Madonna Meadows of Rochester.

correction orders and document the actions taken to comply in the facility's records. The Department reserves the right to return to the facility at any time should the Department receive a complaint or deem it necessary to ensure the health, safety, and welfare of residents in your care. STATE CORRECTIO NORDERS The enclosed State Form documents the state correction orders. MDH documents state licensing correction orders using federal software. Tag numbers are assigned to Minnesota state statutes for Assisted Living Facilities. The assigned tag number appears in the far left column entitled "ID Prefix Tag." The state statute number and the corresponding text of the state statute out of compliance are listed in the "Summary Statement of Deficiencies" column. This column also includes the findings that are in violation of the state statute after the statement, "This MN Requirement is not met as evidenced by . . ." IMPOSITION OF FINES In accordance with Minn. Stat. § 144G.31, Subd. 4, fines and enforcement actions may be imposed based on the level and scope of the violations and may be imposed immediately with no opportunity to correct the violation first as follows: Level 1: no fines or enforcement; Level 2: a fine of $500 per violation, in addition to any enforcement mechanism authorized in § 144G.20; Level 3: a fine of $1,000 per incident, in addition to any enforcement mechanism authorized in § 144G.20; An equal opportunity employer. Letter ID: IS7N REVISE D09/13/2021 Madonna Meadows of Rochester February 17, 2026 Page 2 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. Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, the following fines are assessed pursuant to this survey: St - 0 - 0510 - 144g.41 Subd. 3 - Infection Control Program - $500.00 St - 0 - 0775 - 144g.45 Subd. 2. (a) - Fire Protection And Physical Environment - $500.00 The refor e, in accor danc e wit h Minn. Sta t. §§ 144G.01 to 144G.999 9, the total amount you are assessed is $1,000.00. You will be invoiced approximately 30 days after receipt of this notice, subject to appeal . DOCUMENTATIO ONF ACTION TO COMPLY In accorda nce with Min n. Stat. § 144G.30, Sub d. 5(c), th e lic ens ee mus t docum ent ac tions taken t o comply with the correction orders within the time period outlined on the state form; however, plans of correction are not required to be submitted for approval. The correction order documentation should include the following: Identify how the area( s) of noncompliance was corrected related to the · resident( s)/ employee( s) identified in the correction order. Identify how the area( s) of noncompliance was corrected for all of the provider’s · resident( s)/ employees that may be affected by the noncompliance. Identify what changes to your systems and practices were made to ensure compliance with · the specific statute( s). CORRECTIO NORDER RECONSIDERATIO PNROCESS In accordance with Minn. Stat. § 144G.32, Subd. 2, you may challenge the correction order( s) issued, including the level and scope, and any fine assessed through the correction order reconsideration process. The request for reconsideration must be in writing and received by 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 GA HEARING Alternatively, in accordance with Minn. Stat. § 144G.31, Subd. 5(d), an assisted living provider that has been assessed a fine under this subdivision has a right to a reconsideration or a hearing under this section and chapter 14. Pursuant to Minn. Stat. § 144G.20, Subd. 14 and Subd. 18, a request for a hearing must be in writing and received by the 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 Madonna Meadows of Rochester February 17, 2026 Page 3 factor. To submit a hearing request, please visit: https: / / forms. web. health. state. mn. us/ form/ HRDAppealsForm To appe al fi nes via re cons iderat ion , pl ease follow the procedu r e outl ined abo ve. Plea se no te tha t you may re que st a rec onside rati on or a hearing, bu t not bot h. If you wish to cont est ta gs with out fine s 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 conv enien ce at thi s link: https: / / forms. office.com/ g/ Bm5uQEpHVa. Your inpu t is import 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, Jodi Johnson, Supervisor State Evaluation Team Email: Jodi.Johnson@state. mn.us Telephone: 507-344-2730 Fax: 1-866-890-9290 CLN PRINTED: 02/ 17/ 2026 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 _____________________________ 30704 01/ 28/ 2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3035 SALEM MEADOWS DR SW MADONNA MEADOWS OF ROCHESTER ROCHESTER, MN 55902 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER' S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS- REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 000 Initial Comments 0 000 *****ATTENTION***** Minnesota Department of Health is documenting the State Correction Orders ASSISTED LIVING PROVIDER LICENSING using federal software. Tag numbers have CORRECTION ORDER( S) been assigned to Minnesota State Statutes for Assisted Living 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. " The issued pursuant to a survey. 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. SL30704016- 0 PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On January 26, 2026, through January 28, 2026, STATES, "PROVIDER' S PLAN OF the Minnesota Department of Health conducted a CORRECTION. " THIS APPLIES TO full survey at the above provider and the following FEDERAL DEFICIENCIES ONLY. THIS correction orders are issued. At the time of the WILL APPEAR ON EACH PAGE. survey, there were 61 residents; 61 receiving services under the Assisted Living Facility with THERE IS NO REQUIREMENT TO 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. 0 510 144G. 41 Subd. 3 Infection control program 0 510 SS= F (a) All assisted living facilities must establish and LABORATORY DIRECTOR' S OR PROVIDER/ SUPPLIER REPRESENTATIVE' S SIGNATURE TITLE (X6) DATE STATE FORM 6899 2LIE11 If continuation sheet 1 of 22 PRINTED: 02/ 17/ 2026 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/ SUPPLIER/ CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Finding: Substantiated, individual responsibility O C Nature of Investigation: E The Minnesota Department of Health investigated an allegation of maltreatment, in accordance R with the Minnesota Reporting of Maltreatment of Vulnerable Adults Act, Minn. Stat. 626.557, R and to evaluate compliance Owith applicable licensing standards for the provider type. F T Initial Investigation Allegation(s): S The alleged perpetrator (AP), an unlicensed caregiver, financially exploited the resident when E the AP made unUauthorized purchases with the resident’s debit card and attempted to cash a Q check for $600 at the resident’s bank . E R Investigative Findings and Conclusion: The Minnesota Department of Health determined financial exploitation was substantiated. The AP was responsible for the maltreatment. The AP attempted to cash a check for $600 at the resident’s bank without the resident’s knowledge or consent and left her driver’s license at the bank. The AP had contact with the resident and her personal belongings through her role as an unlicensed caregiver. Additionally, the resident’s bank records showed unauthorized transactions for a food delivery service amounting to a combined total of greater than $500. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted law enforcement, bank personnel, and the resident’s family member. The investigation included review of the resident records, facility internal investigation, facility incident reports, personnel files, staff schedules, law enforcement report, and related facility policy and procedures. Also, the investigator observed staff interactions with residents during an onsite visit. The resident resided in an assisted living facility. The resident’s diagnoses included type 2 diabetes. The resident’s service plan included assistance with medication management and D blood sugar monitoring. The resident’s assessment indicated the resident ambulated with a E walker but used a wheelchair or scooter for longer distances. V I E C A police report indicated the resident’s bank notified her a person attempted to cash what E appeared to be a forged check in the resident’s name for $600. When the resident looked for R the check number in her belongings, the check with the same check number was missing. When N the resident reviewed her bank statement, she identified several transactions on her debit card O through a food delivery service that she did not incur. I T A R The same police report indicated the bank employee reported a woman was in the drive thru E attempting to cash a check where the signature on the check did not match the resident’s D signature on file. While the teller checked the validity of the signatures on the check, the I S person drove away, leaving behind both the check and a driver’s license. The driver’s license N was the AP’s. O C E Facility records and schedules indicated the AP had access to the resident as a course of her job R duties as an unlicensed caregiver. Those same records indicated the AP provided medications R and completed blood sugar checks two times in the week prior to the beginning of the food O delivery transactions and at least three times in the two weeks after the beginning of the food F delivery transactions. T S E Bank statements indicated sixteen transactions through a food delivery service were made that U continued untQil the day the AP attempted to cash a check at the resident’s bank, then the E unauthorized transactions stopped. Those unauthorized transactions totaled more than $500. s R During an interview, the facility manager stated a check and driver’s license was forwarded to her that was recognized by her to be the AP. The manager attempted to reach the AP to notify her of a suspension during the facility investigation, however she was unable to reach the AP by phone. The AP did not contact or return to the facility and was subsequently terminated. During an interview, the resident indicated she was unaware of a check missing form her wallet until the call from the bank reporting the attempt to cash a check in the drive thru. The resident stated her wallet was kept by her dresser in her room and unlicensed caregivers had access to her room when cares were provided. In conclusion, the Minnesota Department of Health determined financial exploitation was substantiated. Substantiated: Minnesota Statutes, section 626.5572, Subdivision 19. “Substantiated” means a preponderance of evidence shows that an act that meets the definition of maltreatment occurred. Financial exploitation: Minnesota Statutes, section 626.5572, subdivision 9 D "Financial exploitation" means: E (1) engages in unauthorized expenditure of funds entrusted to the actor by the vulnerable adult V I which results or is likely to result in detriment to the vulnerable adult; or E C (2) fails to use the financial resources of the vulnerable adult to provide food, clothing, shelter, E health care, therapeutic conduct or supervision for the vulnerable adult, and the failure results R or is likely to result in detriment to the vulnerable adult. N (b) In the absence of legal authority, a person: O (1) willfully uses, withholds, or disposes of funds or property of a vulnerable adult; I T (2) obtains for the actor or another the performance of services by a third person for the A R wrongful profit or advantage of the actor or another to the detriment of the vulnerable adult; E (3) acquires possession or control of, or an interest in, funds or property of a vulnerable adult D through the use of undue influence, harassment, duress, deception, or fraud; or I S (4) forces, compels, coerces, or entices a vulnerable adult against the vulnerable adult's will to N perform services for the profit or advantaOge of another. C E Vulnerable Adult interviewed: Yes R Family/Responsible Party interviewed: Yes R Alleged Perpetrator interviewed: Attempts to interview the AP were unsuccessful O F Action taken by facility: T S The facility notified law enforcement, completed an investigation and the AP is no longer E employed at the facility. U Q Action takeEn by the Minnesota Department of Health: R The facility was issued a correction order regarding the vulnerable adult’s right to be free from maltreatment. You may also call 651-201-4200 to receive a copy via mail or email The responsible party will be notified of their right to appeal the maltreatment finding. If the maltreatment is substantiated against an identified employee, this report will be submitted to the nurse aide registry for possible inclusion of the finding on the abuse registry and/or to the Minnesota Department of Human Services for possible disqualification in accordance with the provisions of the background study requirements under Minnesota 245C. cc: The Office of Ombudsman for Long Term Care The Office of Ombudsman for Mental Health and Developmental Disabilities Olmsted County Attorney Rochester City Attorney Rochester Police Department D MN Department of Human Services E V I E C E R N O I T A R E D I S N O C E R R O F T S E U Q E R PRINTED: 12/23/2024 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 _____________________________ 30704 10/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3035 SALEM MEADOWS DR SW MADONNA MEADOWS OF ROCHESTER ROCHESTER, MN 55902 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 D E ******ATTENTION****** Minnesota Department of Health is V documenting the State Correction Orders I In accordance with Minnesota Statutes, section using federal software. Tag numbers have E 144G.08 to 144G.95, these correction orders are been assigned to CMinnesota State issued pursuant to a complaint investigation. Statutes for Assisted Living Facilities. The E assigned tagR number appears in the Determination of whether a violation is corrected far-left column entitled "ID Prefix Tag." The N requires compliance with all requirements state Statute number and the O provided at the statute number indicated below. corresponding text of the state Statute out I When a Minnesota Statute contains several of Tcompliance is listed in the "Summary items, failure to comply with any of the items will AStatement of Deficiencies" column. This R be considered lack of compliance.

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 a resident when the facility failed to provide appropriate nutrition for the resident. The resident had difficulty eating certain foods due to a past stomach surgery complications and lost a significant amount of weight while at the facility. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was inconclusive. There was conflicting information regarding the facility offering alternative foods to the resident and the resident not desiring to eat. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted an outside care agency that saw the resident during her time at the facility. The investigation included review of medical records, policy and procedures, and staff records. Also, the investigator observed staff interacting with residents and residents eating meals. An equal opportunity employer. The resident resided in an assisted living facility. The resident’s diagnoses included history of stomach surgery complications, lactose intolerance, and chronic acid reflux. The resident’s service plan included assistance with vital signs, housekeeping and laundry, escorts and transfers, medication management, and reminders. The resident’s assessment indicated the resident had mild forgetfulness and a history of hallucinations, a tendency to refuse cares, chronic weight loss, and chronic pain. The resident’s assessment indicated when asked about any changes or ways the facility could best care for the resident, the resident responded, “Nothings changed, I am a picky eater.” The resident’s assessment also indicated she did not have difficulty chewing or swallowing, was independent with eating, and independently managed being lactose intolerant. Review of documentation indicated the resident lost fourteen pounds in a period of five months, resulting in the resident weighing 90 pounds. Documentation indicated the resident would refuse services at times and struggled to eat food due to stomach pain, food intolerances, and dislike of foods. Documentation also indicated the resident had a preference for fruits and fruit juices and that dietician requests to the facility were not fulfilled. During an interview, an outside of facility nurse indicated the resident was not someone who would eat much but did have items, such as sandwiches, that she liked to eat. The nurse stated she would ask the facility to provide sandwiches but was told the kitchen was closed and when meals were delivered, the resident would not receive the requested item. The nurse also stated facility staff reported the resident was eating meals, but the resident was losing weight and had wounds indicating poor nutrition. During an interview, another outside nurse stated the resident would pick at food or food would be out of reach when the resident was in bed. The nurse stated she requested facility staff feed the resident, but facility staff stated they did not help the resident with eating meals. During an interview, a caregiver stated the resident preferred to eat meals in her room, was particular about foods, and at times did not like the food she was given. The care giver stated if the resident needed another food item, staff would give it to her. During an interview, a second caregiver stated the resident would often decline food and cares and wanted to stay in bed. The caregiver stated she would offer the resident alternative food items, but the resident would refuse the offer. 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, resident deceased. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Not Applicable. Action taken by facility: No action taken. 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: 08/24/2023 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 _____________________________ 30704 07/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3035 SALEM MEADOWS DR SW MADONNA MEADOWS OF ROCHESTER ROCHESTER, MN 55902 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: #HL307047067M/ #HL307043452C #HL307042843M/ #HL307044648C On July 12, 2023, 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 60 residents receiving services under the provider's Assisted Living with Dementia Care license. The following correction order is issued for #HL307047067M/ #HL307043452C, 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 4DIS11 If continuation sheet 1 of 2 PRINTED: 08/24/2023 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 _____________________________ 30704 07/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3035 SALEM MEADOWS DR SW MADONNA MEADOWS OF ROCHESTER ROCHESTER, MN 55902 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) reviewed (R1) was free from maltreatment. 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 4DIS11 If continuation sheet 2 of 2

correction orders. The MDH documents state licensing correction orders using federal software. Tag numbers are assigned to Minnesota state statutes for Assisted Living Facilities. The assigned tag number appears in the far left column entitled "ID Prefix Tag." The state statute number and the corresponding text of the state statute out of compliance are listed in the "Summary Statement of Deficiencies" column. This column also includes the findings that are in violation of the state statute after the statement, "This MN Requirement is not met as evidenced by . . ." IMPOSITION OF FINES In accordance with Minn. Stat. § 144G.31, Subd. 4, fines and enforcement actions may be imposed based on the level and scope of the violations and may be imposed immediately with no opportunity to correct the violation first as follows: Level 1: no fines or enforcement. Level 2: a fine of $500 per violation, in addition to any enforcement mechanism authorized in § 144G.20 for widespread violations; Level 3: a fine of $3,000 per violation per incident, in addition to any enforcement mechanism authorized in § 144G.20. Level 4: a fine of $5,000 per incident, in addition to any enforcement mechanism authorized in § 144G.20. In accordance with Minn. Stat. § 144G.31, Subd. 4 (a)(5), the MDH may impose fine amounts of either $1,000 or $5,000 to licensees who are found to be responsible for maltreatment. The MDH may impose a fine of $1,000 for each substantiated maltreatment violation that consists of abuse, neglect, or financial exploitation according to Minn. Stat. § 626.5572, Subds. 2, 9, 17. The MDH also may impose a fine of $5,000 for each substantiated maltreatment violation consisting of sexual An equal opportunity employer. Letter ID: IS7N REVISED 09/13/ 2021 Madonna Meadows Of Rochester July 24, 2023 Page 2 assault, death, or abuse resulting in serious injury. In accordance with Minn. Stat. § 144G.31, Subd. 4 (b), when a fine is assessed against a facility for substantiated maltreatment, the commissioner shall not also impose an immediate fine under this chapter for the same circumstance. Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, the following fines are assessed pursuant to this survey: St - 0 - 0510 - 144g.41 Subd. 3 - Infection Control Program = $500.00 The re fore , in accorda nc e wi th Mi nn. Sta t. §§ 144G. 01 to 144 G .9999, the total amount you are assessed is $500.00. You will be invoiced approximately 30 days after receipt of this notice, subject to appeal . DOCUMENTATIO ONF ACTION TO COMPLY In accorda nc e wi th Mi nn. Sta t. § 144G.30, Subd. 5(c), the licens ee mus t doc ument acti ons ta ken to comply with the correction orders within the time period outlined on the state form; however, plans of correction are not required to be submitted for approval. The correction order documentation should include the following: Identify how the area( s) of noncompliance was corrected related to the · resident( s)/ employee(s) identified in the correction order. Identify how the area( s) of noncompliance was corrected for all of the provider’s · resident( s)/ employees that may be affected by the noncompliance. Identify what changes to your systems and practices were made to ensure compliance with the · specific statute( s). CORRECTIO NORDER RECONSIDERATIO PNROCESS In accordance with Minn. Stat. § 144G.32, Subd. 2, you may challenge the correction order(s) issued, including the level and scope, and any fine assessed through the correction order reconsideration process. The request for reconsideration must be in writing and received by the MDH within 15 calendar days of the correction order receipt date. A state correction order under Minn. Stat. § 144G.91, Subd. 8, Free from Maltreatment is associated with a maltreatment determination by the Office of Health Facility Complaints. If maltreatment is substantiated, you will receive a separate letter with the reconsideration process under Minn. Stat. § 626.557. Pl ea se ema il rec ons idera ti on reques ts to: Health. HRDA. ppeals@state. mn. us. Pl ea se atta c h thi s letter as part of your reconsideration request. Please clearly indicate which tag( s) you are contesting and submit information supporting your position(s). Please address your cover letter for reconsideration requests to: Madonna Meadows Of Rochester July 24, 2023 Page 3 Reconsideration Unit 85 East Seventh Place St. Paul, MN 55164-0970 REQUESTIN GA HEARING Alternatively, in accordance with Minn. Stat. § 144G.31, Subd. 5(d), an assisted living provider that has been assessed a fine under this subdivision has a right to a reconsideration or a hearing under this section and chapter 14. Pursuant to Minn. Stat. § 144G.20, Subd. 14 and Subd. 18, a request for a hearing must be in writing and received by the MDH within 15 business days of the correction order receipt date. The request must contain a brief and plain statement describing each matter or issue contested and any new information you believe constitutes a defense or mitigating factor. Requests for hea ri ng ma y be ema iled to: Health. HRDA. ppeals@state. mn. us. To appe al fi ne s vi a rec ons ider a ti on, pl ease fol low the proc edure outl ined above . Pl ease note tha t you ma y re ques t a rec ons idera ti on or a hea ri ng , but not both. You are encouraged to retain this document for your records. It is your responsibility to share the information contained in the letter and state form with your organization’s Governing Body. If you have any questions, please contact me. Sincerely, Jodi Johnson, Supervisor State Evaluation Team Email: jodi.johnson@state. mn.us Telephone: 507 344-2730 Fax: 651-281-9796 PRINTED: 07/ 24/ 2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/ SUPPLIER/ CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 30704 06/ 29/ 2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3035 SALEM MEADOWS DR SW MADONNA MEADOWS OF ROCHESTER ROCHESTER, MN 55902 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER' S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS- REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 000 Initial Comments 0 000 ******ATTENTION****** Minnesota Department of Health is documenting the State Correction Orders ASSISTED LIVING PROVIDER LICENSING using federal software. Tag numbers have CORRECTION ORDER( S) been assigned to Minnesota State Statutes for Assisted Living License In accordance with Minnesota Statutes, section Providers. The assigned tag number 144G. 08 to 144G. 95, these correction orders are appears in the far left column entitled "ID issued pursuant to a survey. Prefix Tag." The state Statute number and the corresponding text of the state Statute Determination of whether violations are corrected out of compliance is listed in the requires compliance with all requirements "Summary Statement of Deficiencies" provided at the Statute number indicated below. column. This column also includes the When Minnesota Statute contains several items, findings which are in violation of the state failure to comply with any of the items will be requirement after the statement, "This considered lack of compliance. Minnesota requirement is not met as evidenced by." Following the surveyors' INITIAL COMMENTS: findings is the Time Period for Correction. SL30704015- 0 PLEASE DISREGARD THE HEADING OF On June 26, 2023, through June 29, 2023, the THE FOURTH COLUMN WHICH survey at the above provider, and the following CORRECTION. " THIS APPLIES TO correction orders are issued. At the time of the FEDERAL DEFICIENCIES ONLY. THIS survey, there were 60 active residents; 58 WILL APPEAR ON EACH PAGE. receiving services under the Assisted Living with Dementia Care license. THERE IS NO REQUIREMENT TO SUBMIT A PLAN OF CORRECTION FOR VIOLATIONS OF MINNESOTA STATE STATUTES. The letter in the left column is used for tracking purposes and reflects the scope and level issued pursuant to 144G. 31 subd. 1, 2, and 3. 0 485 144G. 41 Subd 1.