Ecumen Hutchinson the Pines.

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 2: a fine of $500 per violation, 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: St - 0 - 0510 - 144g.41 Subd. 3 - Infection Control Program - $500 Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, the total amount you are assessed is $500.00. You will be invoiced approximately 30 days after receipt of this notice, subject to appeal. An equal opportunity employer. Letter ID: IS7N REVISED 09/13/2021 Ecumen Hutchinson the Pines August 6, 2025 Pa ge 2 DOCUMENTATION OF ACTION TO COMPLY In accordance wi th 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. Please note that you may request a reconsideration or a hearing, but not both . If you wish to contest tags wi thout 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 import ant 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 Ecumen Hutchinson the Pines August 6, 2025 Pa ge 3 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, Kelly Thorson, Supervisor State Evaluation Team Email: Kelly.Thorson@state.mn.us Telephone: 320-223-7336 Fax: 1-866-890-9290 KKM PRINTED: 08/06/2025 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 _____________________________ 23788 06/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1015 CENTURY AVENUE SW ECUMEN HUTCHINSON THE PINES HUTCHINSON, MN 55350 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 144G.08 to 144G.95, these correction orders are far-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. SL23788016-0 PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On June 2, 2025, through June 4, 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 93 residents; 78 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 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 EZVK11 If continuation sheet 1 of 14 PRINTED: 08/06/2025 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 _____________________________ 23788 06/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1015 CENTURY AVENUE SW ECUMEN HUTCHINSON THE PINES HUTCHINSON, MN 55350 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) 0 480 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.

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), an unlicensed facility staff member, financially exploited three residents (resident #1, resident #2, and resident #3) when the AP removed narcotic medications from the blister pack cards for their own personal use and replaced them with other non-narcotic medications. As a result, the residents were administered medications which were not prescribed. Investigative Findings and Conclusion: The Minnesota Department of Health determined financial exploitation was not substantiated. Although narcotic diversion occurred, a specific alleged perpetrator could not be identified, as numerous staff were allowed access to the narcotic medications. When suspicion of narcotic diversion was identified, the facility took immediate action, reported the incident, and began an internal investigation. Although resident #1, resident #2, and resident #3 were administered medication not prescribed to them, no harm occurred as a result of the error. An equal opportunity employer. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigation included review of the resident’s medical record, police report, personnel files, and facility policies and procedures. At the time of the onsite visit, the investigator toured the facility and observed interactions between staff and residents. Resident #1 resided in an assisted living memory care unit. Resident #1’s diagnoses included Alzheimer’s disease and anxiety disorder. Resident #1’s service plan included assistance with bathing, dressing, grooming, oral care, transfers, and medication management. Resident #1’s assessment indicated the resident was orientated to person and place, however, unable to give accurate information consistently. Resident #1 was also enrolled in hospice services. Resident #2 resided in an assisted living facility. Resident #2’s diagnoses included type two diabetes, generalized pain, and heart disease. Resident #2’s service plan included assistance with bathing, dressing, and medication management. Resident #2’s assessment indicated the resident was cognitively intact with some short-term memory loss. Resident #3 resided in an assisted living facility. Resident #3’s diagnoses included anxiety disorder, paraplegia, and traumatic brain injury. Resident #3’s service plan included assistance with bathing, dressing, transfers, and medication management. Resident #3’s assessment indicated the resident was cognitively intact but had some short-term memory impairments due to the traumatic brain injury. During a routine medication pass, a facility staff member identified a different shaped pill on resident #1’s methadone (opioid medication is used to treat moderate to severe pain) blister pack medication card. The staff member immediately reported the discrepancy and contacted the on-call nurse. The following day, facility nursing staff followed up on the reported discrepancy of the pill size and shape from the medication card. Nursing staff contacted the pharmacy to review the medication in the blister pack to question if medication was filled correctly. The pharmacy’s review confirmed the medication was filled as prescribed; however, pharmacy staff noticed the methadone medication had been replaced with ondansetron (anti-nausea medication) tablets that were of a similar size and shape to the methadone tablets. Upon learning of this, nursing staff contacted the police, reported the narcotic diversion, and began an internal investigation. The facility’s internal investigation included a full reconciliation of the facility’s narcotic medication and assessment of affected residents. The internal investigation identified resident #1, resident #2, and resident #3’s narcotic medication cards had tape on the back of the pill packaging and the narcotic medications were replaced with non-narcotic medications of a similar shape and color. It was identified that the narcotic medications from the blister packs were being switched out with other non-narcotic medications that were packaged in bottles. The facility replaced all medications identified through the internal investigation. All staff were educated on narcotic diversion, how to inspect medication cards to identify potential diversion of medication, and nurse notification. Resident #1, resident #2, and resident #3 were assessed by nursing staff and their physicians were notified of the incident. Resident #1, resident #2, and resident #3’s medical records were reviewed and included no evidence of significant adverse effects due to the medication diversion and administration of the medications which were not prescribed. The police report indicated “approximately 15 staff members” had access to the narcotics and there wasn’t sufficient evidence to warrant criminal charges. During an interview, an unlicensed staff member stated he did not notice any change in condition of the residents around the time of the incident, but if he had, he would have reported the changes to the nurse. During an interview, the facility nurse indicated the residents involved in the medication diversion were assessed and their medical providers were updated. The facility nurse stated all staff were retrained after the incident and facility procedures were reviewed. During an interview, Resident #1’s family member stated he was notified of the incident and was very pleased with how the facility responded. Resident #1’s family member stated the care at the facility was excellent. Resident #2 and resident #3 were interviewed and stated they were not aware of the incident. Resident #2 and Resident #3’s family members were also interviewed and stated they were not aware of the incident. In conclusion, the Minnesota Department of Health determined financial exploitation 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. 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: Resident #1: No, resident was not cognitively intact to interview. Resident #2: Yes. Resident #3: Yes, however resident declined recorded interview. Family/Responsible Party interviewed: Resident #1: Yes. Resident #2: Yes. Resident #3: Yes. Alleged Perpetrator interviewed: No, attempts to contact were unsuccessful. Action taken by facility: The facility completed an internal investigation, monitored the residents involved, and completed staff education. 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: 01/02/2024 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 _____________________________ 23788 11/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1015 CENTURY AVENUE SW ECUMEN HUTCHINSON THE PINES HUTCHINSON, MN 55350 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 November 13, 2023, the Minnesota Minnesota Department of Health is Department of Health initiated an investigation of documenting the State Correction Orders complaint #HL237888886C/#HL237885168M. No using federal software. Tag numbers have correction orders are issued. been 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 is listed in the "Summary Statement of Deficiencies" column. This column also includes the findings which are in violation of the state requirement after the statement, "This Minnesota 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.