Diamond Willow Assisted Living.

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 alleged perpetrator (AP) neglected the resident when the AP transported the resident on the seat of a four-wheel walker while outside. The walker hit a rock, tipped over, and the resident was injured. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. The resident was outside, became short of breath, and was directed by the AP to sit on her four-wheeled walker. The AP pushed the resident on the four-wheeled walker back to the facility and hit a bump on the sidewalk. The resident was sent to the emergency room and returned to the facility later that evening. The AP was acting in the resident’s best interest to provide medical care, and the incident does not rise to the level of neglect. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted a medical facility. The investigation included review of the resident record(s), hospital records, rounding provider records, pharmacy records, facility internal investigation, facility incident reports, personnel files, staff schedules, related facility policy and procedures. Also, the investigator observed facility staff interact with the resident. The resident resided in an assisted living memory care unit. The resident’s diagnoses included dementia and an anxiety disorder. The resident’s service plan included assistance with pendant checks, fall coordination and behavior management for anxiety. The resident’s assessment indicated the resident required assistance from one staff and a gait belt for walker ambulation. The resident’s assessment indicated the resident utilized as needed oxygen at two liters per minute (LPM) for shortness of breath and facility staff were directed to contact a nurse if the resident experienced respiratory distress. The resident record indicated the resident seen a rounding provider and had a history of anxiety. The resident’s record indicated distractions, redirection, and activities were used to comfort the resident when the resident experienced anxiety. Rounding provider notes indicated the resident had a history of falls and the resident’s strength had decreased over the prior week. The rounding provider notes indicated the resident was seen three days prior to the incident and the provider ordered a physical therapy evaluation and a standard wheelchair. The resident’s progress notes indicated the AP, and the resident walked outside with the resident’s four-wheel walker. The resident became anxious and reported shortness of breath and weakness. Progress notes indicated the AP instructed the resident to sit on the walker and the AP attempted to push the resident back into the facility with the resident seated on the walker. Progress notes indicated when the AP pushed the resident back to the facility the walker hit a rock and tipped over. Progress notes indicated the resident struck her head when the walker tipped over and the AP was instructed by licensed triage staff to call emergency medical services. Progress notes indicated the resident was transported to the hospital and an incident report was completed. An incident report indicated the resident went outside for a walk with the AP when the resident was anxious. When outside, the resident became weak, and the AP utilized the resident’s walker to return the resident to the facility. The incident report indicated a walker wheel had gone off the sidewalk and the resident fell backwards and struck her head. The incident report indicated licensed staff, 911 and the family were notified. The incident report indicated the resident was transported to a hospital emergency room for evaluation. The resident’s hospital records indicated the resident was seated on her walker and being pushed when the walker hit a crack in the sidewalk ejecting the resident and the resident hit her head. Hospital records indicated the resident reported back pain and CT scans (non-invasive imaging tests) were completed. Hospital records indicated a compression fracture was found at the T12 (vertebra bone in spine) level; however, it could not be determined if it was an old or new injury. During an interview, licensed staff stated the resident required an assist of one staff with ambulation. Licensed staff stated she was contacted by the AP when the resident fell, however her workday had ended, and she directed the AP to call triage on-call to maintain continuity of care for the resident. Licensed staff stated she was updated of the details of the fall when she returned to work. Licensed staff stated it was reported to her the AP was outside with the resident and the resident reported shortness of breath and was directed by the AP to sit on the seat of the walker. Licensed staff stated while the resident was seated on the walker, the AP attempted to push the resident back to the facility, the walker hit a stone and tipped over and the resident hit her head. Licensed staff stated the resident returned from the emergency room the same night with pain medication orders. Licensed staff stated the on-call followed the resident throughout the weekend assisted with orders and notified the resident’s family. Licensed staff stated there were no changes to the resident’s services until the resident was seen by the rounding provider the next week. During an interview, the resident stated she did not recall the walker tipping over or the fall. The resident stated she went to the emergency room and returned to the facility. The resident stated she was “almost” at baseline. During an interview, a family member stated they were notified of the fall and taking the resident outside was one of the interventions used to manage the resident’s anxiety. A family member stated there were no concerns with cares the resident received at the facility and the AP acted appropriately for the situation when she pushed the resident on her walker. During an interview, the AP stated the resident had become anxious and the AP took the resident outside for a walk with the resident’s walker. The AP stated while outside the resident became weak and the AP feared for the resident’s safety and didn’t want the resident to fall. The AP stated she had the resident sit on the seat of the walker and was pushing the resident back towards the building when the front wheel of the walker went off the uneven sidewalk and the resident and the AP fell. The AP stated the resident had fallen backward and hit her head. The AP stated she called for assistance from a co-worker, notified licensed facility staff, on-call licensed staff. and emergency services. The AP stated emergency services transported the resident to the hospital for evaluation and the resident returned that night. 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: Yes Family/Responsible Party interviewed: Yes Alleged Perpetrator interviewed: Yes. the Action taken by facility: The facility summoned emergency services. 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: 10/27/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ C B.

CORRECTION ORDERS 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 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. Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, the following fines are assessed pursuant to this survey: 0775 - 144g.45 Subd. 2. (a) - Fire Protection And Physical Environment - $500.00 2310 - 144g.91 Subd. 4 (a) - Appropriate Care And Services - $3,000.00 Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, the total amount you are assessed is $3,500.00. You will be invoiced approximately 30 days after receipt of this notice, subject to appeal. An equal opportunity employer. Letter ID: IS7N REVISED 09/13/2021 Diamond Willow Assisted Living April 4, 2025 Page 2 DOCUMENTATION OF ACTION TO COMPLY In accordance with Minn. Stat. § 144G.30, Subd. 5(c), the licensee must document actions taken to comply with the correction orders 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). CORRECTION ORDER RECONSIDERATION PROCESS In accordance with Minn. Stat. § 144G.32, Subd. 2, you may challenge the correction order(s) issued, including the level and scope, and any fine assessed through the correction order reconsideration process. The request for reconsideration must be in writing and received by MDH within 15 calendar days of the correction order receipt date. To submit a reconsideration request, please visit: https://forms.web.health.state.mn.us/form/HRDAppealsForm REQUESTING A HEARING Alternatively, in accordance with Minn. Stat. § 144G.31, Subd. 5(d), an assisted living provider that has been assessed a fine under this subdivision has a right to a reconsideration or a hearing under this section and chapter 14. Pursuant to Minn. Stat. § 144G.20, Subd. 14 and Subd. 18, a request for a hearing must be in writing and received by the Department of Health within 15 business days of the correction order receipt date. The request must contain a brief and plain statement describing each matter or issue contested and any new information you believe constitutes a defense or mitigating factor. To submit a hearing request, please visit: https://forms.web.health.state.mn.us/form/HRDAppealsForm To appeal fines via reconsideration, please follow the procedure outlined above. Please note that you may request a reconsideration o r a hearing, but not both. If you wish to contest tags without fines in a reconsideration and tags with the fines at a hearing, please submit two separate appeals forms at the website listed above. 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: h ttps://forms.office.com/g/Bm5uQEpHVa. Your input is important 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. Diamond Willow Assisted Living April 4, 2025 Page 3 If you have any questions, please contact me. Sincerely, Jessie Chenze, Supervisor State Evaluation Team Email: jessie.chenze@state.mn.us Telephone: 218-332-5175 Fax: 1-866-890-9290 JMD PRINTED: 04/04/2025 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 _____________________________ 24425 03/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 130 WEST NORTH ROAD DIAMOND WILLOW ASSISTED LIVING CLOQUET, MN 55720 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 ASSISTED LIVING PROVIDER LICENSING Minnesota Department of Health is CORRECTION ORDER(S) documenting the State Correction Orders using federal software. Tag numbers have In accordance with Minnesota Statutes, section been assigned to Minnesota State 144G.08 to 144G.95, these correction orders are Statutes for Assisted Living Facilities. The issued pursuant to a survey. assigned tag number appears in the far-left column entitled "ID Prefix Tag." The Determination of whether violations are corrected state Statute number and the requires compliance with all requirements corresponding text of the state Statute out provided at the Statute number indicated below. of compliance is listed in the "Summary When Minnesota Statute contains several items, Statement of Deficiencies" column. This failure to comply with any of the items will be column also includes the findings which considered lack of compliance. are in violation of the state requirement after the statement, "This Minnesota INITIAL COMMENTS: requirement is not met as evidenced by." Following the evaluators ' findings is the SL24425016-0 Time Period for Correction. On March 3, 2025, through March 6, 2025, the PLEASE DISREGARD THE HEADING OF survey at the above provider. At the time of the STATES,"PROVIDER'S PLAN OF survey, there were 20 residents; 20 receiving CORRECTION." THIS APPLIES TO services under the Assisted Living Facility with FEDERAL DEFICIENCIES ONLY. THIS Dementia Care license. WILL APPEAR ON EACH PAGE. 2310: An immediate correction order was THERE IS NO REQUIREMENT TO identified on March 4, 2025. The licensee took SUBMIT A PLAN OF CORRECTION FOR action to mitigate the risk, however, the correction VIOLATIONS OF MINNESOTA STATE order remains at a scope and level of isolated, STATUTES. level three (G). THE LETTER IN THE LEFT COLUMN IS USED FOR TRACKING PURPOSES AND REFLECTS THE SCOPE AND LEVEL ISSUED PURSUANT TO 144G.31 SUBDIVISION 1-3. 0 480 144G.41 Subdivision 1 Subd. 1a (a-b) Minimum 0 480 SS=F requirements; required food services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 Q1RS11 If continuation sheet 1 of 33 PRINTED: 04/04/2025 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 _____________________________ 24425 03/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 130 WEST NORTH ROAD DIAMOND WILLOW ASSISTED LIVING CLOQUET, MN 55720 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 480 Continued From page 1 0 480 (a) Except as provided in paragraph (b), food must be prepared and served according to the Minnesota Food Code, Minnesota Rules, chapter 4626. (b) For an assisted living facility with a licensed capacity of ten or fewer residents: (1) notwithstanding Minnesota Rules, part 4626.