Prairie Senior Cottages of Isa.

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. Level 4: a fine of $5,000 per incident, in addition to any enforcement mechanism authorized in An equal opportunity employer. Letter ID: IS7N REVISED 09/13/2021 Prairie Senior Cottages of Isanti, LLC July 1, 2025 Page 2 § 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 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. To submit a hearing request, please visit: Prairie Senior Cottages of Isanti, LLC July 1, 2025 Page 3 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, Kelly Thorson, Supervisor State Evaluation Team Email: Kelly.Thorson@state.mn.us Telephone: 320-223-7336 Fax: 1-866-890-9290 HHH PRINTED: 07/01/2025 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 _____________________________ 30809 05/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 706 6TH AVENUE NE PSC OF ISANTI LLC ISANTI, MN 55040 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 SL#30809016 Time Period for Correction. On May 12, 2025, through May 14, 2025, the PLEASE DISREGARD THE HEADING OF survey at the above provider. At the time of the STATES,"PROVIDER'S PLAN OF survey, there were 44 residents; 44 receiving CORRECTION." THIS APPLIES TO services under the Assisted Living Facility with FEDERAL DEFICIENCIES ONLY. THIS 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 IIW211 If continuation sheet 1 of 13 PRINTED: 07/01/2025 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 _____________________________ 30809 05/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 706 6TH AVENUE NE PSC OF ISANTI LLC ISANTI, MN 55040 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: 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 emotionally abused the resident when unlicensed facility staff shaved the resident’s hair in retaliation for the resident requesting staff prepare him a sandwich. Staff physically restrained the resident during the haircut. Investigative Findings and Conclusion: The Minnesota Department of Health determined abuse was not substantiated. Facility unlicensed staff did cut the resident’s hair; however, the resident gave the staff permission to cut his hair, and the resident verbalized to the investigator he liked his haircut. No harm resulted from the resident haircut. There was no evidence the resident was restrained during the haircut. Additionally, facility staff provided the resident with his preferred snack of peanut butter and jelly sandwiches anytime requested throughout each day. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted the resident’s advocate and a family member. The investigation included review of the resident record(s), pharmacy records, facility internal investigation, facility incident reports, personnel files, staff schedules, related facility policy and procedures. Also, the investigator observed facility staff provide direct care to the resident and the resident. The resident resided in an assisted living memory care unit. The resident’s diagnoses included a stroke, major depressive disorder and cognitive communication deficit. The resident’s service plan included assistance with personal cares, medication administration, safety checks and bathing. The resident was able to make his needs known to staff with a history of being demanding and refusing cares. The resident utilized a wheelchair for mobility and required reminders and staff assistance with preparing foods. The resident’s record indicated the resident had worn his hair shoulder length most of his adult life. The resident’s record indicated the resident was resistive to bathing and at times would be verbally or physically aggressive with staff when assistance with care tasks was offered. The resident’s record indicated unlicensed staff offered and provided snacks for the resident throughout the day. Progress notes indicated a friend of the resident visited the facility and was upset that staff had cut the resident’s hair. The resident’s friend said she knew someone that cut hair and stated she would have scheduled a haircut at the facility for the resident. Unlicensed staff reported during the resident’s bath as they were trimming the resident’s hair the resident told unlicensed staff to cut it all off. The resident was not upset during or after the haircut. During an interview, unlicensed staff stated some families and residents ask staff to trim their hair. Unlicensed staff stated the resident had shoulder length hair and often refused bathing but one day while she was at work she trimmed the resident’s hair and the next day when she returned to work the resident’s hair was short. Unlicensed staff stated the resident rubbed his head showing off the new haircut. Unlicensed staff stated she was told while the resident was being assisted with a bath other unlicensed staff asked the resident if he would like a haircut and the resident stated yes and told the unlicensed staff to take it all off. Unlicensed staff stated the resident had not complained, acted depressed or expressed any unhappiness with the haircut. Unlicensed staff stated the haircut was offered because the resident’s hair was “getting icky” because the resident refused bathing and would spray stuff in his hair. Unlicensed staff stated the resident was excited to show off his new haircut. During an interview, another unlicensed staff stated it was not uncommon for residents or families to request unlicensed staff trim or cut residents hair or beards. Unlicensed staff stated a coworker had trimmed the resident’s hair a couple days earlier and when unlicensed staff gave the resident a bath unlicensed staff asked if the resident wanted his hair trimmed again and the resident said yes. The resident was taken to the facility beauty salon and unlicensed staff trimmed off a couple inches at a time and asked the resident if he liked it in between and he said yes and wanted a couple more inches off and the resident “really liked it” and asked for more to be cut off until it was cut short. Unlicensed staff stated it seemed to boost his self-esteem and he seemed excited. Unlicensed staff stated he was very proud of his new haircut, however, a few hours later a friend arrived for a visit and was very vocal and upset with staff. Unlicensed staff stated the resident told the friend he liked the haircut until the resident realized the friend was upset about the cut. Unlicensed staff stated the resident requested between fifteen and twenty peanut butter and jelly sandwiches during the day and the unlicensed staff had not retaliated against the resident by cutting his hair when he asked for a sandwich. During an interview, licensed staff stated it was not uncommon for residents or family members to request staff trim residents’ hair. Licensed staff stated unlicensed staff should have checked with a licensed staff prior to following through on the resident’s instructions to cut his hair, however, the resident had reported to licensed staff he liked the haircut. Licensed staff stated a friend of the resident was unhappy with the haircut because the friend had always known the resident to have longer hair. Licensed staff stated the resident had told staff to “take it all off or something like that”. Licensed staff stated the friend did not feel the resident had the clarity to understand what that meant and was upset with facility staff. Licensed staff stated the facility was not notified that a barber appointment had been setup by the resident’s friend. Licensed staff stated the facility no longer allowed unlicensed staff to trim or cut residents’ hair, even when requested. During interview, the resident stated about a month ago while bathing he got a haircut from unlicensed staff, and he liked the haircut. The resident stated staff asked if they could cut his hair and he told them yes. The resident stated he had never had a barber come to the facility to cut his hair and he felt safe at the facility. The resident stated he had no concerns with the haircut. In conclusion, the Minnesota Department of Health determined abuse 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. 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 609.224; (2) the use of drugs to injure or facilitate crime as defined in section 609.235; (3) the solicitation, inducement, and promotion of prostitution as defined in section 609.322; and (4) criminal sexual conduct in the first through fifth degrees as defined in sections 609.342 to 609.3451. A violation includes any action that meets the elements of the crime, regardless of whether there is a criminal proceeding or conviction. (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. (c) Any sexual contact or penetration as defined in section 609.341, between a facility staff person or a person providing services in the facility and a resident, patient, or client of that facility.

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 staff failed transfer the resident according to the plan of care causing a fractured left collarbone. In addition, the facility failed to provide the resident with a new mattress when the old mattress was urine soaked and made the resident lay on plastic one night causing a skin rash. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. Facility staff transferred the resident according to the resident’s assessed and care planned needs. When the resident’s mattress became soiled, the facility replaced the mattress. Also, there was no evidence the resident laid on plastic for a night and the resident had a previous skin condition that presented as blisters. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted the resident’s family members and hospice nurse. The investigation included review of the resident records, facility incident reports, staff schedules, law enforcement report, related facility policy and procedures. Also, the investigator observed staff and resident interactions. The resident resided in an assisted living memory care unit. The resident’s diagnoses included Alzheimer disease, urine retention, recurrent urine tract infection, and contact dermatitis (skin rash caused when a substance irritates the skin or an allergic reaction.) The resident’s service plan included assistance with transfers, toileting, safety checks, bedding change, morning cares, evening care, was incontinent of bladder, and at risk for falling. The resident required two staff with a mechanical sling lift for transfers and two staff assist for activities of daily living. The resident was moderately cognitively impaired. One month, the resident complained of shoulder pain. The resident received hospice services and was prescribed medications that relieved the pain. In addition, at the same time the facility changed the resident from a standing lift to a mechanical sling lift for transfers. About one month later, the resident complained of increased pain in his shoulders not relieved with the current pain medications. An x-ray was completed and revealed a left collarbone fracture. The resident had no previous falls prior to the pain in the shoulders. The provider ordered a sling for the resident’s left arm for healing. During an interview, a nurse stated the resident required two staff for cares and used a mechanical sling lift for transfers. One day the resident complained of increased shoulder pain and an x-ray was ordered. The x-ray revealed the resident’s left collarbone was fractured. The nurse stated the facility completed an investigation into the fracture of the resident’s collarbone and were not able to determine a cause of the fracture. The nurse stated the resident had fractured the left collarbone in approximately the same area two years earlier. The nurse stated when the resident’s mattress became soiled, the facility replaced the mattress. The nurse stated the resident had recurring skin concerns. The resident had been treated for a yeast infection and would get fluid filled blisters randomly on his body. If the blisters opened, the area would be cleansed and treated. During an interview the resident’s family members stated after the fracture was revealed on x-ray, the resident was to wear a sling for his arm. The family members stated the resident’s mattress was replaced by the facility. The family members stated the resident’s blisters were not new and that the resident had suffered from random blisters for years. 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. Resident resided at a different facility. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Not Applicable. the Action taken by facility: The facility followed up on the resident’s report of increased left shoulder pain, an x-ray was ordered, and an arm sling was ordered for the resident. The resident’s skin was monitored weekly on bath days and treatment provided when needed. The resident’s soiled mattress was replaced with a different mattress. 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: 09/10/2024 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ C B. WING _____________________________ 30809 08/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 706 6TH AVENUE NE OF ISANTI LLC PRAIRIE SENIOR COTTAGES ISANTI, MN 55040 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 August 5, 2024, the Minnesota Department of Health initiated an investigation of complaint #HL308091680M/#HL308099247C. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 WL0J11 If continuation sheet 1 of 1

correction orders. The 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. Level 4: a fine of $5,000 per incident, in addition to any enforcement mechanism authorized in § 144G.20. In accordance with Minn. Stat. § 144G.31, Subd. 4 (a)(5), the MDH may impose fine amounts of either $1,000 or $5,000 to licensees who are found to be responsible for maltreatment. The MDH may impose a fine of $1,000 for each substantiated maltreatment violation that consists of abuse, neglect, or financial exploitation according to Minn. Stat. § 626.5572, Subds. 2, 9, 17. The MDH also may impose a fine of $5,000 for each substantiated maltreatment violation consisting of sexual An equal opportunity employer. Letter ID: IS7N REVISED 09/13/ 2021 PSC Of Isanti, LLC August 9, 2023 Page 2 assault, death, or abuse resulting in serious injury. In accordance with Minn. Stat. § 144G.31, Subd. 4 (b), when a fine is assessed against a facility for substantiated maltreatment, the commissioner shall not also impose an immediate fine under this chapter for the same circumstance. 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 The re fore , in accorda nc e wi th Mi nn. Sta t. §§ 144G. 01 to 144 G .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 accorda nc e wi th Mi nn. Sta t. § 144G.30, Subd. 5(c), the licens ee mus t doc ument acti ons ta ken 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). 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 the 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. Pl ea se ema il rec ons idera ti on reques ts to: Health. HRDA. ppeals@state. mn. us. Pl ea se atta c h thi s letter as part of your reconsideration request. Please clearly indicate which tag( s) you are contesting and submit information supporting your position(s). Please address your cover letter for reconsideration requests to: PSC Of Isanti, LLC August 9, 2023 Page 3 Reconsideration Unit 85 East Seventh Place St. Paul, MN 55164-0970 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 MDH 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. Requests for hea ri ng ma y be ema iled to: Health. HRDA. ppeals@state. mn. us. To appe al fi ne s vi a rec ons ider a ti on, pl ease fol low the proc edure outl ined above . Pl ease note tha t you ma y re ques t a rec ons idera ti on or a hea ri ng , but not both. 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: 651-281-9796 PMB PRINTED: 08/ 09/ 2023 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 _____________________________ 30809 07/ 19/ 2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 706 6TH AVENUE NE PSC OF ISANTI LLC ISANTI, MN 55040 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. SL30809015- 0 PLEASE DISREGARD THE HEADING OF On July 17, 2023, through July 19, 2023, the THE FOURTH COLUMN WHICH survey at the above provider, and the following CORRECTION. " THIS APPLIES TO correction orders are issued. At the time of the FEDERAL DEFICIENCIES ONLY. THIS survey, there were 37 active residents; all of WILL APPEAR ON EACH PAGE. whom were receiving services under the Assisted Living with Dementia Care license. 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 subd. 1, 2, and 3. 0 510 144G. 41 Subd.