Claddagh Senior Living.

correction orders issued pursuant to the June 12, 2025 survey. In accordance with Minn. Stat. § 144G3. 1 Subd .4 (a), state correction orders issued pursuant to the last survey, completed on June 12, 2025, found not corrected at the time of the Septembe r12, 2025, follow-up survey and/or subject to penalty assessmen at re as follows: 0775 - Fire Protection And Physica lEnvironment - 144g.45 Subd. 2. (a) - $500.00 The details of the violations noted at the time of this follow-up survey completed on Septembe r12, 2025 (listed above), are on the attached State Form. Brackets around the ID Prefix Tag in the left hand column, e.g., {2 ----} will identify the uncorrected tags. Therefore ,in accordance with Minn. Stat. §§ 144G0. 1 to 144G9. 999, the total amount you are assesse dis $500.00. You will be invoiced approximately 30 days after receipt of this notice, subject to appeal. DOCUMENTATIO ONF ACTION TO COMPLY In accordance with Minn. Stat. § 144G3. 0, Subd .5(c), the licensee must document actions taken to comply with the correction orders outlined on the state form; however, plans of correction are not required to be submitted for approval. IMPOSITION OF FINES In accordance with Minn. Stat. § 144G3. 1, 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: Leve l1: no fines or enforcement; Leve l2: a fine of $500 per violation, in addition to any enforcemen tmechanism authorized in § 144G2. 0; Leve l3: a fine of $1,000 per incident, in addition to any enforcemen tmechanism authorized in § 144G2. 0; Leve l4: a fine of $3,000 per incident, in addition to any enforcemen tmechanism authorized in § 144G2. 0; An equal opportunity employer . Letter ID: 8GKP Revised 04/14/2023 Claddagh Senior Living October 16, 2025 Page 2 Leve l5: a fine of $5,000 per violation, in addition to any enforcemen tmechanism authorized in § 144G2. 0. CORRECTIO ONRDER RECONSIDERATI OPRNOCESS In accordance with Minn. Stat. § 144G3. 2, Subd .2, you may challenge the correction order(s) issued ,including the level and scope ,and any fine assesse dthrough 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 REQUESTIN AG HEARING Alternatively ,in accordance with Minn. Stat. § 144G3. 1, Subd .5(d), an assisted living provider that has been assesse da fine under this subdivision has a right to a reconsideration or a hearing under this section and chapter 14. Pursuan tto Minn. Stat. § 144G2. 0, 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 appea lfines 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. We urge you to review these orders carefully. If you have questions ,please contact Jodi Johnson at You are encouraged to retain this document for your records . It is your responsibility to share the information contained in the letter and/or state form with your organizations’ Governing Body. Sincerely, Jod iJohnson ,Supervisor State Evaluation Team Email :jodi.johnson@state.mn.us Telephone :507-344-2730 Fax :1-866-890-9290 JMD PRINTED: 10/16/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ R B. WING _____________________________ 33458 09/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 508 KRUCKOW AVENUE NORTH CLADDAGH SENIOR LIVING CALEDONIA, MN 55921 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE PREFIX PREFIX 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 FOLLOW UP using federal software. Tag numbers have SURVEY WITH RE-ISSUE OF ORDERS been assigned to Minnesota State Statutes for Assisted Living Facilities. The INITIAL COMMENTS assigned tag number appears in the SL33458017-1 far-left column entitled "ID Prefix Tag." The state Statute number and the On August 22, 2025, through September 12, corresponding text of the state Statute out 2025, the Minnesota Department of Health of compliance is listed in the "Summary conducted a follow-up survey at the above Statement of Deficiencies" column. This provider to follow-up on orders issued pursuant column also includes the findings which to a survey completed on June 12, 2025. As a are in violation of the state requirement result of the follow-up survey, the following after the statement, "This Minnesota orders were reissued. requirement is not met as evidenced by." Following the evaluators ' findings is the Time Period for Correction. PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH STATES,"PROVIDER'S PLAN OF CORRECTION." THIS APPLIES TO FEDERAL DEFICIENCIES ONLY. THIS 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. {0 480} 144G.41 Subdivision 1 Subd. 1a (a-b) Minimum {0 480} SS=F requirements; required food services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 G6HL12 If continuation sheet 1 of 14 PRINTED: 10/16/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ R B. WING _____________________________ 33458 09/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 508 KRUCKOW AVENUE NORTH CLADDAGH SENIOR LIVING CALEDONIA, MN 55921 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE PREFIX PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) {0 480} Continued From page 1 {0 480} (a) Except as provided in paragraph (b), food must be prepared and served according to the Minnesota Food Code, Minnesota Rules, chapter 4626. (b) For an assisted living facility with a licensed capacity of ten or fewer residents: (1) notwithstanding Minnesota Rules, part 4626.0033, item A, the facility may share a certified food protection manager (CFPM) with one other facility located within a 60-mile radius and under common management provided the CFPM is present at each facility frequently enough to effectively administer, manage, and supervise each facility's food service operation; (2) notwithstanding Minnesota Rules, part 4626.0545, item A, kick plates that are not removable or cannot be rotated open are allowed unless the facility has been issued repeated correction orders for violations of Minnesota Rules, part 4626.1565 or 4626.1570; (3) notwithstanding Minnesota Rules, part 4626.0685, item A, the facility is not required to provide integral drainboards, utensil racks, or tables large enough to accommodate soiled and clean items that may accumulate during hours of operation provided soiled items do not contaminate clean items, surfaces, or food, and clean equipment and dishes are air dried in a manner that prevents contamination before storage; (4) notwithstanding Minnesota Rules, part 4626.1070, item A, the facility is not required to install a dedicated handwashing sink in its existing kitchen provided it designates one well of a two-compartment sink for use only as a handwashing sink; (5) notwithstanding Minnesota Rules, parts 4626.1325, 4626.1335, and 4626.1360, item A, STATE FORM 6899 G6HL12 If continuation sheet 2 of 14 PRINTED: 10/16/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ R B.

STATE LICENSING COMPLIANCE REPORT Report #: HL334589645C Date Concluded: February 5, 2025 Name, Address, and County of Facility Investigated: Claddagh Senior Living 508 Kruckow Ave. North Caledonia, MN 55921 Houston County Facility Type: Assisted Living Facility with Evaluator’s Name: Brooke Anderson, RN Dementia Care (ALFDC) Special Investigator The Minnesota Department of Health conducted a complaint investigation to determine compliance with state laws and rules governing the provision of care under Minnesota Statutes, 144G. The purpose of this complaint investigation was to review if facility policies and practices comply with applicable laws and rules. No maltreatment under Minnesota Statutes, Chapter 626 was alleged. To view a copy of the correction orders, if any, please visit: https://www.health.state.mn.us/facilities/regulation/directory/provcompselect.html, or call website, please see the attached state form. 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 _____________________________ 33458 01/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 508 KRUCKOW AVENUE NORTH CLADDAGH SENIOR LIVING CALEDONIA, MN 55921 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 30, 2025, the Minnesota Department of Health initiated an investigation of complaint #HL334589645C. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 LDWE11 If continuation sheet 1 of 1