Prairie Bluffs Senior Living O

Last evaluation

February 12, 2025

Evaluations on record

2

Investigations substantiated

6 kept 7 years

Inconclusive

0 kept 4 years

Unsubstantiated

3 kept 3 years

Most recent evaluation (February 12, 2025, state report 106411)

MDH: “On February 10, 2025, through February 12, 2025, the Minnesota Department of Health conducted a full survey at the above provider.”

Survey completed February 12, 2025: 8 correction orders

• Tag 100: 144G.10 Subdivision 1 License required Level 2, widespread scope, scope/level letter F · correction period: Twenty-one (21) days
  Details

  Summary: MDH found the licensee was not legally responsible for the management, control, and operation of the whole facility in which the licensee allowed use of the assisted living facility space to operate third party outpatient therapy services.

  MDH’s finding, as written: “Based on observation, interview, and record review, the licensee was not legally responsible for the management, control, and operation of the whole facility in which the licensee allowed use of the assisted living facility space to operate third party outpatient therapy services. This had the potential to affect all residents, staff, and visitors. [...]”

  Rule cited: “(a)(1)Beginning August 1, 2021, no assisted living facility may operate in Minnesota unless it is licensed under this chapter. [...]”

• Tag 480: 144G.41 Subdivision 1 Subd. 1a (a-b) Minimum requirements; required food services Level 2, widespread scope, scope/level letter F · correction period: Please refer to the FBEIR for any compliance dates
  Details

  Summary: MDH found the licensee failed to ensure food was prepared and served according to the Minnesota Food Code.

  MDH’s finding, as written: “Based on observation, interview, and record 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, but was not likely to cause serious injury, impairment, or death), and is issued at a widespread scope (when problems are pervasive or represent a systemic failure that has [...]”

  Rule cited: “(a) Except as provided in paragraph (b), food must be prepared and served according to the Minnesota Food Code, Minnesota Rules, chapter 4626. [...]”

• Tag 550: 144G.41 Subd. 7 Resident grievances; reporting maltreatment Level 2, widespread scope, scope/level letter F · correction period: Twenty-one
  Details

  Summary: MDH found the licensee failed to post the required information related to the grievance procedure to include contact information for the facility individuals responsible for handling complaints, the Office of Ombudsman for Mental Health and Developmental Disabilities, and the Office of Health Facility Complaints (OHFC) at the Minnesota Department of Health (MDH).

  MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to post the required information related to the grievance procedure to include contact information for the facility individuals responsible for handling complaints, the Office of Ombudsman for Mental Health and Developmental Disabilities, and the Office of Health Facility Complaints (OHFC) at the Minnesota Department of Health (MDH). This had the potential to affect all residents receiving assisted living services. [...]”

  Rule cited: “All facilities must post in a conspicuous place information about the facilities' grievance procedure, and the name, telephone number, and email contact information for the individuals who are responsible for handling resident grievances. [...]”

• Tag 660: 144G.42 Subd. 9 Tuberculosis prevention and control Level 2, isolated scope, scope/level letter D · correction period: Twenty-one (21) days
  Details

  Summary: MDH found the licensee failed to establish and maintain a tuberculosis (TB) prevention program based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC) which included baseline screening and testing for one of two employees (unlicensed personnel (ULP)-C).

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to establish and maintain a tuberculosis (TB) prevention program based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC) which included baseline screening and testing for one of two employees (unlicensed personnel (ULP)-C). [...]”

  Rule cited: “(a) The facility must establish and maintain a comprehensive tuberculosis infection control program according to the most current tuberculosis infection control guidelines issued by the United States Centers for Disease Control and Prevention (CDC), Division [...]”

• Tag 775: 144G.45 Subd. 2. (a) Fire protection and physical environment Level 2, widespread scope, scope/level letter F · correction period: Seven (7) days
  Details

  Summary: MDH found the licensee failed to comply with the current Minnesota Fire Code Provisions.

  MDH’s finding, as written: “Based on observation and interview, the licensee failed to comply with the current Minnesota Fire Code Provisions. This had the potential to directly affect all residents, staff, and visitors. [...]”

  Rule cited: “Each assisted living facility must comply with the State Fire Code in Minnesota Rules, chapter 7511, and:”

From MDH’s letter: no immediate fines.

Substantiated investigations (state reports)

• October 17, 2024 · report HL355615562M · MDH finding: Substantiated, facility responsibility
  Details

  Allegation, as written: “The resident was neglected when the facility failed to timely assess the resident after a change in condition/function until 2 days later when the resident was transferred to the emergency department (ED).”

  “The Minnesota Department of Health determined neglect was substantiated.”

  Summary: MDH looked into an allegation and found: neglect substantiated (facility responsibility).

  MDH’s conclusion, as written: “The Minnesota Department of Health determined neglect was substantiated. The facility failed to timely assess the resident after staff reported an elbow injury, and left leg/hip pain with a decline in function. As a result, the resident had a delay in care when she was not transferred to the ED until 2 days later where it was identified the resident sustained an open elbow laceration with exposed bone and hip fracture requiring hospitalization and surgical repair.”

  Action taken by facility: “Facility staff communicated the resident's elbow injury, pain, and refusal of care to triage nursing. 2 days later when the facility nurse observed the resident's elbow injury with exposed bone and left leg swelling, the resident was transferred to the ED for evaluation and treatment of her injuries. The facility provided education to staff on the facility fall protocol.”

  Action taken by MDH: “The responsible party will be notified of their right to appeal the maltreatment finding. The facility was found to be in noncompliance.”

  Survey completed September 25, 2024: 3 correction orders

  • Tag 1500: 144G.63 Subd. 5 Required annual training Level 2, widespread scope, scope/level letter F · correction period: Fourteen (14) days
    Details

    Summary: MDH found the licensee failed to ensure all employees had at least eight hours of annual training for each 12 months of employment that included required training on reporting of maltreatment of vulnerable adults, resident bill of rights, Alzheimer's dementia and related disorders, and training on the licensee policies and procedures for falls under section 626.557 for one of one employees, unlicensed personnel (ULP)-A, with employee records reviewed.

    MDH’s finding, as written: “Based on interview and document review, the licensee failed to ensure all employees had at least eight hours of annual training for each 12 months of employment that included required training on reporting of maltreatment of vulnerable adults, resident bill of rights, Alzheimer's dementia and related disorders, and training on the licensee policies and procedures for falls under section 626.557 for one of one employees, unlicensed personnel (ULP)-A, with employee records reviewed. [...]”

    Rule cited: “(a) All staff that perform direct services must complete at least eight hours of annual training for each 12 months of employment. [...]”

  • Tag 2310: 144G.91 Subd. 4 (a) Appropriate care and services Level 3, isolated scope, scope/level letter G · correction period: Seven (7) days
    Details

    MDH’s finding, as written: “Based on interview and record review the licensee failed to provide appropriate care, services, and timely assessment after staff reported the resident had an elbow injury, and left leg/hip pain with a decline in function for one of one residents (R1). [...]”

    Rule cited: “(a) Residents have the right to care and assisted living services that are appropriate based on the resident's needs and according to an up-to-date service plan subject to accepted health care standards.”

  • Tag 2360: 144G.91 Subd. 8 Freedom from maltreatment
    Details

    Summary: MDH found the facility failed to ensure one of one of one residents reviewed, (R1) was free from maltreatment.

    MDH’s finding, as written: “Based on interview and document review, the facility failed to ensure one of one of one residents reviewed, (R1) was free from maltreatment. R1 was neglected. 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. No plan of correction is required for this tag.”

    Rule cited: “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.”

• August 14, 2024 · report HL355613761M · MDH finding: Substantiated, individual responsibility
  Details

  Allegation, as written: “The alleged perpetrator (AP) abused a resident when the AP got into a physical altercation with the resident causing the resident to fall.”

  “The Minnesota Department of Health determined abuse was substantiated.”

  “The AP was responsible for the maltreatment.”

  Summary: MDH looked into an allegation and found: abuse substantiated (individual responsibility).

  MDH’s conclusion, as written: “The Minnesota Department of Health determined abuse was substantiated. The AP was responsible for the maltreatment. The resident hit the AP and the AP grabbed the resident's arm and twisted it. The AP continued grabbing and twisting the residents arms, and when the AP let go of the resident, the resident fell backwards onto the floor.”

  Action taken by facility: “The facility filed a report with the Minnesota Adult Abuse Reporting Center. The AP no longer works for the facility.”

  Action taken by MDH: “The facility was issued a correction order regarding the vulnerable adult's right to be free from maltreatment.”

  Survey completed July 2, 2024: 1 correction order

  • Tag 2360: 144G.91 Subd. 8 Freedom from maltreatment
    Details

    Summary: MDH found the facility failed to ensure one of one resident(s) reviewed (R1) was free from maltreatment.

    MDH’s finding, as written: “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 an individual person was responsible for the maltreatment, in connection with incidents which occurred at the facility. Please refer to the public maltreatment report for details. No plan of correction is required for this tag.”

    Rule cited: “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.”

• June 20, 2024 · report HL355613061M · MDH finding: Substantiated, facility responsibility
  Details

  Allegation, as written: “The facility neglected the resident when staff members did not administer the resident's atenolol medication (an antihypertensive) for intracranial hemorrhage scheduled at night for multiple consecutive days but still documented it as given.”

  “The Minnesota Department of Health determined neglect was substantiated.”

  Summary: MDH looked into an allegation and found: neglect substantiated (facility responsibility).

  MDH’s conclusion, as written: “The Minnesota Department of Health determined neglect was substantiated. The facility medication passers did not administer half tablet of atenolol 25 milligram (mg) for intracranial hemorrhage scheduled in the evening for multiple days. The missed medication was necessary to reduce the resident's risk of intracranial bleed, which was identified when the resident was hospitalized the following day.”

  Action taken by facility: “The facility posted a sign reminding medication passers to give the resident his medications.”

  Action taken by MDH: “The responsible party will be notified of their right to appeal the maltreatment finding. The facility was found to be in noncompliance.”

  Survey completed May 23, 2024: 1 correction order

  • Tag 2360: 144G.91 Subd. 8 Freedom from maltreatment
    Details

    Summary: MDH found the facility failed to ensure one of one resident reviewed (R1) was free from maltreatment.

    MDH’s finding, as written: “The facility failed to ensure one of one resident 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.”

    Rule cited: “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.”

• April 4, 2024 · report HL355619485M · MDH finding: Substantiated, facility responsibility
  Details

  Allegation, as written: “The alleged perpetrator (AP) neglected the resident by making a transcription error, causing the resident to miss several medications including Eliquis (a blood thinner) and Lasix (a water pill to treat fluid retention) for three days upon return to the facility.”

  “The Minnesota Department of Health determined neglect was substantiated.”

  “The facility was responsible for the maltreatment.”

  Summary: MDH looked into an allegation and found: neglect substantiated (facility responsibility).

  MDH’s conclusion, as written: “The Minnesota Department of Health determined neglect was substantiated. The facility was responsible for the maltreatment. Although the AP made a transcription error, the unlicensed caregivers failed to notify the nurse when there were the extra medications in the resident's cart during their daily medication administration. The facility's nurse did not perform a double check in a timely manner when the resident was discharged from the hospital and returned to the facility.”

  Action taken by facility: “The provider was informed about the missing medication and an ultrasound was ordered from the primary provider to rule out any clots. The facility provided education and trained all the licensed practical nurses. Additionally, they initiated a process to ensure the registered nurse would review the discharged documents and verify that all medications were processed accurately.”

  Action taken by MDH: “The responsible party will be notified of their right to appeal the maltreatment finding. The facility was found to be in noncompliance.”

  Survey completed March 6, 2024: 2 correction orders

  • Tag 1760: 144G.71 Subd. 8 Documentation of administration of medication Level 4, isolated scope, scope/level letter J · correction period: Seven (7) days
    Details

    MDH’s finding, as written: “Based on interview and record review, the license failed to ensure and/or double check the newly hired licensed practical nurses after they did medication transcriptions for two of two residents (R1 and R2) reviewed resulting in medications not administered as prescribed. [...]”

    Rule cited: “Each medication administered by the assisted living facility staff must be documented in the resident's record. The documentation must include the signature and title of the person who administered the medication. [...]”

  • Tag 2360: 144G.91 Subd. 8 Freedom from maltreatment
    Details

    Summary: MDH found the facility failed to ensure two of two residents reviewed (R1, R2) was free from maltreatment.

    MDH’s finding, as written: “The facility failed to ensure two of two residents reviewed (R1, R2) was free from maltreatment. Findings include: Regarding HL355619950M involving R1 and HL355619485M involving R2 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.”

    Rule cited: “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.”

• April 4, 2024 · report HL355619950M · MDH finding: Substantiated, facility responsibility
  Details

  Allegation, as written: “The alleged perpetrator (AP) neglected the resident by accidently discontinuing the resident's atorvastatin and losartan for three months.”

  “The Minnesota Department of Health determined neglect was substantiated.”

  “The facility was responsible for the maltreatment.”

  Summary: MDH looked into an allegation and found: neglect substantiated (facility responsibility).

  MDH’s conclusion, as written: “The Minnesota Department of Health determined neglect was substantiated. The facility was responsible for the maltreatment. The AP made an error and discontinued the resident's medications. However, the pharmacy continued to deliver the medication every thirty days, but the facility destroyed the medications without verifying if the medications had been discontinued for three months. The error was identified when the resident went to the hospital and the hospital attempted to reconcile the resident's medications.”

  Action taken by facility: “Medication error documented in the tracking log. AP was taken off the schedule, and a vulnerable adult report was filed. The incident was discussed with the AP. The AP had already submitted her notice due to other concerns brought to her attention. Following this discussion, the AP did not return to work and no longer works here. [...]”

  Action taken by MDH: “The responsible party will be notified of their right to appeal the maltreatment finding. The facility was found to be in noncompliance.”

  Survey completed March 6, 2024: 2 correction orders

  • Tag 1760: 144G.71 Subd. 8 Documentation of administration of medication Level 4, isolated scope, scope/level letter J · correction period: Seven (7) days
    Details

    MDH’s finding, as written: “Based on interview and record review, the license failed to ensure and/or double check the newly hired licensed practical nurses after they did medication transcriptions for two of two residents (R1 and R2) reviewed resulting in medications not administered as prescribed. [...]”

    Rule cited: “Each medication administered by the assisted living facility staff must be documented in the resident's record. The documentation must include the signature and title of the person who administered the medication. [...]”

  • Tag 2360: 144G.91 Subd. 8 Freedom from maltreatment
    Details

    Summary: MDH found the facility failed to ensure two of two residents reviewed (R1, R2) was free from maltreatment.

    MDH’s finding, as written: “The facility failed to ensure two of two residents reviewed (R1, R2) was free from maltreatment. Findings include: Regarding HL355619950M involving R1 and HL355619485M involving R2 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.”

    Rule cited: “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.”

• October 11, 2023 · report HL355616724M · MDH finding: Substantiated, individual responsibility
  Details

  Allegation, as written: “The alleged perpetrator (AP) abused a resident when she forcefully pulled the resident down the hallway.”

  “The Minnesota Department of Health determined abuse was substantiated.”

  “The AP was responsible for the maltreatment.”

  Summary: MDH looked into an allegation and found: abuse substantiated (individual responsibility).

  MDH’s conclusion, as written: “The Minnesota Department of Health determined abuse was substantiated. The AP was responsible for the maltreatment. The AP forcefully pulled the resident down the hallway. The abuse was witnessed by a facility direct care member and captured on video surveillance.”

  Action taken by facility: “The facility completed an internal investigation, reported the incident to the state agency, assessed the resident, and provided re-education or training to AP and the witness.”

  Action taken by MDH: “The facility was issued a correction order regarding the vulnerable adult's right to be free from maltreatment.”

  Survey completed September 18, 2023: 1 correction order

  • Tag 2360: 144G.91 Subd. 8 Freedom from maltreatment
    Details

    Summary: MDH found the facility failed to ensure one of one resident reviewed (R1) was free from maltreatment.

    MDH’s finding, as written: “The facility failed to ensure one of one resident reviewed (R1) was free from maltreatment. Findings include: The Minnesota Department of Health (MDH) issued a determination maltreatment occurred, and an indivudual alleged perpetrator was responsible for the maltreatment, in connection with incidents which occurred at the facility.Please refer to the public maltreatment report for details.”

    Rule cited: “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.”

Summaries are ours and are marked “Summary”; quoted text is MDH’s own, shortened where marked [...]. Read the full reports at the links above or search every report on MDH’s site.

MDH keeps investigation results for seven years when allegations are substantiated, four years when inconclusive, and three years when unsubstantiated, so the counts cover different periods. This community is licensed for 110 residents; larger communities are evaluated and reported on more often, so read counts with size in mind. Source: Minnesota Department of Health, Health Regulation Division, data as of September 28, 2026. Always visit in person and ask the community about anything listed here.