Abilit Holdings Prairie Meadow.

correction orders issued pursuant to the May 7, 2025 survey. The Department of Health concludes the licensee is in substantial compliance. State law requires the facility must take action to correct the state 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. In accordance with Minn. Stat. § 144G.31 Subd. 4 (a), state correction orders issued pursuant to the last survey, completed on May 7, 2025, found not corrected at the time of the July 21, 2025, follow-up survey and/or subject to penalty assessment are as follows: 1460 - Orientation Of Staff And Supervisors - 144g.63 Subdivision 1 - $500.00 1470 - Content Of Required Orientation - 144g.63 Subd. 2 - $500.00 1540 - Training In Dementia, Mental Illness, And De -- 144g.64 (a) (3) - $500.00 1640 - Service Plan, Implementation And Revisions To - 144g.70 Subd. 4 (a-E) - $500.00 1940 - Individualized Treatment Or Therapy Managemen - 144g.72 Subd. 3 - $500.00 1970 - Treatment And Therapy Orders - 144g.72 Subd. 6 - $500.00 The details of the violations noted at the time of this follow-up survey completed on July 21, 2025 (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. Also, at the time of this follow-up survey completed on July 21, 2025, we identified the following violation(s): 1370 - Training And Evaluation Of Unlicensed Personn - 144g.61 Subd. 2 (a) 1380 - Training And Evaluation Of Unlicensed Personn - 144g.61 Subd. 2 (b) An equal opportunity employer. Letter ID: 8GKP Revised 04/14/2023 Abilit Holdings (Prairie Meadow) Septembe r18, 2025 Page 2 The details of the violation(s) noted at the time of this follow-up survey are delineated on the attached State Form. Only the ID Prefix Tag in the left hand column without brackets will identify these state correction orders. It is not necessary to develop a plan of correction. Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, t he total amount you are assessed is $3,000.00. 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 outlined on the state form; however, plans of correction are not required to be submitted for approval. IMPOSITION OF FINES In accordance with Minn. Stat. § 144G.31, Subd. 4, fines and enforcement actions may be imposed based on the level and scope of the violations and may be imposed immediately with no opportunity to correct the violation first as follows: Level 1: no fines or enforcement; Level 2: a fine of $500 per violation, in addition to any enforcement mechanism authorized in § 144G.20; Level 3: a fine of $1,000 per incident, in addition to any enforcement mechanism authorized in § 144G.20; Level 4: a fine of $3,000 per incident, in addition to any enforcement mechanism authorized in § 144G.20; Level 5: a fine of $5,000 per violation, in addition to any enforcement mechanism authorized in § 144G.20. 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 Abilit Holdings (Prairie Meadow) Septembe r18, 2025 Page 3 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. 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. We urge you to review these orders carefully. If you have questions, please contact Jodi Johnson 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, Jodi Johnson, Supervisor State Evaluation Team Email: Jodi.Johnson@state.mn.us Telephone: 507-344-2730 Fax: 1-866-890-9290 AH PRINTED: 09/18/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ R B. WING _____________________________ 24053 07/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 800 5TH AVE NW ABILIT HOLDINGS (PRAIRIE MEADO W) KASSON, MN 55944 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 FOLLOW UP using federal software. Tag numbers have SURVEY WITH RE-ISSUE OF ORDERS been assigned to Minnesota State Statutes for Assisted Living Facilities. The INITIAL COMMENTS assigned tag number appears in the SLSL24053016-1 far-left column entitled "ID Prefix Tag." The state Statute number and the On July 21, 2025, the Minnesota Department of corresponding text of the state Statute out Health conducted a follow-up survey at the above of compliance is listed in the "Summary provider to follow-up on orders issued pursuant to Statement of Deficiencies" column. This a survey completed on May 7, 2025. At the time column also includes the findings which of the survey, there were 61 residents; 56 are in violation of the state requirement receiving services under the Assisted Living after the statement, "This Minnesota Facility with Dementia Care license. As a result of requirement is not met as evidenced by." the follow-up survey, the following orders were Following the evaluators ' findings is the reissued and/or issued. Time Period for Correction. PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH STATES,"PROVIDER'S PLAN OF CORRECTION." THIS APPLIES TO FEDERAL DEFICIENCIES ONLY. THIS 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 SNNN12 If continuation sheet 1 of 28 PRINTED: 09/18/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ R B. WING _____________________________ 24053 07/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 800 5TH AVE NW ABILIT HOLDINGS (PRAIRIE MEADO KASSON, MN 55944 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.

findings, which are in violation of the state statute after the INITIAL COMMENTS: statement, "This Rule is not met as evidenced by." Following the evaluators' #HL240534721C findings is the Time Period for Correction. PLEASE DISREGARD THE HEADING OF On July 31, 2024, the Minnesota Department of THE FOURTH COLUMN, WHICH Health conducted a complaint investigation at the STATES, "PROVIDER'S PLAN OF above provider, and the following correction CORRECTION." THIS APPLIES TO orders are issued. At the time of the complaint FEDERAL DEFICIENCIES ONLY. THIS investigation, there were 59 residents receiving WILL APPEAR ON EACH PAGE. services under the provider's Assisted Living with Dementia Care license. THERE IS NO REQUIREMENT TO SUBMIT A PLAN OF CORRECTION FOR The following correction order is issued/orders VIOLATIONS OF MINNESOTA STATE are issued for #HL240534721C, tag identification STATUTES/RULES. 0470. 0 470 144G.41 Subdivision 1 Minimum requirements 0 470 SS=D (11) develop and implement a staffing plan for determining its staffing level that: (i) includes an evaluation, to be conducted at least twice a year, of the appropriateness of LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 8ILV11 If continuation sheet 1 of 4 PRINTED: 09/04/2024 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 _____________________________ 24053 07/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 800 5TH AVE NW ABILIT HOLDINGS (PRAIRIE MEADO WS) KASSON, MN 55944 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) 0 470 Continued From page 1 0 470 staffing levels in the facility; (ii) ensures sufficient staffing at all times to meet the scheduled and reasonably foreseeable unscheduled needs of each resident as required by the residents' assessments and service plans on a 24-hour per day basis; and (iii) ensures that the facility can respond promptly and effectively to individual resident emergencies and to emergency, life safety, and disaster situations affecting staff or residents in the facility; (12) ensure that one or more persons are available 24 hours per day, seven days per week, who are responsible for responding to the requests of residents for assistance with health or safety needs. Such persons must be: (i) awake; (ii) located in the same building, in an attached building, or on a contiguous campus with the facility in order to respond within a reasonable amount of time; (iii) capable of communicating with residents; (iv) capable of providing or summoning the appropriate assistance; and (v) capable of following directions; This MN Requirement is not met as evidenced by: Based on interview and record review, the licensee failed to ensure the facility had sufficient staffing to meet the scheduled and reasonably foreseeable unscheduled needs, as required by the resident's assessments and service plans on a 24-hour per day basis, for one of one resident (R1) who required two-person assist with a mechanical lift. This practice resulted in a level two violation (a violation that did not harm a resident's health or safety but had the potential to have harmed a resident's health or safety, but was not likely to STATE FORM 6899 8ILV11 If continuation sheet 2 of 4 PRINTED: 09/04/2024 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 _____________________________ 24053 07/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 800 5TH AVE NW ABILIT HOLDINGS (PRAIRIE MEADO WS) KASSON, MN 55944 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) 0 470 Continued From page 2 0 470 cause serious injury, impairment, or death) and was issued at an isolated scope (when one or a limited number of residents are affected or one or a limited number of staff are involved, or the situation has occurred only occasionally). During the overnight shift [10:00 p.m. until 6:00 a.m.], the facility was routinely staffed with only one unlicensed caregiver in the Assisted Living where R1 resided. R1 required the assistance of two unlicensed personnel (ULP) and a mechanical lift for transfers. The licensee 's plan for unscheduled transfer needs of R1 was to utilize the local fire department to provide lift assistance during the overnight shift. Minnesota Rule 4659.0180, Subpart 5, indicates a minimum of two direct-care staff must be scheduled and available to assist at all times whenever a resident requires the assistance of two direct-care staff for scheduled and reasonably foreseeable and unscheduled needs, as reflected in the resident's assessments and service plans. The findings include: R1 was admitted to the facility on March 12, 2018. R1's diagnoses included Alzheimer's disease and chronic pain. R1's service plan, dated May 3, 2024, indicated R1 required a two-person assist for transfers with a Hoyer (brand of mechanical patient lift) and R1 required frequent assistance with transfers and/or a change in position. R1 assessment, dated March 20, 2024, indicated R1 needed extensive and frequent hands-on assistance with transfers and/or changes in STATE FORM 6899 8ILV11 If continuation sheet 3 of 4 PRINTED: 09/04/2024 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 _____________________________ 24053 07/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 800 5TH AVE NW ABILIT HOLDINGS (PRAIRIE MEADO WS) KASSON, MN 55944 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) 0 470 Continued From page 3 0 470 position using a Hoyer lift. The licensee's employee schedule for June 1, 2024, through July 31, 2024, indicated one ULP was consistently scheduled in the Assisted Living area. The licensee's Uniform Disclosure of Assisted Living Services & Amenities (UDALSA) indicated the licensee staffed three unlicensed personnel (ULP) during the overnight shift. During an interview on July 31, 2024, the Health Care Coordinator stated the goal was to staff three ULP for the overnight shift, however they had difficulty staffing that shift. The Health Care Coordinator stated if the resident had a request to transfer during the overnight the ULP would have to call the Fire Department for assistance, but also stated the resident had not requested to get up during the night. The Health Care Coordinator stated R1 had not had any falls in the previous 3 months, and the only skin breakdown R1 experienced occurred when R1 was hospitalized and quickly healed upon his return. The licensee-provided policy titled "Staffing and Scheduling" dated August 01, 2021, indicated the clinical nurse supervisor must ensure that staffing levels are adequate to meet the residents needs as identified in the residents' service plan, and staff must be able to meet the foreseeable unscheduled needs. TIME PERIOD FOR CORRECTION: Seven (7) days STATE FORM 6899 8ILV11 If continuation sheet 4 of 4

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 safety interventions failed to be implemented while the resident was unsteady and under the influence of alcohol. The resident was found on the floor with a cut to her head and went to the hospital for treatment. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. The resident experienced falls possibly related to her state during alcohol use, however, the facility contacted nursing staff regarding concerns and implemented hourly safety checks of the resident. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigation included review of resident records, hospital records, facility incident reports, staff schedules, and related facility policy and procedures. Also, the investigator observed staff providing resident care at the facility. The resident resided in an assisted living facility. The resident’s diagnoses included falls, high blood pressure, and alcohol abuse. The resident’s service plan included assistance with medication management and judgment regarding alcohol use. The resident’s assessment indicated she was able to walk independently with use of a four wheeled walker and was able to communicate needs. Progress notes from the time in question indicate a staff member found the resident barefoot, sitting on the hallway floor, and smelling of alcohol. The unlicensed personnel contacted the nurse. The resident was free from injury and vital signs were within range for the resident. The resident stood up and was able to walk normally with the use of her walker. Approximately half an hour later while an unlicensed personnel administered medications to the resident, the resident became unsteady and leaned on the unlicensed personnel who lowered the resident to the floor. The unlicensed personnel contacted the nurse. The resident was free from injury, vital signs were within range for the resident, and the resident’s family were contacted. The resident was placed on hourly checks. Approximately one hour later, unlicensed personnel found the resident sitting on the floor next to her bed with a cut on her head. Vital signs revealed a lower blood pressure, and the resident was sent to the hospital where she received three staples to the cut on her head. No other injury was noted. During interview, a leadership member stated the resident could become unsteady while drinking alcohol. When staff believed the resident was drinking, staff contacted the resident’s family and increased resident safety checks. The leadership member stated the resident and the resident’s family did not want the resident drinking alcohol and the facility assists with these wishes by monitoring the resident, not taking the resident to the liquor store during shopping outings, and locking up and dispensing the resident’s alcohol mouthwash. During interview, an unlicensed staff member stated alcohol was removed from the resident per the resident’s and family’s request, however, the resident hid alcohol and mouthwash from staff members at times and denied drinking. The unlicensed staff member stated the nurse was contacted during the time in question and the resident was checked hourly. During interview, a family member stated he did not have any concerns regarding the facility’s care of the resident during the time of the fall and the cause of the fall could have been related to low blood pressure issues. The family member stated the facility has been communicating with the resident, resident’s family, and provider to best assist the resident. In conclusion, the Minnesota Department of Health determined neglect was not substantiated. “Not Substantiated” means: An investigatory conclusion indicating the preponderance of evidence shows that an act meeting the definition of maltreatment did not occur. Neglect: Minnesota Statutes, section 626.5572, subdivision 17 “Neglect” means neglect by a caregiver or self-neglect. (a) "Caregiver neglect" means the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to, food, clothing, shelter, health care, or supervision which is: (1) reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult; and (2) which is not the result of an accident or therapeutic conduct. Vulnerable Adult interviewed: Yes. Family interviewed: Yes. Alleged Perpetrator interviewed: Not Applicable. Action taken by facility: Ongoing care plan creation with resident and family regarding alcohol use. 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: 06/13/2024 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 _____________________________ 24053 03/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 800 5TH AVE NW ABILIT HOLDINGS (PRAIRIE MEADO W) LLC KASSON, MN 55944 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****** ASSISTED LIVING PROVIDER CORRECTION ORDER In accordance with Minnesota Statutes, section 144G.08 to 144G.95, these correction orders are issued pursuant to a complaint investigation. Determination of whether a violation is corrected requires compliance with all requirements provided at the statute number indicated below. When a Minnesota Statute contains several items, failure to comply with any of the items will be considered lack of compliance. INITIAL COMMENTS: #HL240536552C/#HL240539025M #HL240538953C/#HL240531401M On March 19, 2024, the Minnesota Department of Health conducted a complaint investigation at the above provider, and the following correction orders are issued. At the time of the complaint investigation, there were 56 residents receiving services under the provider's Assisted Living with Dementia Care license. The following correction order is issued for #HL240536552C/#HL240539025M, tag identification 2360. 02360 144G.91 Subd. 8 Freedom from maltreatment 02360 Residents have the right to be free from physical, sexual, and emotional abuse; neglect; financial exploitation; and all forms of maltreatment covered under the Vulnerable Adults Act. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 0KXF11 If continuation sheet 1 of 2 PRINTED: 06/13/2024 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 _____________________________ 24053 03/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 800 5TH AVE NW ABILIT HOLDINGS (PRAIRIE MEADO KASSON, MN 55944 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) 02360 Continued From page 1 02360 This MN Requirement is not met as evidenced by: The facility failed to ensure one of one resident(s) No plan of correction is required for this reviewed (R1) was free from maltreatment. tag. Findings include: The Minnesota Department of Health (MDH) issued a determination maltreatment occurred, and the facility was responsible for the maltreatment, in connection with incidents which occurred at the facility. Please refer to the public maltreatment report for details. STATE FORM 6899 0KXF11 If continuation sheet 2 of 2

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) neglected a resident when they failed to direct staff to get the resident out of bed and give her food and fluids. As a result, the resident’s health declined. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. The resident received services from a hospice agency and the AP directed staff to follow the hospice plan of care. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted hospice care providers. The investigation included review of resident records and employee files. Also, the investigator toured the facility and observed interactions between staff and residents. An equal opportunity employer. The resident resided in an assisted living memory care unit. The resident’s diagnoses included dementia (memory loss), depression, failure to thrive, and delirium. The resident’s service plan included assistance with housekeeping, medications, meals, dressing, grooming, bathing, mobility, and toileting. The resident’s nursing assessment indicated the resident was on hospice care services and her health was declining. The nursing assessment indicated the resident had multiple falls and required increased assistance with mobility and transfers. During a one-month period around the time of the alleged incident, the resident’s progress notes indicated the resident had increased swallowing difficulties when she ate, and an overall decline in her health. Eventually, the resident required puree texture food. The progress notes indicated there were days the resident would not eat or drink. The resident began to vomit and required medication to control nausea and vomiting. In addition, staff observed the resident did not have any urine output for two-day period. The resident’s progress notes indicated staff offered the resident food and fluid and got her up into the Broda chair. The resident’s progress notes indicated hospice staff changed the resident’s medications multiple times and were involved in care planning. The resident’s medical record indicated a nurse practitioner (NP) observed the resident about three weeks prior to the alleged incident. The NP’s note indicated the resident had a decline in her physical and mental health and was sleeping about twenty-two hours a day. The NP’s note indicated the resident was sleeping in her Broda chair during her exam and appeared to be comfortable. The resident’s treatment administration record (TAR) indicated staff repositioned the resident every two hours and provided incontinent cares. The TAR indicated staff encouraged the resident to take food and fluids. The TAR indicated staff offered the resident extra fluids at meals and snack times. During an interview, an unlicensed personnel (ULP) said the resident lived in memory care because she had advanced memory loss. The ULP said the resident received services from a hospice agency and her health was declining. The ULP said the resident had multiple falls and increased difficulty walking. The ULP said the resident required a Broda chair (oversized, reclining wheelchair), assistance from two staff members, and a mechanical lift to get her into the Broda chair. The ULP said there were differences in the staff’s opinions when to get the resident out of bed and into the Broda chair. The ULP said there was one incident where the resident was in bed for several days and she requested staff get the resident out of bed and into the Broda chair. Staff told her the AP told them they were not supposed to get the resident out of bed because she was minimally responsive. The ULP said she did not agree with the AP. The ULP said the resident appeared comfortable in bed at the time but felt staff should have gotten her up. During an interview, the AP said the resident walked when she admitted into the facility, however her health status declined quickly. The AP said the resident required increased supervision and had multiple falls. The AP said the resident required assistance with all her cares. The AP said the resident had “good days” and “bad days” and she slept often. The AP said the resident even slept when she was in the Broda chair. The AP said the resident’s eating and drinking would also vary. The AP said there were days the resident ate and drank very little, but then there were days she ate everything on her plate. The AP said the care plan directed ULP to offer the resident food and fluids, but they could not force her to eat. The AP said there were days when the resident was sleepy and would stay in bed, but she encouraged staff to get her up into her Broda chair. The AP said the care plan directed staff to reposition and provide skin cares to the resident when she was in bed. The AP said hospice caregivers were involved in care planning and they directed the resident’s end of life plan of care. 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: (a) 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. Deceased. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Yes. the Action taken by facility: The facility worked in collaboration with hospice care providers. 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: 08/04/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ C B. WING _____________________________ 24053 07/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 800 5TH AVE NW ABILIT HOLDINGS (PRAIRIE MEADO KASSON, MN 55944 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 July 5, 2023, the Minnesota Department of Health initiated an investigation of complaint #HL240534826C/#HL240532886M. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 DGQU11 If continuation sheet 1 of 1