Country Manor Apartments.

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 . . ." In accordance with Minn. Stat. § 144G.31 Subd. 4, MDH may assess fines based on the level and scope of the violations; h owever, no immediate fines are assessed for this survey of your facility. 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 An equal opportunity employer. Letter ID: IS7N REVISED 09/13/2021 Country Manor Apartments May 30, 2025 Page 2 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 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, Kelly Thorson, Supervisor State Evaluation Team Email: Kelly.Thorson@state.mn.us Telephone: 320-223-7336 Fax: 1-866-890-9290 AH PRINTED: 05/30/2025 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 _____________________________ 30448 04/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 520 1ST STREET NE COUNTRY MANOR APARTMENTS SARTELL, MN 56377 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 CORRECTION ORDER(S) In accordance with Minnesota Statutes, section 144G.08 to 144G.95, these correction orders are issued pursuant to a survey. Determination of whether violations are corrected requires compliance with all requirements provided at the Statute number indicated below. When Minnesota Statute contains several items, failure to comply with any of the items will be considered lack of compliance. INITIAL COMMENTS: SL30448016-0 On April 21, 2025, through April 23, 2025, the survey at the above provider. At the time of the survey, there was thirteen (13) residents who received services under the Assisted Living Facility with Dementia Care license. 0 775 144G.45 Subd. 2. (a) Fire protection and physical 0 775 SS=D environment Each assisted living facility must comply with the State Fire Code in Minnesota Rules, chapter 7511, and: This MN Requirement is not met as evidenced by: Based on observation and interview, the licensee failed to comply with the requirements of Minnesota State Fire Code Rules, Chapter 7511. This practice resulted in a level two violation (a LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 K5VZ11 If continuation sheet 1 of 2 PRINTED: 05/30/2025 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 _____________________________ 30448 04/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 520 1ST STREET NE COUNTRY MANOR APARTMENTS SARTELL, MN 56377 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) 0 775 Continued From page 1 0 775 violation that did not harm a resident's health or safety but had the potential to have harmed a resident's health or safety) and was issued at an isolated scope (when one or a limited number of residents are affected or one or a limited number of staff are involved, or the situation has occurred only occasionally). The findings include: On April 22, 2025, at 11:15 a.m., the surveyor toured the facility with director of maintenance (DM)-E. During the facility tour, the surveyor observed electromagnetic locks were installed on the controlled egress doors. During the facility tour interview, DM-E stated a button or switch was not installed in the dementia care building that had the capability of unlocking the controlled egress locking system by directly breaking power to the locks. Controlled egress doors must comply with Minnesota State Fire Code Rules, Chapter 7511. TIME PERIOD FOR CORRECTION: Twenty-one (21) days STATE FORM 6899 K5VZ11 If continuation sheet 2 of 2 Food, Pools, and Lodging St. Paul, MN 55164 Type: Full Page 1 Food and Beverage Establishment Date: 04/22/25 Inspection Report Time: 10:30:06 Report: 1046251091 Location: Establishment Info: Country Manor Apartments ID #: 0002779 Risk: High 520 First Street NE Announced Inspection: No Sartell, MN56377 Benton County, 05 License Categories: Operator: FBLB, FBSW Country Manor Campus, LLC Phone #: 3202531920 Expires on: 12/31/25 27860 ID #: The violations listed in this report include any previously issued orders and deficiencies identified during this inspection. Compliance dates are shown for each item. No NEW orders were issued during this inspection. Total Orders In This Report Priority 1 Priority 2 Priority 3 0 0 0 ALL FOOD IS PREPPED AND COOKED AT "CARE CENTER", NOT ONSITE. FOOD IS BROUGHT OVER IN PORTIONED MEALS FOR RESIDENTS. STAFF PASS MEALS TO RESIDENTS DIRECTLY. DISHES ARE BROUGHT BACK TO "CARE CENTER" FOR CLEANING AND SANITIZING. SMALL KITCHENETTE ONSITE USED ONLY FOR RESIDENT ACTIVITIES. NO FOOD IS STORED ONSITE. NOTE: Plans and specifications must be submitted for review and approval prior to new construction, remodeling or alterations. I acknowledge receipt of the Minnesota Department of Health inspection report number 1046251091 of 04/22/25. Certified Food Protection Manager: / / Certification Number: Expires: Inspection report reviewed with person in charge and emailed. Signed: Signed: Establishment Representative Nicole Larrison Public Health Sanitarian St. Cloud nicole.larrison@state.mn.us Food Establishment Inspection Report Report #: 1046251091 Food, Pools, and Lodging No. of Repeat RF/PHI Categories Out 0 Time In 10:30:06 St.