Silvercrest Properties Llc.

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 § 144G.20. An equal opportunity employer. Letter ID: IS7N REVISED 09/13/2021 Silvercrest Properties LLC April 3, 2025 Page 2 Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, the following fines are assessed pursuant to this survey: 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 $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 Silvercrest Properties LLC April 3, 2025 Page 3 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, Casey DeVries, Supervisor State Evaluation Team Email: casey.devries@state.mn.us Telephone: 651-201-5917 Fax: 1 -866-890-9290 JMD PRINTED: 04/03/2025 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 _____________________________ 20427 03/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3633 PARK CENTER BOULEVARD SILVERCREST PROPERTIES LLC SAINT LOUIS PARK, MN 55416 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 ASSISTED LIVING PROVIDER LICENSING Minnesota Department of Health is CORRECTION ORDER(S) documenting the State Correction Orders using federal software. Tag numbers have In accordance with Minnesota Statutes, section been assigned to Minnesota State 144G.08 to 144G.95, these correction orders are Statutes for Assisted Living Facilities. The issued pursuant to a survey. assigned tag number appears in the far-left column entitled "ID Prefix Tag." The Determination of whether violations are corrected state Statute number and the requires compliance with all requirements corresponding text of the state Statute out provided at the Statute number indicated below. of compliance is listed in the "Summary When Minnesota Statute contains several items, Statement of Deficiencies" column. This failure to comply with any of the items will be column also includes the findings which considered lack of compliance. are in violation of the state requirement after the statement, "This Minnesota INITIAL COMMENTS: requirement is not met as evidenced by." Following the evaluators ' findings is the SL20427016-0 Time Period for Correction. On March 3, 2025, through March 5, 2025, the PLEASE DISREGARD THE HEADING OF survey at the above provider. At the time of the STATES,"PROVIDER'S PLAN OF survey, there were 86 residents; all 86 receiving CORRECTION." THIS APPLIES TO services under the Assisted Living Facility with FEDERAL DEFICIENCIES ONLY. THIS Dementia Care license. WILL APPEAR ON EACH PAGE. THERE IS NO REQUIREMENT TO SUBMIT A PLAN OF CORRECTION FOR VIOLATIONS OF MINNESOTA STATE STATUTES. THE LETTER IN THE LEFT COLUMN IS USED FOR TRACKING PURPOSES AND REFLECTS THE SCOPE AND LEVEL ISSUED PURSUANT TO 144G.31 SUBDIVISION 1-3. 0 550 144G.41 Subd. 7 Resident grievances; reporting 0 550 SS=F maltreatment LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 491D11 If continuation sheet 1 of 12 PRINTED: 04/03/2025 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 _____________________________ 20427 03/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3633 PARK CENTER BOULEVARD SILVERCREST PROPERTIES LLC SAINT LOUIS PARK, MN 55416 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) 0 550 Continued From page 1 0 550 All facilities must post in a conspicuous place information about the facilities' grievance procedure, and the name, telephone number, and email contact information for the individuals who are responsible for handling resident grievances. The notice must also have the contact information for the Office of Ombudsman for Long-Term Care and the Office of Ombudsman for Mental Health and Developmental Disabilities and must have information for reporting suspected maltreatment to the Minnesota Adult Abuse Reporting Center.

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 alleged perpetrator (AP) abused the resident, when she transferred the resident incorrectly following a recent right arm fracture surgery and the resident sustained another fracture of the right arm. Investigative Findings and Conclusion: The Minnesota Department of Health determined abuse was not substantiated. Documentation reviewed provided no evidence that abuse occurred. Staff reported the resident’s complaints of pain to the nurse and the nurse assessed and monitored the resident. When complaints of pain continued, the physician was contacted, and an x-ray was ordered. Although it was reported that staff improperly transferred the resident, no specific staff member was identified. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted the resident’s hospital case manager and the resident’s provider. The investigation included review of the resident record(s), death record, hospital records, facility internal investigation documentation, facility incident reports, personnel files, staff schedules and related facility policy and procedures. Also, the investigator observed the facility environment and staff interactions with residents. The resident resided in an assisted living facility. The resident’s diagnoses included breast cancer with metastasis to the bone, osteoporosis, history of femur, right pelvic and right shoulder fractures. The resident’s service plan at the time of the incident included assistance with showers, medication management, and mobility escorts. The resident’s assessment at the time of the incident indicated the resident was disoriented with memory impairment. The assessment also indicted the resident required staff assistance with activities of daily living, (ADLs), including dressing, grooming, and toileting. The resident received staff assistance for getting in and out of bed and for transfers. The resident utilized wheeled walker for mobility and a manual wheelchair for physician visits. The resident’s assessment indicated the resident had balance issues when standing and walking. A facility investigation indicted the resident complained of increased right arm pain approximately thirty-nine days post-surgery following repair of a right arm fracture. Internal investigation documentation indicated several staff had assisted the resident with transfers prior to the onset of the new complaints of pain. When staff alerted nurse management of the resident’s pain, the nurse assessed the resident’s pain and initially administered previously ordered pain interventions. Later that evening, the resident’s family contacted the facility about the resident’s complaints of pain. The next day when the resident’s complaints of pain continued, a triage nurse was contacted who directed staff to elevate the arm, administer scheduled pain medications, and to call back if complaints of pain continued. When the resident’s complaints of pain continued, the provider was contacted and an x-ray of the arm was ordered. The resident’s x-ray revealed another fracture to her right arm then the resident’s family transported the resident to the hospital. The resident admitted to the hospital and another surgery to repair the right arm fracture was completed. The resident transferred to a transitional care unit for three days prior to returning to the facility. During an interview, the resident’s family member stated when visiting the resident on a Friday, the resident was found to by laying on her couch unable to get up, stating that her arm hurt. During the visit, the resident reported someone lifted her incorrectly. The resident was unable to give a description of the staff member that transferred her incorrectly. At the time of the visit the resident was not using her walker and family observed staff on several occasions to transfer the resident to a wheelchair with staff assistance and without a transfer belt. During an interview, an unlicensed staff who worked on Friday, stated she approached the resident when she was laying on the couch and did not want to go to BINGO, which she normally attended. The resident was observed to be holding her arm and the unlicensed personnel reported the pain to nursing staff. The unlicensed personnel did not recall receiving a report concerning the resident’s arm prior to the start of her shift. During an interview, a management nurse indicated she was informed on Friday, by the administrative nurse and unlicensed personnel that the resident was having pain in her right arm. The management nurse assessed the resident and instructed an unlicensed staff to administer an as needed pain gel medication to the resident’s right arm. After the pain gel was administered, unlicensed personnel informed the nurse that the resident’s arm was feeling better. During an interview, a second family member of the resident stated when visiting the resident on Tuesday, the resident reported her arm immediately started hurting after a staff member lifted her out of her bed. During an interview, the resident’s provider stated the fracture was likely a result of the transfers and the resident’s diagnoses. During an interview, an administrative nurse stated that the resident’s family member reported the resident to be doing well in therapy the Thursday before the complaints of pain started. The administrative nurse stated facility staff should have completed a follow-up call to a nurse on both Saturday and Sunday if the resident had continued pain. A facility investigation was initiated to investigate the incident and the evening shift staff member demonstrated how he transferred the resident using her walker and held her right arm. The administrative nurse assigned proper transfer training to the staff member. 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: (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. Vulnerable Adult interviewed: No. Deceased. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Not Applicable. the Action taken by facility: The facility completed a facility investigation and incident report. The facility completed re-training of proper transfers. 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: 02/10/2025 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 _____________________________ 20427 12/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3633 PARK CENTER BOULEVARD SILVERCREST PROPERTIES LLC SAINT LOUIS PARK, MN 55416 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 17, 2024, through December 27, 2024, the Minnesota Department of Health conducted a complaint investigation HL204279281C HL204276241M at the above / provider. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 Z15R11 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 alleged perpetrator (AP), a facility staff member, neglected the resident when the AP did not follow the resident’s plan of care, which resulted in the resident falling and fracturing the resident’s hip. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. The AP followed the resident’s plan of care and facility policies and procedures at the time of the fall. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted the resident’s family member. The investigation included review of the resident records, hospital records, facility incident reports, personnel files, staff schedules, and related facility policy and procedures. Also, the investigator toured the facility. The resident resided in an assisted living facility. The resident’s diagnoses included macular degeneration (blurred or reduced vision) and idiopathic peripheral autonomic neuropathy (damage of the peripheral nerves where cause cannot be determined). The resident’s service plan included staff assistance/reminders to use the bathroom throughout the day and night. The resident required supervision from staff to transfer and walk and used a walker to ambulate. The resident was able to make her needs known to staff but required assistance with decision making. The resident was at risk for falling. The facility’s incident report indicated in the early morning hours one day, the AP assisted the resident to the bathroom during a scheduled toileting time. The resident was walking to the bathroom when the resident’s head fell forward and the resident’s leg “gave out.” The AP assisted the resident to the floor. The AP stated, "it was like she fell asleep while walking." The AP contacted the triage nurse and who directed the AP to give the resident Tylenol (for pain relief). Transcripts of the phone call between the AP and the triage nurse indicated the resident walked to the bathroom and was lowered to the floor by the AP. The AP asked the resident “how bad is your pain”, the resident said, “not too bad.” The triage nurse instructed the AP to get the resident off the floor and to give Tylenol for the pain. The AP gave the resident Tylenol and assisted her back into bed. At that time, the resident’s blood pressure was slightly elevated. Approximately, one hour after the fall and as directed by the triage nurse, the AP checked on the resident and the resident’s blood pressure. The resident told the AP she was fine and the resident’s blood pressure had improved following the fall. Approximately four hours later, the resident complained of increased right hip pain and arrangements were made to evaluate the resident at a hospital. Hospital Records indicated the resident had a right femur fracture, diagnosed as pathologic (indicative of or caused by disease) fracture due to osteoporosis (weakened and brittle bones.) During an interview, the AP stated the resident walked to the bathroom, as the resident entered the bathroom, the resident started to go down. The AP stated one of the resident’s legs was straight and the other leg was crossed underneath when the resident was lowered to the floor onto her back. The AP called another co-worker for help and then called the triage nurse. The nurse stated not to move the resident and ask if the resident had any pain. The resident’s blood pressure was checked, and the resident was assisted back into bed. The AP stated the resident was checked on every two hours throughout the early morning, until she had to switch floors for another shift. During an interview, nursing leadership stated the AP assisted the resident to the bathroom during a scheduled service. The AP lowered the resident to the floor when the resident’s legs gave out. The AP called the on-call triage nurse. The resident had pain but was alert and wanted to go back to bed. The AP assisted the resident with getting Tylenol for pain. That morning, the resident’s family member came into the facility, and at that time, it was decided that the resident be sent to the hospital. 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. Resided at an unknown facility. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Yes. Action taken by facility: After the resident fell, the AP notified the triage nurse, checked the resident’s vital signs and gave Tylenol for pain. 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: 07/16/2024 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 _____________________________ 20427 06/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3633 PARK CENTER BOULEVARD SILVERCREST PROPERTIES LLC SAINT LOUIS PARK, MN 55416 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 June 17, 2024, the Minnesota Department of Health initiated an investigation of complaint #HL204273426M/#HL204273627C. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 IY9Q11 If continuation sheet 1 of 1