Sugar Loaf Senior Living.

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 the facility failed to implement a new medication order. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. While it was true the medication change did not get implemented on the date ordered, when the hospice order was located, the medication was ordered from the pharmacy and administered albeit it was delayed. The investigator conducted interviews with facility staff members, including administrative staff and nursing staff. The investigator contacted the hospice agency and a family member. The investigation included review of the resident record(s), progress notes, provider and hospice orders, facility internal investigation, facility medication incident reports and related facility policy and procedures. Also, during an onsite visit the investigator observed where the fax/copy machine was located. The resident resided in an assisted living facility. The resident’s diagnoses included congestive heart failure, automatic implantable cardioverter defibrillator pacemaker, and chronic kidney disease. The resident was on hospice care. The resident’s service plan included monthly vital signs and weight, oxygen management, compression stockings, toileting assistance, medication management, and transfer assistance. The resident’s assessment indicated the resident is alert, oriented, and has poor short-term memory. The resident has edema related to his diagnosis and is prescribed medication to help remove the excess fluid. The resident does experience shortness of breath supplemented with continuous use of oxygen via nasal cannula and oxygen through his continuous positive airway pressure (CPAP) machine at night. The resident was enrolled in hospice, which ordered medication order changes. A concern arose the resident did not receive his medications as ordered. Hospice ordered a medication, a diuretic, to address the resident’s fluid retention on a Friday. However, the medication was not administered until Tuesday. A review of the process for medications indicated hospice orders were sent to the pharmacy and the then the pharmacy entered those orders into resident’s electronic medication administration record (EMAR) for the facility. Those orders were then reviewed by a facility nurse and confirmed in the EMAR. The facility’s internal investigation indicated hospice ordered a change in medication however, the resident’s medical provider was not available to sign the order, and so hospice requested a signature from another provider which took additional time to obtain. Later the same day and once the change in medication order was signed, hospice faxed the order to the facility. This visit and change of order occurred on a Friday of a holiday weekend. The EMAR indicated the increase of medication was for three days only in the mornings. The same document indicate it was entered into the EMAR with an effective date on the following Tuesday, Wednesday, and Thursday. The EMAR indicated the medication was given as ordered although a few days later than originally intended by hospice. During an interview, a nurse, who is also a manager, stated she was reviewing a large amount of paperwork from the facility fax/copier machine related to a possible new admission and found the hospice order in that paperwork but not until the next day (Saturday) however she was at a location without a fax and the pharmacy was not open on Sunday. The order was submitted to the pharmacy on Monday however deliveries from the pharmacy do not come until evening so the medication was started the next day, Tuesday. The nurse stated the pharmacy is responsible for adding medication changes to each resident’s electronic medical record and, when that occurs, an icon comes up in the electronic medication record software to alert the nurse and the nurse clicks on that to confirm or acknowledge the medication changes. The nurse stated on that day, a Friday, the hospice nurse was at the facility however there was no communication when she left to indicate there would be a change in medication. During an interview, a hospice nurse stated it was not unusual to order a short burst of a diuretic during times of increased fluid retentions, increase shortness of breath or other changes of symptoms related to the heart failure. The hospice nurse stated the process for medication changes was for hospice to fax the signed order to the facility and them facility was responsible for sending the order over to the pharmacy. The nurse stated the new order required a physician’s signature which took a little longer as the primary provider was not available. The facility was aware the resident was visited by hospice, however, when leaving the facility, the hospice nurse was unable to locate a staff member to report off to. She stated she saw the resident at approximately 3 p.m. on that Friday. A review of the resident’s medical record did not indicate the resident required medical attention nor hospitalization as a result of the delay. 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 was deceased Family/Responsible Party interviewed: Yes Alleged Perpetrator interviewed: NA the Action taken by facility: The facility’s changes included a discussion with hospice for them to fax orders to the pharmacy as well as the facility. The facility will follow up the pharmacy to ensure order was received and ensure that order has been placed on the resident’s electronic medication record. The facility reinforced with staff members to monitor the copier/fax and any documents not theirs are placed in a hanging wall file for departments to look through to ensure they receive. Hospice will also verbalize to the nurse at the facility any significant medication changes or order changes. 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: 09/11/2025 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 _____________________________ 28896 06/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 765 MENARD ROAD SUGAR LOAF SENIOR LIVING WINONA, MN 55987 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 June 10, 2025, the Minnesota Department of Health initiated an investigation of complaint #HL288963735C/#HL288962183M. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 RDN511 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 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 2: a fine of $500 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 pursuant to this survey: St - 0 - 0510 - 144g.41 Subd. 3 - Infection Control Program $500.00 An equal opportunity employer. Letter ID: IS7N REVISED 09/13/2021 Sugar Loaf Senior Living August 8, 2025 Pa ge 2 Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, the 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. 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. Please 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. Sugar Loaf Senior Living August 8, 2025 Pa ge 3 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/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, Jodi Johnson, Supervisor State Evaluation Team Email: Jodi.Johnson@state.mn.us Telephone: 507-344-2730 Fax: 1-866-890-9290 KKM PRINTED: 08/07/2025 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 _____________________________ 28896 06/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 765 MENARD ROAD SUGAR LOAF SENIOR LIVING WINONA, MN 55987 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. SL28896016-0 PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On June 9, 2025, through June 12, 2025, the STATES,"PROVIDER'S PLAN OF survey at the above provider and the following FEDERAL DEFICIENCIES ONLY. THIS correction orders are issued. At the time of the WILL APPEAR ON EACH PAGE. survey, there were 83 residents; 63 receiving services under the Assisted Living Facility with THERE IS NO REQUIREMENT TO 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 24D711 If continuation sheet 1 of 12 PRINTED: 08/07/2025 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 _____________________________ 28896 06/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 765 MENARD ROAD SUGAR LOAF SENIOR LIVING WINONA, MN 55987 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 4626.0033, item A, the facility may share a certified food protection manager (CFPM) with one other facility located within a 60-mile radius and under common management provided the CFPM is present at each facility frequently enough to effectively administer, manage, and supervise each facility's food service operation; (2) notwithstanding Minnesota Rules, part 4626.