Adith Miller Manor.

correction orders issued pursuant to the July 24, 2025 survey. In accordance with Minn. Stat. § 144G.31 Subd. 4 (a), state correction orders issued pursuant to the last survey, completed on July 24, 2025, found not corrected at the time of the January 27, 2026, follow-up survey and/ or subject to penalty assessment are as follows: 0775-Fire Protection And Physical Environment- 144g.45 Subd. 2. (a) The details of the violations noted at the time of this follow-up survey completed on January 27, 2026 (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. In accordance with Minn. Stat. § 144G.31 Subd. 4, MDH may assess fines based on the level and scope of t he violati ons ; however, no immediate fines are assessed for this survey of your facility. 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 outlined on the state form; however, plans of correction are not required to be submitted for approval. 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 An equal opportunity employer. Letter ID: 8GKP Revised 04/14/2023 Adith Miller Manor February 23, 2026 Page 2 We urge you to review these orders carefully. If you have questions, please contact Stephanie Jones de Palma at 651-201-4320. 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, Stephanie Jones de Palm, Supervisor State Evaluation Team Email: stephanie. jones. de. palma@state. mn.us Telephone: 651-201-4320 Fax: 1-866-890-9290 HHH PRINTED: 02/ 23/ 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: ______________________ R B. WING _____________________________ 20147 01/ 27/ 2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 885 MANKATO AVENUE ADITH MILLER MANOR WINONA, MN 55987 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 FOLLOW UP SURVEY INITIAL COMMENTS SL20417016- 2 On January 26, 2026 through February 6, 2026, the Minnesota Department of Health conducted a follow-up survey at the above provider to follow-up on orders issued pursuant to a survey completed on October 20, 2025. As a result of the follow-up survey, the following order was reissued. {0 480} 144G. 41 Subdivision 1 Subd. 1a (a-b) Minimum {0 480} SS= F requirements; required food services (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 LABORATORY DIRECTOR' S OR PROVIDER/ SUPPLIER REPRESENTATIVE' S SIGNATURE TITLE (X6) DATE STATE FORM 6899 LHKT13 If continuation sheet 1 of 16 PRINTED: 02/ 23/ 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: ______________________ R B. WING _____________________________ 20147 01/ 27/ 2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 885 MANKATO AVENUE ADITH MILLER MANOR WINONA, MN 55987 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} 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. 1070, item A, the facility is not required to install a dedicated handwashing sink in its existing kitchen provided it designates one well of a two-compartment sink for use only as a handwashing sink; (5) notwithstanding Minnesota Rules, parts 4626. 1325, 4626. 1335, and 4626. 1360, item A, existing floor, wall, and ceiling finishes are allowed provided the facility keeps them clean and in good condition; (6) notwithstanding Minnesota Rules, part 4626. 1375, shielded or shatter- resistant lightbulbs are not required, but if a light bulb breaks, the facility must discard all exposed food and fully clean all equipment, dishes, and surfaces to remove any glass particles; and (7) notwithstanding Minnesota Rules, part 4626. 1390, toilet rooms are not required to be provided with a self- closing door. This MN Requirement is not met as evidenced by: Not reviewed during this survey. STATE FORM 6899 LHKT13 If continuation sheet 2 of 16 PRINTED: 02/ 23/ 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: ______________________ R B. WING _____________________________ 20147 01/ 27/ 2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 885 MANKATO AVENUE ADITH MILLER MANOR WINONA, MN 55987 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) {0 630} Continued From page 2 {0 630} {0 630} 144G. 42 Subd. 6 (b) Compliance with {0 630} SS= E requirements for reporting ma (b) The facility must develop and implement an individual abuse prevention plan for each vulnerable adult. The plan shall contain an individualized review or assessment of the person' s susceptibility to abuse by another individual, including other vulnerable adults; the person' s risk of abusing other vulnerable adults; and statements of the specific measures to be taken to minimize the risk of abuse to that person and other vulnerable adults. For purposes of the abuse prevention plan, abuse includes self- abuse. This MN Requirement is not met as evidenced by: Not reviewed during this survey. {0 775} 144G. 45 Subd. 2. (a) Fire protection and physical {0 775} SS= E environment Each assisted living facility must comply with the State Fire Code in Minnesota Rules, chapter 7511, and: This MN Requirement is not met as evidenced by: Based on observation, record review, and interview, the licensee failed to comply with the requirements of Minnesota State Fire Code Rules, Chapter 7511. 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 pattern scope (when more than a limited number STATE FORM 6899 LHKT13 If continuation sheet 3 of 16 PRINTED: 02/ 23/ 2026 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/ SUPPLIER/ CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.