The Prairie Lodge at Earle Bro.

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 - 0775 - 144g.45 Subd. 2. (a) - Fire Protection And Physical Environment - $500.00 Theref ore, in accordance with Mi nn. 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. An equal opportunity employer. Letter ID: IS7N REVISED 09/13/2021 The Prairie Lodge at Earle Brown August 11, 2025 Pa ge 2 DOCUMENTATION OF ACTION TO COMPLY In accordance wi th 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 wi thout 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: https: //forms.office.com/g/Bm5uQEpHVa . Your input 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 The Prairie Lodge at Earle Brown August 11, 2025 Pa ge 3 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 KKM PRINTED: 08/11/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 20315 07/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6001 EARLE BROWN DRIVE THE PRAIRIE LODGE AT EARLE BRO BROOKLYN CENTER, MN 55430 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 License In accordance with Minnesota Statutes, section Providers. The assigned tag number 144G.08 to 144G.95, these correction orders are appears in the far-left column entitled "ID issued pursuant to a survey. Prefix Tag." The state Statute number and the corresponding text of the state Statute Determination of whether violations are corrected out of compliance is listed in the requires compliance with all requirements "Summary Statement of Deficiencies" provided at the Statute number indicated below. column. This column also includes the When Minnesota Statute contains several items, findings which are in violation of the state failure to comply with any of the items will be requirement after the statement, "This considered lack of compliance. Minnesota requirement is not met as evidenced by." Following the surveyors' INITIAL COMMENTS: findings is the Time Period for Correction. SL20315016-0 PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On July 21, 2025, through July 23, 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 46 residents; 44 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 subd. 1, 2, and 3. 0 660 144G.42 Subd. 9 Tuberculosis prevention and 0 660 SS=D control (a) The facility must establish and maintain a LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 08X411 If continuation sheet 1 of 10 PRINTED: 08/11/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 20315 07/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6001 EARLE BROWN DRIVE THE PRAIRIE LODGE AT EARLE BRO BROOKLYN CENTER, MN 55430 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) 0 660 Continued From page 1 0 660 comprehensive tuberculosis infection control program according to the most current tuberculosis infection control guidelines issued by the United States Centers for Disease Control and Prevention (CDC), Division of Tuberculosis Elimination, as published in the CDC's Morbidity and Mortality Weekly Report. The program must include a tuberculosis infection control plan that covers all paid and unpaid employees, contractors, students, and regularly scheduled volunteers. The commissioner shall provide technical assistance regarding implementation of the guidelines. (b) The facility must maintain written evidence of compliance with this subdivision.

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 alleged perpetrator (AP), facility staff, abused a resident when the AP slapped the resident in the face. In addition, the facility neglected the resident when they failed to provide wound care, assistance with eating, and failed to allow the resident to transfer independently or with minimal assistance from staff. Investigative Findings and Conclusion: The Minnesota Department of Health determined abuse was not substantiated. Review of a recorded video showed the AP, contracted hospice staff, lightly touch the resident’s face and cheek. No sound can be heard on the video and the resident had no injury from the AP’s actions. Although not appropriate treatment, the action did not meet the definition of abuse. The Minnesota Department of Health determined neglect was not substantiated. Facility staff provided the resident with services according to the resident’s assessed and care planned needs. An equal opportunity employer. The investigator conducted interviews with facility staff members, including administrative staff, and unlicensed staff. The investigator contacted family members, hospice leadership, the hospice nurse, and the AP. The investigation included review of medical records, recorded video, and facility policies and procedures. Also, the investigator observed cares provided to the resident without concerns. The resident resided in an assisted living memory care unit. The resident’s diagnoses included dementia. The resident’s service plan included assistance with dressing, grooming, bathing, eating, and incontinence care. The resident required two staff and the use of a gait belt for pivot transfers. The resident did not ambulate and used a Broda chair (high back wheelchair) and staff assistance with mobility of the chair. The resident required assistance from others for decision making and staff to anticipate her needs. Staff were directed to provide safety checks every two hours but not to wake the resident during the night when asleep. The resident’s service plan included coordination of care with a contracted hospice agency for comfort care. The resident was a high risk for falls and staff were directed to place a fall matt next to the resident’s bed, check on the resident every two hours, and place the bed in a low position to reduce the resident’s risk for injury. The resident had a history of repeatedly yelling “Help me”, restlessness during the night, daytime dozing, and resisting care. Staff were directed to approach the resident later, have a second staff complete the resident’s care, offer liquids, provide incontinence care, and place the resident in the common area for improved staff supervision, reassurance, and observations. The facility’s progress notes indicated one day; facility leadership was made aware the resident’s camera in her room showed an outside contracted hospice staff member (AP) slap the resident. The facility’s leadership contacted hospice leadership who had completed an investigation into the incident. Hospice staff reviewed the video and determined the AP did not slap the resident, but with one hand touched the resident’s cheek causing her head to turn. The note indicated hospice provided the AP with additional training. Review of the recorded video showed the resident lying in bed with the AP standing next to the bed facing the resident. The AP, with his right hand quickly moves his hand over the resident cheek and mouth causing the resident’s head to turn to the right. No noise can be heard from the AP’s actions. Review of a second video showed the AP in the resident’s room four days later. The video showed the back of the resident’s Broda chair, with the resident sitting in the wheelchair. The AP when standing behind the wheelchair, placed one hand under each of the resident’s arms and pulled the resident into a sitting position. The AP went to face the resident and moved his right hand by the resident’s face. The resident moved her head to the right. No sound of a slap was heard on the video. During an interview, the facility’s leadership stated the AP did not work for the facility. The AP worked for a hospice agency. Leadership stated hospice provided services to the resident two to three times a week. The facility’s leadership stated the video showed the AP touching the resident’s face, but the AP did not slap or hit the resident. During an interview, hospice leadership stated the resident’s family member notified them of an incident between the AP and the resident. Hospice leadership stated they reviewed the recorded video, and the AP did not slap the resident. Facility leadership stated when they became aware of the allegation, the AP was immediately removed from the schedule and before returning to work, required to complete additional training related to caring for residents with dementia. During an interview, the AP stated one day the resident needed assistances with eating. The resident was resistive in the dining room. Because the resident was agitated, the AP took the resident to her room. The AP stated when the resident was agitated, the AP should have left the resident in a safe position to allow the resident to calm down. The AP denied slapping the resident. The AP stated a few days later, the AP came to see the resident and was told by a family member through the video camera, to leave the room. The AP stated he was initially suspended and completed education prior to returning to work. During an interview, a family member stated the first video showed the resident and the AP arguing with each other while cares were being completed. The AP tapped the resident on the mouth. Then four days later, the resident and the AP were arguing, and the AP tapped the resident’s mouth causing the resident head to turn. The family member stated the AP did not slap the resident. The allegation also included concerns facility staff neglected the resident when staff failed to assist the resident to eat, failed to provide wound care, failed to allow for the resident to transfer independently, and failed to check on the resident during the night. Staff assisted the resident to eat in the community dining room. Frequently, the resident refused to eat the facility meal and staff provided the resident an alternative food choice. Usually daily, the resident’s family brought in an evening meal. Review of the resident’s record indicated the resident had a skin tear on a shin cared for by the hospice staff, one to two times a week. There was no indication of additional wounds or wound care. Staff assisted the resident with transfers using two staff and a gait belt according to the resident’s assessment. During an interview, the hospice nurse stated the resident often refused to eat the facility meals. The hospice nurse stated facility offered the resident her meal of choice, peanut-butter, and jelly toast. The resident required a mechanical soft diet and had a decline in heath and apetite. The hospice nurse stated the resident’s skin was fragile and thin, prone to bruising and tears. During an interview, facility leadership stated staff were directed to visually check on the resident during the night by entering the room, and if the resident was asleep, staff were to allow the resident to sleep. Facility leadership said when the resident was restless at night, staff were to place the resident in the common area for staff supervision. Another concern investigated included the facility had a mice and ant infestation. During the onsite visit, a facility tour was completed, and no mice or ant concerns were observed. The facility leadership stated they had an issue with mice a few months ago, hired an exterminator and had no other issues. In conclusion, the Minnesota Department of Health determined abuse and neglect were 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. Abuse: Minnesota Statutes section 626.5572, subdivision 2. "Abuse" means: (a) An act against a vulnerable adult that constitutes a violation of, an attempt to violate, or aiding and abetting a violation of: (1) assault in the first through fifth degrees as defined in sections 609.221 to 609.

correction orders issued pursuant to the July 28, 2023 survey. In accordance with Minn. Stat. § 144G.31 Subd. 4 (a), state correction orders issued pursuant to the last survey, completed on July 28, 2023, found not corrected at the time of the November 16, 2023, follow- up survey and/ or subject to penalty assessment are as follows 1760-Documentation Of Administration Of Medication- 144g.71 Subd. 8 = $500.00 The details of the violations noted at the time of this follow- up survey completed on November 16, 2023 (listed above) , are on the attached State Form. Brackets around the ID Prefix Tag in the left hand column, e. g., {2 ----} will identify the uncorrected tags. 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. DOCUMENTATIO ONF 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. IMPOSITION OF FINES: 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. Level 4: a fine of $5,000 per incident, in addition to any enforcement mechanism authorized in §144G.20. 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. An equal opportunity employer. Le tter ID: 8GKP Revised 04/14/2023 The Prairie Lodge At Earle Brown January 22, 2024 Pa ge 2 The request for reconsideration must be in writing and received by MDH within 15 calendar days of the correction order receipt date. A state correction order under Minn. Stat. § 144G.91, Subd. 8, Free from Maltreatment is associated with a maltreatment determination by the Office of Health Facility Complaints. If maltreatment is substantiated, you will receive a separate letter with the reconsideration process under Minn. Stat. § 626.557. 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 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. We urge you to review these orders carefully. If you have questions, please contact Casey DeVries at You are encouraged to retain this document for your records. It is your responsibility to share the information contained in the letter and/ or state form with your organization’ s Governing Body. Sincerely, Casey DeVries, Supervisor State Evaluation Team Email: casey. devries@ state. mn. us Telephone: 651-201-5917 Fax: 1-866-890-9290 PMB PRINTED: 01/ 22/ 2024 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/ SUPPLIER/ CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ R B. WING _____________________________ 20315 11/16/ 2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6001 EARLE BROWN DRIVE THE PRAIRIE LODGE AT EARLE BRO BROOKLYN CENTER, MN 55430 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 been assigned to Minnesota State Statutes for Assisted Living License In accordance with Minnesota Statutes, section Providers. The assigned tag number 144G. 08 to 144G. 95 this correction order( s) has appears in the far-left column entitled "ID been issued pursuant to a survey. Prefix Tag." The state Statute number and the corresponding text of the state Statute Determination of whether a violation has been out of compliance is listed in the corrected requires compliance with all "Summary Statement of Deficiencies" requirements provided at the Statute number column. This column also includes the indicated below. When Minnesota Statute findings which are in violation of the state contains several items, failure to comply with any requirement after the statement, "This of the items will be considered lack of Minnesota requirement is not met as compliance. evidenced by." Following the surveyors' findings is the Time Period for Correction. INITIAL COMMENTS: SL20315015- 1 PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On November 14, 2023, through November 16, STATES, "PROVIDER' S PLAN OF 2023, the Minnesota Department of Health CORRECTION. " THIS APPLIES TO conducted a revisit at the above provider to FEDERAL DEFICIENCIES ONLY. THIS follow-up on orders issued pursuant to a survey WILL APPEAR ON EACH PAGE. completed on July 28, 2023. At the time of the survey, there were 42 residents: 41 of whom THERE IS NO REQUIREMENT TO received services under the Assisted Living with SUBMIT A PLAN OF CORRECTION FOR Dementia Care license. As a result of the revisit, VIOLATIONS OF MINNESOTA STATE the following orders were reissued and/ or issued. STATUTES. The letter in the left column is used for tracking purposes and reflects the scope and level issued pursuant to 144G. 31 subd. 1, 2, and 3. {0 480} 144G. 41 Subd 1 (13) (i) (B) Minimum {0 480} SS= F requirements (13) offer to provide or make available at least the LABORATORY DIRECTOR' S OR PROVIDER/ SUPPLIER REPRESENTATIVE' S SIGNATURE TITLE (X6) DATE STATE FORM 6899 YGC112 If continuation sheet 1 of 31 PRINTED: 01/ 22/ 2024 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/ SUPPLIER/ CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ R B. WING _____________________________ 20315 11/16/ 2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6001 EARLE BROWN DRIVE THE PRAIRIE LODGE AT EARLE BRO BROOKLYN CENTER, MN 55430 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} following services to residents: (B) food must be prepared and served according to the Minnesota Food Code, Minnesota Rules, chapter 4626; and This MN Requirement is not met as evidenced by: No further action required. {0 510} 144G. 41 Subd. 3 Infection control program {0 510} SS= F (a) All assisted living facilities must establish and maintain an infection control program that complies with accepted health care, medical, and nursing standards for infection control. (b)The facility's infection control program must be consistent with current guidelines from the national Centers for Disease Control and Prevention (CDC) for infection prevention and control in long- term care facilities and, as applicable, for infection prevention and control in assisted living facilities. (c) The facility must maintain written evidence of compliance with this subdivision. This MN Requirement is not met as evidenced by: No further action required. {0 550} 144G. 41 Subd.