Virginia Carefree Living by.

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. An equal opportunity employer. Letter ID: IS7N REVISE D09/13/2021 Virginia Carefree Living By Oxford Living January 22, 2026 Page 2 Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, the following fines are assessed pursuant to this survey: 0510 - 144g.41 Subd. 3 - Infection Control Program - $500.00 2310 - 144g.91 Subd. 4 (a) - Appropriate Care And Services - $3,000.00 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 $3,500.00. 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 Virginia Carefree Living By Oxford Living January 22, 2026 Page 3 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 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, Jessie Chenze, Supervisor State Evaluation Team Email: jessie.chenze@state. mn.us Telephone: 218-332-5175 Fax: 1-866-890-9290 JMD PRINTED: 01/ 22/ 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 _____________________________ 33023 12/ 17/ 2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 421 10TH STREET SOUTH VIRGINIA CAREFREE LIVING BY OXFORD LIVING VIRGINIA, MN 55792 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 SL33023016- 0 Time Period for Correction. On December 15, 2025, through December 17, PLEASE DISREGARD THE HEADING OF 2025, the Minnesota Department of Health THE FOURTH COLUMN WHICH conducted a change of ownership (CHOW) STATES, "PROVIDER' S PLAN OF survey at the above provider. At the time of the CORRECTION. " THIS APPLIES TO survey, there were 35 residents; 35 receiving FEDERAL DEFICIENCIES ONLY. THIS services under the Assisted Living Facility with WILL APPEAR ON EACH PAGE. Dementia Care license. THERE IS NO REQUIREMENT TO An immediate correction order was issued SUBMIT A PLAN OF CORRECTION FOR December 17, 2025, for SL33023016- 0 correction VIOLATIONS OF MINNESOTA STATE order tag identification 2310. The licensee took STATUTES. actions to mitigate risk on December 17, 2025, however, the order remains at a scope and level THE LETTER IN THE LEFT COLUMN IS of level four, widespread (K). USED FOR TRACKING PURPOSES AND REFLECTS THE SCOPE AND LEVEL ISSUED PURSUANT TO 144G. 31 SUBDIVISION 1-3. 0 470 144G. 41 Subdivision 1 Minimum requirements 0 470 SS= F (11) develop and implement a staffing plan for LABORATORY DIRECTOR' S OR PROVIDER/ SUPPLIER REPRESENTATIVE' S SIGNATURE TITLE (X6) DATE STATE FORM 6899 6E9O11 If continuation sheet 1 of 47 PRINTED: 01/ 22/ 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: 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 two unlicensed personnel (ULP) failed to follow medication administration procedures and gave the resident an incorrect dose of Oxycodone (an opioid pain medication). The resident suffered an overdose and was hospitalized. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. Although the resident suffered an overdose and was treated in the hospital due to a medication error, the error was an isolated incident, and the resident returned to their baseline health condition. Facility staff identified the error shortly after it occurred and provided appropriate monitoring, administered Narcan (a medication to reverse opioid overdoses), updated the resident’s responsible party, and contacted emergency services. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted the primary care provider and the case manager. The investigation included review of the resident record, hospital records, facility internal investigation documentation, facility incident reports, personnel files, staff schedules, and related facility policies and procedures. Also, the investigator observed medication administration at the facility and the resident’s medications. The resident resided in an assisted living facility. The resident’s diagnoses included osteoarthritis and chronic pain. The resident’s service plan included assistance with medication administration. The resident’s assessment indicated the facility recently began management of the resident’s medications. The resident’s medication administration record (MAR) included an order for Oxycodone extended release/Xtampza (narcotic pain medication) extended release 18 milligrams (mg) take one tablet by mouth every 12 hours. The resident also had an order for Oxycodone 5 mg every six hours as needed (PRN) for pain. The MAR indicated the medication being despite out of stock, the resident’s Oxycodone 5 mg PRN dose was marked as administered at 6:01 p.m. the night prior to the overdose and again at 12:54 a.m. the morning of the overdose. The resident’s 18 mg Oxycodone dose was marked as administered at 8:00 a.m. the morning of the overdose. The medical record indicated that a nurse was reviewing the medication dashboard when she noticed the resident was given PRN doses of Oxycodone but she recalled that the PRN doses were not available, as they were pending refill from the pharmacy. The resident’s MAR identified that three doses of the 18 mg extended-release Oxycodone were given, two of those doses were in error and documented as 5 mg PRN doses. The most recent dose was given at 8:42 a.m. and a nurse assessed the resident at 9:15 a.m. The resident was noted to be in a “catatonic” state and had a slow heart rate and slow respirations. The resident initially declined being sent to the emergency room. The responsible party agreed to honor the resident’s wishes to decline treatment in the emergency room. A facility nurse administered Narcan and an improvement in vital signs was noted but the resident began to hallucinate and convulse. The resident continued to decline going to the emergency room, but the facility nurse elected to have the resident transported to the emergency room for further evaluation. Hospital records indicated the resident was evaluated for an accidental opioid overdose. The resident returned to the facility two days later. Employee records for the two staff who administered incorrect medication doses were reviewed, and both had received training on medication administration practices. During an interview, the facility registered nurse (RN) stated she reviews the electronic medical record when she comes to work in the morning, and she knew the resident’s PRN dose was pending refill so the resident should not have had any PRN doses administered. The RN stated she was not in the building that morning, so she called the nurse that was there and had her check the medication card and check on the resident. The RN stated once they realized the resident was given too much Oxycodone, they began to monitor symptoms and eventually sent the resident to the emergency room. The RN stated the resident had an order for PRN Narcan so it was available to administer in the event of an overdose. During an interview, another facility nurse stated she was in the building when the RN called her to go check on the medications and the resident. The nurse stated she noticed the resident was bed bound and had some abnormal vital signs. The nurse stated she knew the resident had an order for Narcan and it was administered immediately as they suspected she was experiencing an opioid overdose. During an interview, one of the unlicensed staff who administered the incorrect dose of medication stated he had been working a 12 or 16 hour shift and his other coworker, who also administered an incorrect dose, told him the resident could get the Oxycodone at 12 a.m. The staff stated he was in a rush, wasn’t paying attention and didn’t look at the dose before he administered the pill. 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: Yes Family/Responsible Party interviewed: Yes Alleged Perpetrator interviewed: Not Applicable Action taken by facility: The facility identified the medication error shortly after it occurred. Facility staff administered Narcan, updated the responsible party, and called emergency medical services. The facility also filed a MAARC report. All staff were retrained on medication administration, administration of Narcan, and identifying signs and symptoms of overdose. 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: 01/09/2025 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 _____________________________ 33023 12/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 421 10TH STREET SOUTH VIRGINIA CAREFREE LIVING VIRGINIA, MN 55792 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 December 4, 2024, the Minnesota Department of Health initiated an investigation of complaint #HL330235386M/#HL330237388C. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 JUPL11 If continuation sheet 1 of 1