Cherrywood South St Cloud.

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; Level 3: a fine of $1,000 per incident, in addition to any enforcement mechanism authorized in § 144G.20; Level 4: a fine of $3,000 per incident, in addition to any enforcement mechanism authorized in § 144G.20; Level 5: a fine of $5,000 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 An equal opportunity employer. Letter ID: IS7N REVISE D09/13/2021 Cherrywood South St Cloud February 4, 2026 Page 2 pursuant to this survey: St - 0 - 0510 - 144g.41 Subd. 3 - Infection Control Program - $500.00 St - 0 - 1750 - 144g.71 Subd. 7 - Delegation Of Medication Administration - $1,000.00 The refor e, in accor danc e wit h Minn. Sta t. §§ 144G.01 to 144G.999 9, the total amount you are assessed is $1,500.00. You will be invoiced approximately 30 days after receipt of this notice, subject to appeal . DOCUMENTATIO ONF ACTION TO COMPLY In accorda nce with Min n. Stat. § 144G.30, Sub d. 5(c), th e lic ens ee mus t docum ent ac tions taken t o 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). CORRECTIO NORDER RECONSIDERATIO PNROCESS 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 REQUESTIN GA 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 appe al fi nes via re cons iderat ion , pl ease follow the procedu r e outl ined abo ve. Plea se no te tha t you Cherrywood South St Cloud February 4, 2026 Page 3 may re que st a rec onside rati on or a hearing, bu t not bot h. If you wish to cont est ta gs with out fine s 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 conv enien ce at thi s link: https: / / forms. office.com/ g/ Bm5uQEpHVa. Your inpu t 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 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: KellyT. horson@state. mn.us Telephone: 320-223-7336 Fax: 1-866-890-9290 CLN PRINTED: 02/ 04/ 2026 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 _____________________________ 32764 12/ 19/ 2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3315 COOPER AVENUE SOUTH CHERRYWOOD SOUTH ST CLOUD SAINT CLOUD, MN 56301 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. SL32764016- 0 PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On December 15, 2025, through December 19, STATES, "PROVIDER' S PLAN OF 2025, the Minnesota Department of Health CORRECTION. " THIS APPLIES TO conducted a full survey at the above provider and FEDERAL DEFICIENCIES ONLY. THIS the following correction orders are issued. At the WILL APPEAR ON EACH PAGE. time of the survey, there were 15 residents; 15 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 0UQ611 If continuation sheet 1 of 27 PRINTED: 02/ 04/ 2026 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.

Finding: Substantiated, facility responsibility Nature of Visit: 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 a resident when they failed to provide indwelling urinary catheter care and urinary catheter changes as ordered. The resident was admitted to the emergency department (ED) with a urinary tract infection (UTI), then admitted to hospice for end-of-life care. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was substantiated. The facility was responsible for the maltreatment. The facility failed to provide urinary catheter care and/ or change the resident’s urinary catheter monthly as ordered for three months and 16 days. The resident was transferred to the ED and diagnosed with a UTI. An equal opportunity employer. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigation included a review of the resident’s medication and treatment orders, progress notes, point of care documentation, and provider communication. In addition, the investigator reviewed outside medical records including hospital, ED, urology records, discharge summaries, history and physical, and provider notes. In addition, the investigator observed staff providing care to resident in the facility. The resident resided in an assisted living facility with diagnoses including dementia, UTI, chronic kidney disease, and heart failure. An outside medical record indicated the resident was hospitalized with a UTI. The medical record indicated an internal scan of her abdomen and pelvis identified the resident also had a bladder tumor. The facility re-admission assessment indicated the resident was returning from the hospital with a UTI and had an indwelling urinary catheter. The assessment indicated the resident required staff assistance with obtaining and ordering urinary catheter supplies and indicated the facility would provide catheter cares and change the urinary catheter per provider orders. The facility record included orders from her primary care provider to leave the residents urinary catheter in place until after a urology follow up, with orders received to change the resident’s catheter as needed for malfunction. The facility Medication and Treatment Administration Record (MAR/TAR) lacked orders to change the resident’s catheter for malfunction. A outside medical record urology after visit summary (AVS) indicated two weeks later the resident had a follow up after a cystoscopy procedure (a small tube and camera used to look inside the bladder) and transurethral resection of a bladder tumor (TURBT) procedure. The AVS indicated pathology identified the resident had bladder cancer. The AVS included orders to continue with the indwelling urinary catheter and change monthly. The same day a facility nurse’s note indicated the resident was seen by urology for a follow up with orders received change the resident’s urinary catheter monthly. The facility MAR/TAR lacked the providers orders. One month and 18 days after the urology follow up with orders to change the urinary catheter monthly, a provider rounding form and facility nurses note indicated the resident was seen by her primary care provider on rounds with orders received for catheter supplies and instructions to change the catheter monthly and as needed. The facility MAR/TAR lacked the providers orders, or documentation of the facility changing the resident’s catheter. A physician rounding form indicated the facility informed the primary care provider they had issues obtaining catheter supplies but failed to notify the provider the resident’s urinary catheter had not been changed as ordered for two months by that time. The resident record indicated no action was taken to ensure the resident’s catheter was changed. About a month later, an outside medical record indicated the resident was seen in the ED and treated for a urinary tract infection. The resident record indicated the facility failed to communicate to the ED the resident’s urinary catheter had not been changed. Two days later a nurse’s progress note indicated the resident had increased confusion, weakness, and fever. The nurses note indicated the resident was transferred to the ED and communicated to the ED the resident’s urinary catheter needed to be replaced. A follow up nurses note indicated the resident was admitted with a UTI, and her urinary catheter was changed at the hospital (three months and 16 days after it was placed by urology following the procedure). A hospital AVS indicated the resident was hospitalized and received intravenous antibiotics for a UTI then discharged back to the facility four days later. Three days after being readmitted to the facility the resident was admitted to hospice. The resident record, progress notes, and MAR/TAR had no documentation of the facility ever changing the resident’s urinary catheter prior to the hospital changing it. The resident’s (MAR/TAR) lacked any orders to change the resident’s catheter in the event of malfunction and failed to include the providers orders to change the resident’s catheter monthly prior to being admitted to hospice. The point of care (POC) documentation contained no documentation of daily catheter cares including cleansing the insertion site and urinary catheter tubing being completed daily. Email and text correspondence with the resident’s provider, facility, and family indicated the provider was unaware the facility had not changed the resident’s catheter as ordered. The communication indicated while hospitalized for a UTI, the facility was unable to provide a date of when the resident’s urinary catheter was last changed. During interviews, several facility licensed staff stated they went by the resident’s task list in the resident plan of care and did not routinely review resident physician orders. Since the facility failed to implement urology or providers orders, staff were not alerted the indwelling urinary catheter was due to be changed. During an interview the resident’s family member stated facility leadership told family the resident’s urinary catheter had not been changed at the facility. When interviewed facility leadership stated they had problems obtaining urinary catheter supplies for the resident for three months and verified there was no documentation the resident’s urinary catheter was changed prior to her admission to hospice. In conclusion, neglect was substantiated. Substantiated: Minnesota Statutes, section 626.5572, Subdivision 19. “Substantiated” means a preponderance of evidence shows that an act that meets the definition of maltreatment occurred. Neglect: Minnesota Statutes, section 626.5572, subdivision 17 "Neglect" means: (a) 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. (b) The absence or likelihood of absence of care or services, including but not limited to, food, clothing, shelter, health care, or supervision necessary to maintain the physical and mental health of the vulnerable adult which a reasonable person would deem essential to obtain or maintain the vulnerable adult's health, safety, or comfort considering the physical or mental capacity or dysfunction of the vulnerable adult Vulnerable Adult interviewed: No - deceased. Family/Responsible Party interviewed: Yes Alleged Perpetrator interviewed: Yes the Action taken by facility: The facility identified signs of infection and sent the resident to the ED for evaluation and treatment. Action taken by the Minnesota Department of Health: The facility was found to be in noncompliance. To view a copy of the Statement of Deficiencies and/or correction orders, please visit: https://www.health.state.mn.us/facilities/regulation/directory/provcompselect.html , or call MDH website, please see the attached Statement of Deficiencies. The responsible party will be notified of their right to appeal the maltreatment finding. cc: The Office of Ombudsman for Long Term Care The Office of Ombudsman for Mental Health and Developmental Disabilities Stearns County Attorney St. Cloud, MN City Attorney St. Cloud, MN Police Department PRINTED: 07/24/2023 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.