Prairie View.

Finding: Inconclusive 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 abused the resident resulting in bruises found on two of the resident’s fingers on his right hand along with some redness and swelling to left wrist and the top of his left hand. Investigative Findings and Conclusion: The Minnesota Department of Health determined abuse was inconclusive. Although there were unexplained bruises on two of the resident’s fingers of his right hand and redness with swelling on the top of his left hand/wrist region, it could not be determined how the bruising occurred. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted a family member, law enforcement, and the hospice provider. The investigation included review of the resident record(s), death record, facility internal investigation, staff schedules, law enforcement report, photographs, related facility policy and procedures. Also, the investigator observed the type of hospital bed the resident used and the apartment where the bed would have been located. Observation of the apartment including the walls next to the bed are not a smooth finish but have a textured finish. The resident resided in an assisted living memory care unit. The residents’ diagnoses included end of life hospice care and dementia. The residents’ service plan included assistance with all activities of daily living including transfers, bed mobility, and feeding assistance. The residents’ assessment indicated frequent disruptive, aggressive, or socially inappropriate physical behavior towards staff during cares. The resident was not able to communicate or give accurate information consistently. A concern arose when the facility identified unexplained injuries including bruising on the resident’s right hand and left wrist. The resident’s progress note indicated the medical provider made a routine visit in the morning prior to the bruising discovered by an unlicensed caregiver. The note indicated the provider had been updated regarding the resident’s recent change in condition where he had been sleeping more. The provider assessed a scabbed abrasion located on the bridge of the resident’s nose but did not feel any treatment was needed. The note did not indicate any further findings at that time. The note indicated the facility licensed nurse would update hospice. A second progress note later the same day indicated the resident remained in bed with staff turning and repositioning and providing cares. The progress note indicated bruising to the resident’s fingers/wrists and that the resident slept close to the wall. The same document indicated it was unclear if the bruising was related to resident putting his hand between the wall and bed. Later the same day, the progress notes indicated family was notified the resident may be transitioning into a more active dying stage. The family was notified of the bruising on the third and fourth fingers of the right hand and a bruised left wrist. The same progress note indicated a possible cause of the injury occurred a few days prior when the bed had been found unlevel due to the frame being unhooked and the height adjusting bar had fallen off. No further injuries were noted, and resident was unable to explain what happened due to impaired cognition. During an interview, unlicensed caregiver #1 stated she was working the afternoon shift three days prior to staff noticing the bruising on the fingers and hands. Caregiver #1 stated she was the one who noticed the bed looked unlevel and called another staff member in from the assisted living side. The assisted living caregiver noticed the upper right side of the headboard and frame had somehow become disconnected and staff were able to put the two pieces together that evening. Caregiver #1 stated when she put the resident to bed that night did not see any skin concerns. Caregiver #1 stated it took two caregivers for cares and repositioning as the resident is not always cooperative and will push you away or swat at you. Caregiver #1 stated the left side of bed butted up against the wall and resident would lie on his side facing wall. The bed must be pulled away from the wall in order for two caregivers to complete cares. During an interview, unlicensed caregiver #2 stated she was aware from the communication book the weekend staff reported a concern with regard to the resident’s bed frame and a scratch on the nose. After that weekend, Caregiver #2 stated when giving the resident a sponge bath on Monday she noticed bruising on the right fingers and redness on left hand. Caregiver #2 stated when she picked up the resident’s left hand he cried out in pain. Caregiver #2 stated she notified nursing. Caregiver stated she felt the resident’s skin appeared different and thought it was part of the dying process as he was very fragile and thin. During an interview, nurse #1 stated the resident was known for sleeping on his side next to the wall and would place his hands between the wall and the bed when sleeping. Nurse #1 stated the resident’s hospital bed had been provided by hospice and set up by a durable medical provider originally. During an interview, nurse #2 stated she was unsure of the cause of the scratch, however the resident tended to lie down in bed with his glasses on and would lay on his side facing the wall and may have bumped into the wall. In conclusion, the Minnesota Department of Health determined abuse was inconclusive. Inconclusive: Minnesota Statutes, section 626.5572, Subdivision 11. "Inconclusive" means there is less than a preponderance of evidence to show that maltreatment did or did not occur. Abuse: Minnesota Statutes section 626.5572, subdivision 2. "Abuse" means: (b) Conduct which is not an accident or therapeutic conduct as defined in this section, which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to, the following: (1) hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult; (2) use of repeated or malicious oral, written, or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening; or (3) use of any aversive or deprivation procedure, unreasonable confinement, or involuntary seclusion, including the forced separation of the vulnerable adult from other persons against the will of the vulnerable adult or the legal representative of the vulnerable adult unless authorized under applicable licensing requirements or Minnesota Rules, chapter 9544. Vulnerable Adult interviewed: No, VA was deceased Family/Responsible Party interviewed: Yes Alleged Perpetrator interviewed: Not appicable Action taken by facility: No action required 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: 04/ 24/ 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: ______________________ C B. WING _____________________________ 30230 03/ 16/ 2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1010 EAST ELM AVENUE PRAIRIE VIEW HECTOR, MN 55342 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 March 16, 2026, the Minnesota Department of Health initiated an investigation of complaint #HL302305780C/ #HL302301400M. No correction orders are issued. LABORATORY DIRECTOR' S OR PROVIDER/ SUPPLIER REPRESENTATIVE' S SIGNATURE TITLE (X6) DATE STATE FORM 6899 RCLG11 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 . . ." In accordance with Minn. Stat. § 144G.31 Subd. 4, MDH may assess fines based on the level and scope of the violations; h owever, no immediate fines are assessed for this survey of your facility. 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: An equal opportunity employer. Letter ID: IS7N REVISED 09/13/2021 Prairie View December 23, 2024 Page 2 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 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, Jodi Johnson, Supervisor State Evaluation Team Email: jodi.johnson@state.mn.us Telephone: 507-344-2730 Fax: 1 -866-890-9290 JMD PRINTED: 12/23/2024 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 30230 11/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1010 EAST ELM AVENUE PRAIRIE VIEW HECTOR, MN 55342 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 SL30230016-0 Time Period for Correction. On November 12, 2024, through November 14, 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 31 residents; CORRECTION." THIS APPLIES TO 26 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 1NJS11 If continuation sheet 1 of 16 PRINTED: 12/23/2024 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 30230 11/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1010 EAST ELM AVENUE PRAIRIE VIEW HECTOR, MN 55342 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 4626.0545, item A, kick plates that are not removable or cannot be rotated open are allowed unless the facility has been issued repeated correction orders for violations of Minnesota Rules, part 4626.1565 or 4626.1570; (3) notwithstanding Minnesota Rules, part 4626.0685, item A, the facility is not required to provide integral drainboards, utensil racks, or tables large enough to accommodate soiled and clean items that may accumulate during hours of operation provided soiled items do not contaminate clean items, surfaces, or food, and clean equipment and dishes are air dried in a manner that prevents contamination before storage; (4) notwithstanding Minnesota Rules, part 4626.1070, item A, the facility is not required to install a dedicated handwashing sink in its existing kitchen provided it designates one well of a two-compartment sink for use only as a handwashing sink; (5) notwithstanding Minnesota Rules, parts 4626.1325, 4626.1335, and 4626.1360, item A, existing floor, wall, and ceiling finishes are STATE FORM 6899 1NJS11 If continuation sheet 2 of 16 PRINTED: 12/23/2024 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 30230 11/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1010 EAST ELM AVENUE PRAIRIE VIEW HECTOR, MN 55342 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 2 0 480 allowed provided the facility keeps them clean and in good condition; (6) notwithstanding Minnesota Rules, part 4626.