Cottagewood Senior Communities.

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 necessar yto ensure the health, safety, and welfare of residents in your care. STATE CORRECTIO ONRDERS 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 Requiremen tis not met as evidenced by . . ." IMPOSITION OF FINES In accordance with Minn. Stat. § 144G3. 1, 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: Leve l1: no fines or enforcement; Leve l2: a fine of $500 per violation, in addition to any enforcement mechanism authorized in § 144G2. 0; Leve l3: a fine of $1,000 per incident, in addition to any enforcement mechanism authorized in § 144G2. 0; An equal opportunity employer . Letter ID: IS7N REVISE 0D9/13/2021 Cottagewood Senio rCommunities October 14, 2025 Page 2 Leve l4: a fine of $3,000 per incident, in addition to any enforcement mechanism authorized in § 144G2. 0; Leve l5: a fine of $5,000 per violation, in addition to any enforcement mechanism authorized in § 144G2. 0. Therefore ,in accordance with Minn. Stat. §§ 144G0. 1 to 144G9. 999, the following fines are assessed pursuant to this survey: St - 0 - 0775 - 144g.45 Subd. 2. (a) - Fire Protection And Physica lEnvironment - $500.00 Therefore ,in accordance with Minn. Stat. §§ 144G0. 1 to 144G9. 999, the total amount you are assesse dis $500.00. You will be invoiced approximately 30 days after receipt of this notice, subject to . appeal DOCUMENTATIO ONF ACTION TO COMPLY In accordance with Minn. Stat. § 144G3. 0, Subd .5(c), t he 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: x Identify how the area(s) of noncompliance was corrected related to the resident(s)/ employee(s) identified in the correction order. x 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. x Identify what changes to your systems and practices were made to ensure compliance with the specific statute(s). CORRECTIO ONRDER RECONSIDERATI OPRNOCESS In accordance with Minn. Stat. § 144G3. 2, Subd .2, you may challenge the correction order(s) issued, including the level and scope ,and any fine assesse dthrough 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 REQUESTIN AG HEARING Alternatively, in accordance with Minn. Stat. § 144G3. 1, Subd .5(d), an assisted living provider that has been assesse da fine under this subdivision has a right to a reconsideration or a hearing under this section and chapter 14. Pursuan tto Minn. Stat. § 144G2. 0, 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 Cottagewood Senio rCommunities October 14, 2025 Page 3 factor. To submit a hearing request, please visit: https:/ / forms.web.health.state.mn.us/form/ HRDAppealsForm To appea lfines via reconsideration ,please follow the procedure outlined above. Please note that you may request a reconsideration or 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: https:/ / forms.office.com/g/Bm5uQEpHV.a Your input is important to us and will enable MDH to improve its processe sand communication with providers. If you have any questions regarding the questionnaire ,please contact Susan Winkelmann at susanw. inkelmann@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 organizations’ Governing Body. If you have any questions ,please contact me. Sincerely, Jod iJohnson ,Supervisor State Evaluation Team Email: Jodi.Johnson@state.mn.us Telephone :507-344-2730 Fax :1-866-890-9290 HHH PRINTED: 10/14/2025 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 _____________________________ 20391 09/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4216 55TH ST NW COTTAGEWOOD SENIOR COMM ROCHESTER, MN 55901 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE PREFIX PREFIX 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 Facilities. The In accordance with Minnesota Statutes, section assigned tag number appears in the 144G.08 to 144G.95, these correction orders are far-left column entitled "ID Prefix Tag." issued pursuant to a survey. The state Statute number and the corresponding text of the state Statute out Determination of whether violations are corrected of compliance is listed in the "Summary requires compliance with all requirements Statement of Deficiencies" column. This provided at the Statute number indicated below. column also includes the findings which When Minnesota Statute contains several items, are in violation of the state requirement failure to comply with any of the items will be after the statement, "This Minnesota considered lack of compliance. requirement is not met as evidenced by." Following the evaluators ' findings is the INITIAL COMMENTS: Time Period for Correction. SL20391016-0 PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On September 8, 2025, through September 11, STATES,"PROVIDER'S PLAN OF 2025, the Minnesota Department of Health CORRECTION." THIS APPLIES TO conducted a full survey at the above provider and FEDERAL DEFICIENCIES ONLY. THIS the following correction orders are issued. At the WILL APPEAR ON EACH PAGE. time of the survey, there were 90 residents; 90 receiving services under the Assisted Living THERE IS NO REQUIREMENT TO Facility with Dementia Care license. 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. 0 775 144G.45 Subd. 2. (a) Fire protection and physical 0 775 SS=F environment LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 3W0B11 If continuation sheet 1 of 34 PRINTED: 10/14/2025 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.

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 she fell and hit her head, but the facility delayed having her evaluated by medical staff. She was on anticoagulants and possibly sustained a brain bleed due to the fall. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. Although the resident fell and hit her head the facility did assess the resident appropriately including updating the medical provider and the resident’s family. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted the resident's guardian. The investigation included review of resident's records, facility's policies and procedures, incident reports, and the resident's external medical record. The investigation included an onsite visit, observations, and interactions between residents and facility staff. The resident resided in an assisted living secured memory care building. The resident’s diagnoses include dementia. The resident’s service plan included assistance of one person with all activities of daily living which included hygiene, dressing, toileting, and medications. The service plan also included six to seven times safety checks a day. The resident’s assessment indicated the resident require minimal assistance of one person and a front wheel walker for mobility. One weekend, the resident fell and hit her head, sustaining an abrasion on her left forehead, which was also bruised. The resident was on blood thinner medication. The nurse obtained vital signs and assessed the resident. The family was notified, and a fax was sent to the provider about the incident. Two days later, a post-fall evaluation was conducted, and safety checks were increased to ensure the resident's safety. Five days after the fall, the resident fell again, and the facility sent her to the hospital for further evaluation. The hospital records indicated the resident was admitted due to worsening confusion and recurrent falls. A computed tomography (CT) scan of her head was negative for injury but showed a left frontal subcutaneous hemorrhage, however the injury required no treatment or intervention. During an interview, an unlicensed caregiver stated the resident was independent when she first moved in a few years ago. More recently, her health started declining as her dementia progressed. The unlicensed caregiver stated the facility checked on the resident at least every two hours, or more often due to her condition. She also said staff members often tried to keep her out in the common areas to make it easier to keep an eye on her. She stated that the resident had a fall mat and a baby monitor in her room to alert staff members when she moved around without asking for help. During an interview, a nurse stated the resident’s condition declined as her disease worsened and fell a couple of times due to confusion and restlessness. The nurse stated staff members. checked on the resident frequently and kept her in the common area to make it easier to monitor her. The resident’s interventions had included a fall mat alarm in her room, but it was set off too often by her cat, so they had to remove it. Instead, the facility used a baby monitor with the resident when she rested in her room. The facility’s practice when a fall occurred was included notifying the family and the medical provider whenever the resident fell and to follow-up with a post-fall assessment. During an interview, the resident’s guardian stated that the facility called and notified her of any falls the resident had. She did not have any concerns about the care the resident received. 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 resting. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Not Applicable. 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: 11/12/2024 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 _____________________________ 20391 10/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4216 55TH ST NW COTTAGEWOOD SENIOR COMM UNITIES ROCHESTER, MN 55901 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 October 15, 2024, the Minnesota Department of Health initiated an investigation of complaint #HL203915101M/HL203916788C. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 AQS811 If continuation sheet 1 of 1

Finding: Inconclusive Nature of Investigation: The Minnesota Department of Health investigated an allegation of maltreatment, in accordance with the Minnesota Reporting of Maltreatment of Vulnerable Adults Act, Minn. Stat. 626.557, and to evaluate compliance with applicable licensing standards for the provider type. Initial Investigation Allegation(s): The alleged perpetrator (AP) abused the residents when the AP yanked Resident #1’s arm, yanked and forcefully moved Resident #2, and boosted Resident #3 up on the toilet, causing Resident #3’s head to hit the wall. Investigative Findings and Conclusion: The Minnesota Department of Health determined abuse was inconclusive. Due to conflicting information provided, it could not be determined if the alleged incidents did or did not occur. In addition, there was no evidence of bruising or changes observed with any of the residents’ mood or behaviors. The investigator conducted interviews with facility staff members, including nursing staff and unlicensed staff. The investigation included review of resident records, facility internal investigation documentation, personnel files, staff schedules, and facility policies and procedures. Also, at the time of the onsite visit the investigator observed resident cares. Resident #1 Resident #1 resided in an assisted living memory care unit. The resident’s diagnoses included Parkinson’s Disease and dementia with behavioral disturbance. The resident’s service plan included assistance with all activities of daily living, behavior management, and safety checks. The resident’s assessment indicated the resident was disoriented, had a history of verbal and physical aggression, and was at risk for abuse. The facility’s internal investigation indicated a staff member/alleged perpetrator (AP) pulled on Resident #1’s arm, talked to the resident in a mean tone, and pulled Resident #1 down the hallway. The investigation indicated Resident #1 was assessed and no injuries were observed. Resident #2 Resident #2 resided in an assisted living memory care unit. The resident’s diagnoses included dementia with behavioral disturbance and type 2 diabetes. The resident’s service plan included assistance with all activities of daily living, behavior management, and safety checks. The resident’s assessment indicated the resident was disoriented and was at risk for abuse. The facility’s internal investigation indicated a staff member reported that the AP yanked Resident #2 up by the arms, causing the resident to groan in pain. The investigation indicated Resident #2 was assessed and no injuries were observed. Resident #3 Resident #3 resided in an assisted living memory care unit. The resident’s diagnoses included Alzheimer’s Disease and osteoarthritis. The resident’s service plan included assistance with all activities of daily living including assistance with toileting, behavior management, and safety checks. The resident’s assessment indicated the resident was cognitively impaired, had a history of verbal and physical aggression, and was at risk for abuse. The facility’s internal investigation indicated staff members reported that the AP was rough with Resident #3 when assisting with toileting, and Resident #3 became aggressive and slapped the AP. The AP then boosted Resident #3 up so hard off of the toilet that Resident #3’s head hit the wall. Resident #3 was not able to stand independently, so the AP sat Resident #3 back down and when they assisted Resident #3 to stand up again, the resident’s head hit the wall again. Resident #3 said to the AP, “Ouch, you’re hurting me, why do you hate me? You’re so mean.” Resident #3 was assessed an no injuries were observed. During investigative interviews, unlicensed staff members stated that the AP was impatient when residents did not move fast enough. The AP yanked or forced residents by grabbing their arms to forcefully guide the residents. One unlicensed staff member stated she witnessed the AP boost Resident #3 up hard, causing Resident #3’s head to hit the wall twice while providing toileting assistance. During an interview, the facility nurse stated that prior to these allegations, the AP was never forceful or rough, was good to the residents, and was reliable staff member. The nurse stated that these allegations caught the facility off guard but stated that the investigation revealed that at some point the AP became more intolerant and gruffer when providing cares. The nurse stated skin audits were completed and no injuries were observed on the resident’s involved with the AP’s alleged behavior. The nurse stated that after the alleged incidents were reported to her, an internal investigation was conducted immediately. The nurse also stated that facility wide education was completed with all staff and the AP was no longer employed at the facility. During an interview, the AP denied mistreating, yanking, or using force with residents and that she has never been accused of anything like this before. The AP confirmed Resident #3 hit her head on the wall near the toilet but stated that this occurred when Resident #3 had difficulty standing and during an attempt to pivot Resident #3, the resident’s head hit the wall. The AP stated that the resident did not complain of pain at the time the incident occurred. During interviews with the residents’ family members, they stated that they were notified of the allegations involving the AP and reported no concerns. In conclusion, the Minnesota Department of Health determined abuse was inconclusive. Inconclusive: Minnesota Statutes, section 626.5572, Subdivision 11. "Inconclusive" means there is less than a preponderance of evidence to show that maltreatment did or did not occur. Abuse: Minnesota Statutes section 626.5572, subdivision 2. "Abuse" means: (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; Vulnerable Adult interviewed: R1- deceased, R2 and R3 unable to complete due to cognition. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Yes. the Action taken by facility: The facility completed an internal investigation and facility wide staff education. The AP is no longer employed by the facility. 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: 05/22/2024 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 _____________________________ 20391 03/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4310 55TH STREET NW COTTAGEWOOD SENIOR COMM UNITIES ROCHESTER, MN 55901 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 000 Initial Comments 0 000 On March 6, 2024, the Minnesota Department of Health initiated an investigation of complaint #HL203917475C/#HL203919649M. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 XLIK11 If continuation sheet 1 of 1

Finding: Inconclusive Nature of Investigation: The Minnesota Department of Health investigated an allegation of maltreatment, in accordance with the Minnesota Reporting of Maltreatment of Vulnerable Adults Act, Minn. Stat. 626.557, and to evaluate compliance with applicable licensing standards for the provider type. Initial Investigation Allegation(s): The facility neglected the resident when the resident’s diet was not followed and the resident was hospitalized with aspiration pneumonia. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was inconclusive. Although the resident ate food which was not prescribed, it was unable to be determined how the resident obtained the food. According to facility documentation, when staff noticed a change in the resident’s condition, they immediately contacted the nurse, and the resident was sent to the hospital for an evaluation. The resident received treatment and returned to their baseline health condition. The investigator conducted interviews with facility staff members, nursing staff, and unlicensed staff. The investigation included review of facility documentation and resident records. At the An equal opportunity employer. time of the onsite visit, the investigator observed staff providing care to residents and assistance during meals. The resident resided in an assisted living with dementia care facility. The resident’s diagnoses included dementia and stroke with right sided weakness. The resident’s service plan included assistance with all activities of daily living including eating. The service plan also indicated the resident was on a pureed (pudding consistency) diet with thickened liquids and was not to be left unattended at meals. The service plan identified for staff to complete frequent safety checks on all three shifts. The resident’s progress notes identified staff contacted the facility nurse when they noticed a change in the resident’s condition. The nurse assessed the resident and noticed the resident was leaning in her chair, had abnormal lung sounds, and was minimally responsive. The resident was transferred to the hospital and diagnosed with aspiration pneumonia (an infection that develops after inhaling food, liquid, or vomit into your lungs). The resident received intravenous (IV) antibiotics and returned to the facility three days later. The facility’s internal investigation documentation identified when staff observed a change in condition, they contacted the facility nurse. However, the nurse who assessed the resident’s change in condition was informed by staff that an empty bag of chips and emesis (vomit) were observed on the resident’s bedding that morning. The investigation notes indicated it was unable to be determined how the resident accessed the chips, as resident would not have been able to obtain the chips or open the bag independently. Interviews conducted with staff who worked the evening prior indicated staff did not give the resident chips, did not witness the resident eating chips, and did not notice the empty chip bag. During an interview, an unlicensed staff member stated she noticed the empty chip bag and later noticed a small amount of emesis on the resident’s comforter while assisting the resident with morning cares. The staff member stated she contacted the nurse immediately but could not remember the nurse’s name. The other staff member who worked that morning could not recall details of the incident. During an interview, the RN stated there was no documentation available to identify if the day shift nurse was notified of the open chip bag found near the resident or the emesis observed on the comforter. The RN stated staff who worked with the resident may not have correlated the open chip bag with the small amount of emesis. The RN indicated when staff noticed a change in the condition, they contacted the nurse immediately. The RN stated there were residents who wandered around the unit that could have given the bag of chips to the resident. The RN stated all staff that were interviewed denied giving the chips to the resident and no staff witnessed the resident eat the chips. During an interview, the resident’s family member stated he did not remember the specifics of this incident. The family member stated the facility always notified him with concerns and he was pleased with the care the resident received. In conclusion, the Minnesota Department of Health determined neglect was inconclusive. Inconclusive: Minnesota Statutes, section 626.5572, Subdivision 11. "Inconclusive" means there is less than a preponderance of evidence to show that maltreatment did or did not occur. 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, unable to be interviewed. Family/Responsible Party interviewed: Yes Alleged Perpetrator interviewed: Not Applicable Action taken by facility: The facility reported the incident to the Minnesota Adult Abuse Reporting Center and completed an internal investigation. 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: 12/14/2023 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 _____________________________ 20391 10/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4310 55TH STREET NW COTTAGEWOOD SENIOR COMM ROCHESTER, MN 55901 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 October 25, 2023, the Minnesota Department of Health initiated an investigation of complaint #HL203918755C/#HL203915083M. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 TE5B11 If continuation sheet 1 of 1