Prairie Cottages of Owatonna.

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): Facility staff (unlicensed personnel) neglected the resident when staff failed to report a fall and the resident was found deceased two hours later. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. Although a fall went unreported and the resident was later found deceased, there was not a preponderance of evidence to determine that the fall contributed to the resident’s death. The investigator conducted interviews with administrative staff and a family member of the resident. The investigation included review of the resident’s records, internal investigation documentation, incident reports, staff schedules, and facility policies, and procedures. The resident resided in an assisted living secured memory care facility. The resident’s diagnoses include hypertension, congestive heart failure, chronic kidney disease, and dementia. The resident’s service plan included assistance with all activities of daily living. The service plan also included hourly safety check and repositioning every 2 hours when in bed. The staff schedule indicated that unlicensed personnel (ULP) #1 worked the night shift and ULP #2 worked the morning shift. Documentation indicated that the resident was found on the floor by ULP #1 and was assisted back into bed by ULP #1 and #2 at 6:00 a.m. The resident had slid out of bed, and no injuries were noted at that time. A third ULP entered the resident’s room at 8:00 a.m. later that morning to administer medications and found the resident unresponsive, blue in color, with his mouth open. The death certificate indicated that the cause of death was congestive heart failure and hypertension. Internal investigation documentation included a statement from ULP #1, who indicated that he heard beeping and went to check on the resident. He saw the resident leaning against the bed and then asked ULP #2 to help him return the resident to bed, then rushed to assist another resident. ULP #2’s statement indicated that he received a call from ULP #1 asking for assistance in helping the resident off the floor. Upon entering the room, he saw the resident sitting on the floor, moaning, but appeared to be okay. ULP #2 indicated that it seemed the resident had slid onto the floor. Both ULP helped the resident back into bed before ULP #2 returned to his designated work area and assumed ULP #1 would complete the incident report and notify the nurse. During an interview, management staff stated that she received a call notifying her that the resident had passed away. She said she spoke with staff and learned that the resident had slid out of bed and was found on the floor beside his bed. She questioned ULP #1 and #2, who admitted they each assumed someone else would report the incident, but neither did. Management indicated ULP #1 and #2 were terminated for failing to follow fall protocol. During an interview, the resident’s family member stated the facility called her every time the resident fell and kept her updated on the day he passed. She said she did not believe the fall he had the night he died was what caused his death as he had a long history of heart failure along with several other health issues. 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. The resident was deceased. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Not Applicable. Action taken by facility: Unlicensed Caregivers #1 and #2 were terminated for failing to follow fall protocol. 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: 08/05/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ C B. WING _____________________________ 30580 06/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 150 24TH STREET NE PRAIRIE COTTAGES OF OWATONNA LLC OWATONNA, MN 55060 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 June 10, 2025, the Minnesota Department of Health initiated an investigation of complaints #HL305802822M/HL305804964C . No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 7BDE11 If continuation sheet 1 of 1

correction orders issued pursuant to the November 14, 2024 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 November 14, 2024, found not corrected at the time of the February 3, 2025, follow-up survey and/or subject to penalty assessment are as follows: 0900 - Contract Required - 144g.50 Subdivision 1 1540 - Training In Dementia Care Required - 144g.64 (a) 1650 - Service Plan, Implementation And Revisions To - 144g.70 Subd. 4 (f) 1750 - Delegation Of Medication Administration - 144g.71 Subd. 7 2170 - Services For Residents With Dementia - 144g.84 - $500.00 The details of the violations noted at the time of this follow-up survey completed on February 3, 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. Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, the total amount you are assessed is $500.00. You will be invoiced approximately 30 days after receipt of this notice, subject to appeal. 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: Level 1: no fines or enforcement. Level 2: a fine of $500 per violation, in addition to any enforcement mechanism authorized in An equal opportunity employer. Letter ID: 8GKP Revised 04/14/2023 Prairie Cottages Of Owatonna March 6, 2025 Page 2 §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 §144 G.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 factor. To submit a hearing request, please visit: https://forms.web.health.state.mn.us/form/HRDAppealsForm To appeal fines via reconsideration, please follow the procedure outlined above. Please note that you may request a reconsideration 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 JMD PRINTED: 03/06/2025 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 _____________________________ 30580 02/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 150 24TH STREET NE PRAIRIE COTTAGES OF OWATONNA LLC OWATONNA, MN 55060 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 SL30580016-1 far-left column entitled "ID Prefix Tag." The state Statute number and the On February 3, 2025, the Minnesota Department corresponding text of the state Statute out of Health conducted a follow-up survey at the of compliance is listed in the "Summary above provider to follow-up on orders issued Statement of Deficiencies" column. This pursuant to a survey completed on November 14, column also includes the findings which 2024. At the time of the survey, there were 37 are in violation of the state requirement residents; 37 receiving services under the after the statement, "This Minnesota Assisted Living with Dementia Care License. As a requirement is not met as evidenced by." result of the follow-up survey, the following orders Following the evaluators ' findings is the were reissued: 0900, 1540, 1650, 1750 and 2170. 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 VUGU12 If continuation sheet 1 of 18 PRINTED: 03/06/2025 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 _____________________________ 30580 02/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 150 24TH STREET NE PRAIRIE COTTAGES OF OWATONNA LLC OWATONNA, MN 55060 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.