Countryside Catered Senior Liv.

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 facility neglected the resident when it did not to provide the resident appropriate monitoring and follow-up regarding medication administration when the resident refused medications and/or deceived the facility she was taking the medications but was not. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. The resident refused her prescribed clozapine (an antipsychotic) for several days, which resulted in hospitalization. When the concern for refusal arose, the facility notified the resident’s physician and guardian appropriately. The investigator conducted interviews with facility staff members, including administrative staff, and nursing staff. The investigation included review of the resident’s records, incident reports, staff schedules, policies, and procedures. The resident resided in an assisted living facility. The resident’s diagnoses schizoaffective disorder. The resident’s service plan included assist with medication administration. The resident’s assessment indicated a history of medication noncompliance and frequent nonadherence to treatment, which had previously resulted in worsening psychosis, including delusions and paranoia. A concern was identified when a staff member reported the resident had refused to take her prescribed clozapine for three consecutive days. The Medication Administration Record (MAR) indicated the resident was prescribed clozapine 325 mg nightly, consisting of 200 mg, 100 mg and 25 mg tablets, to be taken by mouth at bedtime. The physician’s order allowed administration between 7:00 p.m. and 9:30 p.m. If the resident refused the medication, staff were required to notify the nurse immediately. Staff were also instructed to perform a mouth check after administration to ensure the medication was swallowed. Per physician instruction, if a dose was missed, it was permissible to administer the missed evening dose the following morning and resume the regular dosing schedule thereafter. The resident’s service plan directed staff to bring the pill cards to the resident’s room and allow her to remove the medication from the card. It also required staff to complete a mouth check to verify the resident had swallowed her medication and to notify nursing staff immediately of any refusals. In addition, the service plan indicated the physician and the resident’s guardian must be notified as soon as possible when the resident refused her clozapine. If the resident refused the medication for two consecutive evenings, she was to be hospitalized for dose titration. If the resident refused Emergency Medical Services (EMS) transport, staff were instructed to contact the guardian for authorization to override the president’s refusal and arrange transport to the emergency room. The resident’s progress note on the fifteenth of the month indicated the nurse notified the resident’s guardian the resident had refused clozapine for the two previous nights. The physician was also updated that same day. The resident’s vital signs were within normal limits, and she came to the dining room for meals, appearing in a good mood and denied any paranoid or negative thoughts. The physician ordered if the resident refused clozapine again, staff were to notify the guardian and send the resident to the emergency room via ambulance for evaluation. On the seventeenth, the resident’s notes indicated the nurse again notified the guardian the resident had refused clozapine for three consecutive nights on the thirteenth, fourteenth, and fifteenth. The notes indicated the resident had refused two of her scheduled doses the previous evening, saying the medication upset her stomach. Later that evening, the resident was transported to the emergency room per the physician’s order. The hospital record indicated the resident was admitted due to noncompliance with clozapine and lorazepam for at least five days prior to admission. Two days after hospitalization, hospital staff found two baggies filled with pills in the resident’s pockets. Many of the pills appeared to have been licked or partially dissolved, making identification difficult; however, one of the identified pills was clozapine. During an interview, a county worker stated she learned about the incident from the resident’s guardian. She said the resident went three to four days without taking her medications and was subsequently admitted to the hospital. The county worker also said the resident had lived at the facility for more than ten years and generally did well in that environment. She stated the facility communicated appropriately with the guardian regarding the resident’s medication refusals. During an interview, a manager stated she was not working directly with the resident but had assigned one of her nurses to monitor the situation closely. She said the nurse notified the pharmacy, the physician, and the guardian about the resident’s medication refusals. The manager stated the resident eventually admitted to the hospital due to refusing her medications. The manager stated the hospital informed the facility they had discovered a bag containing unidentified medications in the resident’s possession, and the hospital was unable to determine where the medications originated. Following the incident, the facility provided staff additional education on proper mouth-check procedures, including instructing staff to ask the resident to open her mouth and move her tongue from side-to-side to ensure medications were swallowed during each administration. 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 refused. Family/Responsible Party interviewed: no, unable to reach the guardian. Alleged Perpetrator interviewed: Not Applicable. Action taken by facility: The facility notified the guardian and the physician in a timely manner. Following the incident, the facility took steps to reduce the risk of unknown medication refusals including education and re-training focused on performing thorough mouth checks during medication administration. 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: 11/14/2025 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 _____________________________ 30584 09/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 650 EL DORADO STREET COUNTRYSIDE CATERED SENIOR LIV OWATONNA, MN 55060 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 On September 12, 2025, the Minnesota Department of Health initiated an investigation of complaints #HL305845202M/HL305841820C. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 396R11 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 necessar yto ensure the health, safety, and welfare of residents in your care. STATE CORRECTIO ONRDERS 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 Statemen tof Deficiencies "column. This column also includes the findings that are in violation of the state statute after the statement, "This MN Requiremen tis not met as evidenced by . . ." 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 enforcement mechanism authorized in § 144G2. 0; Leve l3: a fine of $1,000 per incident, in addition to any enforcement mechanism authorized in § 144G2. 0; An equal opportunity employer . Letter ID: IS7N REVISE 0D9/13/2021 Countryside Catered Senio rLiving Novembe r12, 2025 Page 2 Leve l4: a fine of $3,000 per incident, in addition to any enforcement mechanism authorized in § 144G2. 0; Leve l5: a fine of $5,000 per violation, in addition to any enforcement mechanism authorized in § 144G2. 0. Therefore ,in accordance with Minn. Stat. §§ 144G0. 1 to 144G9. 999, the following fines are assessed pursuant to this survey: St - 0 - 0775 - 144g.45 Subd. 2. (a) - Fire Protection And Physica lEnvironment - $500.00 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 docum ent 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: x Identify how the area(s) of noncompliance was corrected related to the resident(s)/ employees( ) identified in the correction order. x 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. x Identify what changes to your systems and practices were made to ensure compliance with the specific statute(s). 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. Countryside Catered Senio rLiving Novembe r12, 2025 Page 3 To submit a hearing request, please visit: https:/ / forms.web.health.state.mn.us/form/ HRDAppealsForm To appea lfines via reconside ration, please follow the pr ocedur e outlined above. Plea se 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: https:/ / forms.office.com/g/ Bm5uQEpHV.a Your input is important to us and will enable MDH to improve its processe sand communication with providers . If you have any questions regarding the questionnaire ,please contact Susan Winkelmann at susanw. inkelmann@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 organizations’ Governing Body. If you have any questions ,please contact me. Sincerely, Jod iJohnson ,Supervisor State Evaluation Team Email: Jodi.Johnson@state.mn.us Telephone :507-344-2730 Fax :1-866-890-9290 CLN PRINTED: 11/12/2025 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 _____________________________ 30584 10/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 650 EL DORADO STREET COUNTRYSIDE CATERED SENIOR LIV OWATONNA, MN 55060 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 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." issued pursuant to a survey. The 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. SL30584016-0 PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On October 27, 2025, through October 30, 2025, STATES,"PROVIDER'S PLAN OF the Minnesota Department of Health conducted a CORRECTION." THIS APPLIES TO full survey at the above provider and the FEDERAL DEFICIENCIES ONLY. THIS following correction orders are issued. At the time WILL APPEAR ON EACH PAGE. of the survey, there were 61 residents; 26 receiving services under the Assisted Living THERE IS NO REQUIREMENT TO Facility with 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 NJC911 If continuation sheet 1 of 20 PRINTED: 11/12/2025 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.