Praha Village.

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 ; however, no immediate fines are assessed for this survey of your facility. DOCUMENTATIO ONF ACTION TO COMPLY In ac cordanc e with Minn. Stat. § 144G .30, Subd . 5(c), the lice ns ee mus t doc um ent ac tion s 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). An equal opportunity employer. Letter ID: IS7N REVISED 09/13/2021 Praha Village March 7, 2024 Pag e 2 CORRECTIO ONRDER 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 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 con venien ce at this lin k : https: / / forms. office.com/ g/ Bm5uQEpHVa. Your inpu t is im port 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 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, Carrie Euerle, Supervisor State Evaluation Team Email: carrie.euerle@ state. mn.us Telephone: 651-242-8846 Fax: 1-866-890-9290 PMB PRINTED: 03/ 07/ 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 _____________________________ 34459 02/ 22/ 2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1100 1ST STREET SE PRAHA VILLAGE NEW PRAGUE, MN 56071 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 LICENSING CORRECTION ORDER In accordance with Minnesota Statutes, section 144G. 08 to 144G. 95, these correction orders are issued pursuant to a survey. Determination of whether violations are corrected requires compliance with all requirements provided at the Statute number indicated below. When Minnesota Statute contains several items, failure to comply with any of the items will be considered lack of compliance. INITIAL COMMENTS: SL#34459016- 0 On February 20, 2024, through February 22, 2024, the Minnesota Department of Health conducted a CHOW (change of ownership) survey at the above provider, and the following correction order is issued. At the time of the survey there were 94 residents receiving services under the provider' s Assisted Living Facility with Dementia Care license. 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 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: Based on observation, interview, and record LABORATORY DIRECTOR' S OR PROVIDER/ SUPPLIER REPRESENTATIVE' S SIGNATURE TITLE (X6) DATE STATE FORM 6899 OUHD11 If continuation sheet 1 of 2 PRINTED: 03/ 07/ 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 _____________________________ 34459 02/ 22/ 2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1100 1ST STREET SE PRAHA VILLAGE NEW PRAGUE, MN 56071 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 review, the licensee failed to ensure food was prepared and served according to the Minnesota Food Code. 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) and was issued at a widespread scope (when problems are pervasive or represent a systemic failure that has affected or has the potential to affect a large portion or all the residents) . The findings include: Please refer to the document titled, Food and Beverage Establishment Inspection Report (FBEIR) dated February 20, 2024, for the specific Minnesota Food Code violations. The Inspection Report was provided to the licensee within 24 hours of the inspection. TIME PERIOD FOR CORRECTION: Please refer to the FBEIR for any compliance dates. STATE FORM 6899 OUHD11 If continuation sheet 2 of 2 Environmental Health, FPLS St. Paul, MN 55164-0975 6512014500 Type: Full Page 1 Food and Beverage Establishment Date: 02/20/24 Inspection Report Time: 13:00:00 Report: 1047241044 Location: Establishment Info: Praha Village ID #: 0038647 Risk: 1100 1st Street Se Announced Inspection: No New Prague, MN56071 Le Sueur County, 40 License Categories: Operator: Phone #: 9528558855 Expires on: / / ID #: The violations listed in this report include any previously issued orders and deficiencies identified during this inspection. Compliance dates are shown for each item. The following orders were issued during this inspection. 4-500 Equipment Maintenance and Operation 4-501.114C1 ** Priority 1 ** MN Rule 4626.0805C1 Provide and maintain an approved chlorine chemical sanitizer solution that has a minimum concentration of 50 ppm and a minimum temperature of 75 degrees F (24 degrees C) for water with a pH of 8 or less or a minimum temperature of 100 degrees F (38 degrees C) for water with a pH of 8.1 to 10. CHLORINE CONCENTRATION IN DISHMACHINE MEASURED 0 PPM. CORRECTED ON SITE- NEW CONCENTRATION WAS 100 PPM. Comply By: 02/20/24 4-100 Equipment Construction Materials 4-101.11BCDE MN Rule 4626.0450BCDE Remove all multi-use equipment, utensils, and food storage containers that are not durable, corrosion-resistant, nonabsorbent, smooth, easily cleanable, resistant to pitting, chipping, scratching or not able to withstand repeated warewashing. CUTTING BOARDS ON COOK LINE HAVE SIGNIFICANT WEAR & ARE UNABLE TO EASILY BE CLEANED. FACILITY STATED THEY ARE HAVE STARTED THE PROCESS OF ACQUIRING NEW ONES TO REPLACE THEM. Comply By: 04/09/24 Surface and Equipment Sanitizers Chlorine: = 0 ppm at Degrees Fahrenheit Location: Dishmachine Violation Issued: Yes Type: Full Page 2 Food and Beverage Establishment Date: 02/20/24 Inspection Report Time: 13:00:00 Report: 1047241044 Praha Village Chlorine: = 100 ppm at Degrees Fahrenheit Location: Dishmachine *corrected Violation Issued: No Quaternary Ammonia: = 400 ppm at Degrees Fahrenheit Location: 3 comp.

Finding: Not Substantiated Nature of Investigation: The Minnesota Department of Health investigated an allegation of maltreatment, in accordance with the Minnesota Reporting of Maltreatment of Vulnerable Adults Act, Minn. Stat. 626.557, and to evaluate compliance with applicable licensing standards for the provider type. Initial Investigation Allegation(s): The facility neglected the resident when the resident was not sent to the hospital after a change in condition and later diagnosed with a mild stroke. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. The facility nurse completed an assessment after notification from unlicensed staff of a concern, the nurse found no variation in condition and attributed change in condition related to increased fatigue. Unlicensed caregivers reported resident was up wandering during the night and resident’s reporting she was tired. The facility nurse followed the facility procedure and the resident returned to baseline health condition. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted the resident’s family members. The investigation included review of the resident’s medical records, the facility’s policies and procedures, incident reports, and staff schedules. Also, the investigation included an onsite visit, observations, and interactions between residents and facility staff. The resident resided in an assisted living memory care unit. The resident’s diagnoses included Alzheimer’s disease and dementia. The resident’s service plan indicated the resident was able to walk with assistance and set-up assistance and reminders during meals. The resident’s assessment indicated resident was oriented to self only with difficulty communicating needs due to impaired speech pattern. The residents medical record indicated a progress note where the facility nurse documented notification of a concern the resident was more tired, talking slower with left sided drooping. The facility nurse assessed the resident and found the only deviation from the resident’s baseline condition was increased fatigue. The facility nurse did re-assess the resident a second time and found the initial assessment unchanged. The facility nurse notified the resident’s family at that time. The resident’s progress notes indicated the resident had an unwitnessed fall later the same day. The facility updated the resident’s medical provider and spoke with the resident’s family, who requested the resident transfer the hospital as she did not seem herself. The next day the resident remained in the hospital and had been diagnosed with mild stroke with left-sided weakness. During an interview, the facility nurse stated she assessed the resident after an unlicensed caregiver reported the resident was not acting like herself. The facility nurse found the resident responsive, reporting was tired, but assessment was otherwise negative. The facility nurse reported the unlicensed caregivers ambulated with the resident to the noon meal where the resident consumed 100% of the meal without incident. The facility nurse stated she notified the resident’s provider and family member and continued to follow up on resident’s condition until she left for the day. During an interview, the resident’s family member reported she was working and received a call from the facility nurse relaying the resident condition. The family member stated she visited the resident later in the afternoon and knew something was wrong, an ambulance was called, and the resident was transferred to the hospital. The family member states the resident did have a mild stroke but is currently back at her baseline health condition. 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. (5) an individual makes an error in the provision of therapeutic conduct to a vulnerable adult that results in injury or harm, which reasonably requires the care of a physician, and: (i) the necessary care is provided in a timely fashion as dictated by the condition of the vulnerable adult; (ii) if after receiving care, the health status of the vulnerable adult can be reasonably expected, as determined by the attending physician, to be restored to the vulnerable adult's preexisting condition; (iii) the error is not part of a pattern of errors by the individual; (iv) if in a facility, the error is immediately reported as required under section 626.557, and recorded internally in the facility; Vulnerable Adult interviewed: No, due to cognitive impairment Family/Responsible Party interviewed: Yes Alleged Perpetrator interviewed: Not Applicable the 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: 01/02/2024 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 _____________________________ 34459 12/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1100 1ST STREET SE PRAHA VILLAGE NEW PRAGUE, MN 56071 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 December 12, 2023, the Minnesota Department of Health initiated an investigation of complaint #HL344596666C/#HL344599065M. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 N1DU11 If continuation sheet 1 of 1