. The residents service plan indicated caregivers were instructed to give medication in applesauce, do not crush unless indicated, and to notify the nurse of refusals. During an interview, a manager stated the AP was educated on proper medication administration, which included not crushing medications unless directed by nursing. The manager also stated that the internal investigation found no used. During an interview, a nurse stated the resident was assessed by the resident’s medical provider after this incident and no sign of injury was identified. During an interview, an unlicensed caregiver, who witnessed this event, stated the resident drank the milk without force and without difficulty or complaint. This unlicensed care giver also stated that it would be wrong to use force, and he had never seen this at the facility. During an interview, another witness of the event stated two unlicensed caregivers were at the resident’s side while he was sitting in bed to ensure the resident did not tip back, each had a hand on the residents back. This witness stated the AP was verbally forceful in trying to get the resident to drink the milk. During an interview, the AP stated it was sometimes difficult to get the resident to take his medications, however she denied crushing his medications. The AP stated the resident liked milk and this was part of the effort to encourage him to take his medications. The Minnesota Department of Health determined that abuse 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. Abuse: Minnesota Statutes section 626.5572, subdivision 2. "Abuse" means: (a) An act against a vulnerable adult that constitutes a violation of, an attempt to violate, or aiding and abetting a violation of: (1) assault in the first through fifth degrees as defined in sections 609.221 to 609.224; (2) the use of drugs to injure or facilitate crime as defined in section 609.235; (3) the solicitation, inducement, and promotion of prostitution as defined in section 609.322; and (4) criminal sexual conduct in the first through fifth degrees as defined in sections 609.342 to 609.3451. A violation includes any action that meets the elements of the crime, regardless of whether there is a criminal proceeding or conviction. (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; (2) use of repeated or malicious oral, written, or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening; or (3) use of any aversive or deprivation procedure, unreasonable confinement, or involuntary seclusion, including the forced separation of the vulnerable adult from other persons against the will of the vulnerable adult or the legal representative of the vulnerable adult unless authorized under applicable licensing requirements or Minnesota Rules, chapter 9544. (c) Any sexual contact or penetration as defined in section 609.341, between a facility staff person or a person providing services in the facility and a resident, patient, or client of that facility. (d) The act of forcing, compelling, coercing, or enticing a vulnerable adult against the vulnerable adult's will to perform services for the advantage of another. Vulnerable Adult interviewed: No due to impaired cognition Family/Responsible Party interviewed: Yes Alleged Perpetrator interviewed: Yes Action taken by facility: The facility re-educated caregivers regarding medication pass technique including following instructions regarding crushing medications. The AP was no longer employed at the facility. Action taken by the Minnesota Department of Health: No further action at this time. cc: The Office of Ombudsman for Long Term Care The Office of Ombudsman for Mental Health and Developmental Disabilities PRINTED: 02/18/2025 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 _____________________________ 39425 01/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2601 STINSON PARKWAY HAYDEN GROVE OF ST ANTHONY ST ANTHONY, MN 55418 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 January 15, 2025, the Minnesota Department of Health initiated an investigation of complaint #HL394254980C/#HL394258342M. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 MNLK11 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: The facility neglected the resident when staff did not supervise the resident after the resident went into her apartment and choked on her food. Staff did not attempt the Heimlich maneuver on the resident. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. Facility staff interacted with the resident during the meal and again before she left the dining room. The resident walked out of the dining room and into her apartment without signs she was choking. Video indicated staff checked on her approximately a minute later. Staff found the resident unresponsive, called 911 and followed the dispatcher’s instructions until emergency responders arrived. The investigator conducted interviews with facility administrative staff, nursing staff, and unlicensed staff. The investigation included review of the resident record, death record, facility internal investigation, facility incident reports, staff schedules, and related facility policy and procedures. The investigator observed staff interactions and supervision in the dining room at mealtime. The resident resided in an assisted living memory care unit. The resident’s diagnoses included Alzheimer’s disease. The resident’s service plan included assistance with meal preparation but the resident ate independently. The resident’s assessment indicated the resident had cognitive impairment and required cues and redirection. The facility investigation report indicated that over the evening mealtime, a staff member checked on the resident and heard the resident gasping from the resident’s bathroom. The staff member found the resident slumped over on the toilet. The staff member saw food in the resident’s mouth, tried to remove it and went to get help. The facility dining room video indicated staff interacted with the resident several times throughout the meal. The resident ate most of her meal, stood up and walked out of the dining room toward her apartment. Although the video does not include audio, it did not appear the resident was experiencing signs of choking at that time. Approximately one minute after the resident left the dining room, a staff member walked out of the dining and in the direction of the resident’s apartment. Review of infrared video captured inside the resident’s apartment showed the resident enter her apartment, walked into her bathroom, and closed the door behind her. Approximately a minute later, an image of another person, presumed to be a staff member, walked into the apartment, and entered the resident’s bathroom. During an interview, another staff member who was in the dining room that day, stated the resident did cough some and offered her something to drink. He stated the resident did not show any indication she was choking or in distress when she left the dining room. During an interview, a facility manager stated a staff member checked on the resident only minutes after she left the dining room. The manager stated the staff member followed the plan of care, called 911 and followed the dispatcher’s instructions, which included CPR. Emergency responders attempted to revive the resident, but the resident passed away. The investigation could not conclude if staff performed the Heimlich maneuver on the resident. The resident’s cause of death was choking on food and her manner of death was ruled an accident. 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 deceased. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Not Applicable. Action taken by facility: The facility investigated the incident. Action taken by the Minnesota Department of Health: No further action taken at this time. cc: The Office of Ombudsman for Long Term Care The Office of Ombudsman for Mental Health and Developmental Disabilities PRINTED: 06/21/2024 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 _____________________________ 39425 05/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2601 STINSON PARKWAY HAYDEN GROVE OF ST ANTHONY ST ANTHONY, MN 55418 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 May 23, 2024, the Minnesota Department of Health initiated an investigation of complaint #HL394253004C/#HL394253081M. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 M1MJ11 If continuation sheet 1 of 1

correction orders and document the actions taken to comply in the facility's records. The Department reserves the right to return to the facility at any time should the Department receive a complaint or deem it necessary to ensure the health, safety, and welfare of residents in your care. STATE CORRECTION ORDERS The enclosed State Form documents the state correction orders. The Department of Health documents state correction orders using federal software. Tag numbers are assigned to Minnesota state statutes for Home Care Providers. 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 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. An equal opportunity employer. Letter ID: 9GJX Revise d04/20/2023 Hayden Grove of St. Anthony June 6, 2024 Page 2 In accordance with Minn. Stat. § 144G.31, Subd. 4(a)(5), MDH may impose fine amounts of either $1,000 or $5,000 to licensees who are found to be responsible for maltreatment. MDH may impose a fine of $1,000 for each substantiated maltreatment violation that consists of abuse, neglect, or financial exploitation according to Minn. Stat. § 626.5572, Subds. 2, 9, 17. MDH also may impose a fine of $5,000 for each substantiated maltreatment violation consisting of sexual assault, death, or abuse resulting in serious injury. In accordance with Minn. Stat. § 144G.31, Subd. 4(b), when a fine is assessed against a facility for substantiated maltreatment, the commissioner shall not also impose an immediate fine under this chapter for the same circumstance. 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 The total amount you are assessed is $500.00. You will be invoiced approximately 30 days after receipt of this notice, subject to appeal. DOCUMENTATION OF ACTION TO COMPLY Per Minn. Stat. § 144G.30, Subd. 5(c), t he 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 residents/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 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 the Department of Health within 15 calendar days of the correction order receipt date. A state correction order under Minn. Stat. § 144G.91, Subd. 8, Free from Maltreatment is associated with a maltreatment determination by the Office of Health Facility Complaints. If maltreatment is substantiated, you will receive a separate letter with the reconsideration process under Minn. Stat. § 626.557. 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 Hayden Grove of St. Anthony June 6, 2024 Page 3 writing and received by MDH 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 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: 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, Casey DeVries, Supervisor State Evaluation Team Email: Casey.DeVries@state.mn.us Telephone: 651-201-5917 Fax: 1-866-890-9290 HHH PRINTED: 06/06/2024 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 39425 05/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2601 STINSON PARKWAY HAYDEN GROVE OF ST ANTHONY ST ANTHONY, MN 55418 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(S) 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 survey. entitled "ID Prefix Tag." The state Statute number and the corresponding text of the Determination of whether violations are 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 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. SL39425015-0 PLEASE DISREGARD THE HEADING OF On, May 13, 2024, to May 15, 2024, the THE FOURTH COLUMN WHICH provisional survey at the above provider, and the CORRECTION." THIS APPLIES TO following correction orders are issued. At the time FEDERAL DEFICIENCIES ONLY. THIS of the survey, there were 110 residents, 32 of WILL APPEAR ON EACH PAGE. which were receiving services under the Provisional Assisted Living with Dementia Care THERE IS NO REQUIREMENT TO 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. 0 510 144G.41 Subd.