The Lodge.

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 1: no fines or enforcement. Level 2: a fine of $500 per violation, in addition to any enforcement mechanism authorized in § 144G.20 for widespread violations; Level 3: a fine of $3,000 per violation per incident, in addition to any enforcement mechanism authorized in § 144G.20. An equal opportunity employer. Letter ID: IS7N REVISED 09/13/2021 The Lodge January 28, 2025 Page 2 Level 4: a fine of $5,000 per incident, 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 - $500.00 Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, t he total amount you are assessed is $500.00. You will be invoiced approximately 30 days after receipt of this notice, subject to appeal. 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 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. The Lodge January 28, 2025 Page 3 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. P lease note that you may request a reconsideration o r 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: 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, Casey DeVries, Supervisor State Evaluation Team Email: Casey.DeVries@state.mn.us Telephone: 651-201-5917 Fax: 1-866-890-9290 HHH PRINTED: 01/28/2025 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 _____________________________ 35051 12/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 107 BRIDGEWATER WAY THE LODGE STILLWATER, MN 55082 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 Minnesota Department of Health is CORRECTION ORDER(S) documenting the State Correction Orders using federal software. Tag numbers have In accordance with Minnesota Statutes, section been assigned to Minnesota State 144G.08 to 144G.95, these correction orders are Statutes for Assisted Living Facilities. The issued pursuant to a survey. assigned tag number appears in the far-left column entitled "ID Prefix Tag." The Determination of whether violations are corrected state Statute number and the requires compliance with all requirements corresponding text of the state Statute out provided at the Statute number indicated below. of compliance is listed in the "Summary When Minnesota Statute contains several items, Statement of Deficiencies" column. This failure to comply with any of the items will be column also includes the findings which considered lack of compliance. are in violation of the state requirement after the statement, "This Minnesota INITIAL COMMENTS: requirement is not met as evidenced by." Following the evaluators ' findings is the SL35051016-0 Time Period for Correction. On December 16, 2024, through December 19, PLEASE DISREGARD THE HEADING OF 2024, the Minnesota Department of Health THE FOURTH COLUMN WHICH conducted a full survey at the above provider. At STATES,"PROVIDER'S PLAN OF the time of the survey, there were 129 residents; CORRECTION." THIS APPLIES TO 81 receiving services under the Assisted Living FEDERAL DEFICIENCIES ONLY. THIS Facility with Dementia Care license. 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 IYYB11 If continuation sheet 1 of 26 PRINTED: 01/28/2025 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 _____________________________ 35051 12/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 107 BRIDGEWATER WAY THE LODGE STILLWATER, MN 55082 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.

Finding: Substantiated, individual responsibility 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) financially exploited a resident when they took the resident’s Percocet (narcotic) medication. Investigative Findings and Conclusion: The Minnesota Department of Health determined financial exploitation was substantiated. The AP was responsible for the maltreatment. The AP counted narcotic medications at the beginning of her shift and the narcotic medication count was correct. The AP counted narcotic medications at the end of her shift and three narcotic pills (Percocet) were unaccounted for. A staff member saw the AP tape pills into a medication card during the shift. The AP said she did not go into the narcotic box for the entirety of her shift, but camera images showed the AP entered the narcotic box multiple times during the shift. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted law enforcement. The An equal opportunity employer. investigation included review of resident records, employee files, narcotic logs, law enforcement reports, and the facility’s internal investigation. Also, the investigator observed multiple staff members count narcotic medications, administer medications, and the facility’s record keeping systems. The resident resided in an assisted living memory care unit. The resident’s diagnoses included Alzheimer’s disease and cancer. The resident’s service plan included assistance with medication management. The resident’s nursing assessment indicated her health was declining, and she required narcotic medication to manage her pain. During an interview, a manager said she received a call during the night because the nighttime unlicensed personnel (ULP) noticed a discrepancy when they counted narcotic medications with the AP. The ULP noticed there was a Percocet pill missing from the resident’s medication card of Percocet. Additionally, there were two pills taped into the resident’s medication card, but the two pills were not Percocet. The manager said prior to the AP’s shift, the narcotic medication count was correct. The manager said the AP told her she cleaned out the narcotic box, because she did not want germs in there, and found two pills in the bottom of the narcotic box. She taped them into the resident’s medication card (containing Percocet). The manager said the AP told her she thought it was the right thing to do. The manager said the pills were Tylenol, not Percocet. The facility does not keep Tylenol in the narcotic compartments of the medication carts. The manager said there were multiple cards of narcotic medications in the locked narcotic box and the AP was unable to explain why she chose to tape the Tylenol pills into the resident’s card of Percocet as opposed to any of the other cards located in the narcotic box. The manager said the resident was not in the facility at the time of the incident because she was out of town receiving treatments for cancer. The manager said she reviewed images from the facilities cameras and noticed the AP was in the narcotic compartment “a lot” during the shift, but the images were inconsistent with medication administration. The manager said the AP was a new employee and only worked a few shifts prior to this incident. The manger said she contacted law enforcement, and terminated the AP. The facility ordered Percocet for the resident to replace the three missing pills. During an interview, the ULP working with the AP at the time of the incident said there were two medication carts on the unit. The medication carts have keys to unlock the carts, and the compartments for narcotics. Each medication cart has its own locked box for narcotic medications. The keys only unlock one cart, not the other. The AP was the only staff member during the shift, who had the keys to unlock the narcotic box in the medication cart where the discrepancy occurred. The ULP said there were no discrepancies when they counted narcotic medications at the beginning of the shift. The ULP said at the end of the shift they counted narcotics with the oncoming shift and the oncoming staff member noticed there was a pill missing from a medication card in the AP’s cart. The ULP said then she also looked at the card of Percocet and noticed two pills in the card, secured by tape. The two pills looked different than the other pills. In addition, to a missing pill. The AP told her she found loose pills and taped them in the medication card. During an interview, the AP said she counted narcotic medications with the ULP at the start of her shift. When they counted at the beginning of the shift, the AP said there were two pills taped into the resident’s card of Percocet and the ULP told her to re-tape the pills if the tape came off. The AP said the medication count was correct at the start of her shift. The AP said she did not go into the locked narcotic box for the entirety of her shift. The AP said when she counted the narcotics at the end of her shift the tape came loose from the two pills, and she re-taped them into the card. The AP said the morning shift documented in the narcotic book they gave the resident two Percocet before she left the facility in the morning. The resident did not return to the facility until after her shift. Narcotic medication logs indicated facility staff members consistently counted narcotic medications between shifts. There were no discrepancies within the narcotic counts until the end of the AP’s shift. The narcotic logs indicated the AP counted narcotics with the ULP at the beginning of her shift and the narcotic medication count was correct. The resident’s narcotic log indicated the last time she received a Percocet was on the evening shift, one day prior to this incident. Additionally, the narcotic logs indicated there were two pills (Tylenol) taped into the resident’s card of Percocet, but another pill was missing so there were three missing Percocet pills. Law enforcement records indicated the AP gave her keys to the medication cart to a different staff member during her shift for approximately four minutes, however the report indicated camera images showed the staff member did not access the medication cart. During consultation with law enforcement, video images did not show any other staff members enter the AP’s medication cart. Law enforcement observed images of the AP taping “pills” into the medication card. The AP told law enforcement she taped pills into medication cards but denied taking the Percocet tablets. AP’s employment records indicated the facility provided medication management education to her when they hired her and evaluated her performance with medication administration. This included narcotic medications. In conclusion, the Minnesota Department of Health determined financial exploitation 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. 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; Mitigating Factors considered, Minnesota Statutes, section 626.557, Subd. 9c(f): (1) The AP did not follow an erroneous order, direction or care plan with awareness and failure to take action. The facility did not direct an erroneous order, direction, or care plan. (2) The facility was in compliance with regulatory standards. The facility provided proper training and/or supervision of staff. The facility provided adequate staffing levels. The AP failed to follow the facility directive and/or policies and procedures. (3) The AP failed to follow professional standards and/or exercise professional judgement. The AP failed to act in good faith interest of the vulnerable adult. The maltreatment was not a sudden or foreseen event. Vulnerable Adult interviewed: No. Memory loss. Family/Responsible Party interviewed: No. Declined interview. Alleged Perpetrator interviewed: Yes. Action taken by facility: The facility provided education to staff members regarding narcotic diversion. Action taken by the Minnesota Department of Health: No further action taken at this time.