Ecumen Detroit Lakes the Cotta.

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 Statemen tof 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; Leve l4: a fine of $3,000 per incident, in addition to any enforcement mechanism authorized in An equal opportunity employer . Letter ID: IS7N REVISE 0D9/13/2021 Ecumen Detroit Lakes the Cotta October 31, 2025 Page 2 § 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 - 0510 - 144g.41 Subd. 3 - Infection Control Program - $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), the licensee must docum ent 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)/ employees( ) 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 factor. Ecumen Detroit Lakes the Cotta October 31, 2025 Page 3 To submit a hearing request, please visit: https:/ / forms.web.health.state.mn.us/form/ HRDAppealsForm To appea lfines via reconside ration, please follow the pr ocedur e outlined above. Plea se 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, Jessie Chenze ,Supervisor State Evaluation Team Email: JessieC. henze@state.mn.us Telephone :218-332-5175 Fax :1-866-890-9290 KKM PRINTED: 10/31/2025 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 _____________________________ 25997 10/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1435 MADISON AVENUE ECUMEN DETROIT LAKES THE COTTA DETROIT LAKES, MN 56501 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. SL25997016-0 PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On September 29, 2025, through October 2, 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 19 residents; 19 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. 0 480 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 VYDQ11 If continuation sheet 1 of 23 PRINTED: 10/31/2025 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: 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), an unlicensed personnel (ULP), sexually abused the resident when he forced the resident to have sex with him. Investigative Findings and Conclusion: The Minnesota Department of Health determined sexual abuse was inconclusive. There was not a preponderance of evidence that sexual abuse occurred. Due to cognitive impairment, the resident was not able to be interviewed. The AP deferred all questions to his attorney. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted law enforcement, the police department, the AP’s attorney, hospice, and the primary care provider (PCP). The investigation included review of the resident’s records, internal investigation documentation, facility incident reports, personnel files, staff schedules, law enforcement reports, and related facility policies and procedures. Also, the investigator observed care and services in the facility and the resident’s room. The resident resided in an assisted living memory care unit. The resident’s diagnoses included mild cognitive impairment. The resident’s service plan included assistance with dressing, grooming, bathing, escorts, and medication administration. The resident required reassurance, redirection, and reorientation due to severe cognitive impairment. The resident’s assessment indicated the resident was dependent on staff to perform most activities of daily living. The resident was noted to have impaired short- and long-term memory and was unable to provide accurate information consistently. There was no noted history of the resident making sexual comments or allegations. The AP’s employee file included disciplinary action for failing to complete assigned tasks, taking breaks during four-hour shifts, and for making “threatening and inappropriate comments towards another team member.” The corrective action form was not signed by the AP. The employee received a final written warning approximately one month before the allegations were reported. The AP was put on suspension related to allegations of sexual harassment towards a team member on the same day that the resident stated someone had sex with her. The AP passed a background study prior to beginning employment at the facility. A police report was not available as the incident was still an open investigation. Facility documents indicated the resident reported that someone had “hurt her” and “forced her to have sex and it hurt.” The facility's internal investigation indicated the resident told unlicensed personnel (ULP) she had been raped. Camera footage from the evening prior was reviewed. The AP was noted to have been assisting the resident in her room with toileting, grooming, and oral cares from 7:21 p.m. to 7:27 p.m. Other ULP were noted in and out of the resident's room providing care and services throughout the day. The internal investigation included written statements from several staff members. A nurse wrote that a ULP "told me that [resident] stated her brothers had raped her last night. Writer stated that there were two female staff working last night. [ULP] replied that [alleged perpetrator] worked the PM shift." The nurse assessed the resident and "...saw an open area to the left groin. Area had serosanguinous [a type of wound drainage composed of blood] drainage..." The registered nurse’s (RN) statement included "I was stopped by [ULP] who asked, "have you heard what's going on with [resident]?" I answered, no, and she stated that resident had expressed that her brothers were having sex with her...Dime sized excoriated lesion noted to left groin fold. Resident was scratching at area and stated she had pain in her genitals. RN asked resident if someone had harmed her. She stated, yes, that her brothers were having sex with her. RN asked when this had occurred. Resident stated, "all the time". When asked if resident could name the alleged perpetrators, resident states that there are too many of them. RN updated the provider. The facility interviewed ULP two days after the initial allegations were made. The ULP reported that the AP was "bragging to her and other team members about [resident] kissing him." The ULP reported the AP "thought it was cute." Another ULP showed the resident a picture of the AP on her phone and the resident stated the person in the photograph was her brother. The facility’s internal investigation lacked evidence the AP was interviewed about the allegations or how the facility responded to allegations that the AP may have been involved with the incident. The conclusion of the investigation indicated there was no evidence that anyone harmed the resident in question. Video audited for staff contact with resident and no suspicious activity seen on video. Resident assessed morning [after allegations were made] and reported no pain or concerns. During investigative interviews, multiple unlicensed personnel (ULP) stated the AP made them uncomfortable and sexually harassed other female staff. The ULP stated the AP discussed his sex life in front of residents, he followed younger female staff around the facility, started rumors that certain staff were having sex with him in resident rooms, and would brush up against other staff in inappropriate ways. The ULP stated the AP would come in to visit a different resident at 11:00 p.m. when he was not on the clock, and they found it strange he would come in and visit when he was not working. The ULP stated if they brought concerns to management about the AP’s inappropriate behavior and sexual harassment, they were told they were targeting the AP or trying to get him fired and they felt their concerns weren’t taken seriously. The ULP who reported the resident’s initial concern was told by management that her report to the LPN and the RN weren’t consistent, and she was just trying to get the AP in trouble. Several ULP stated the resident frequently called the AP her brother and one day the resident kissed the AP on the cheek, saying he was her brother. ULP stated the resident lived at the facility for several years and prior to this, had never made comments about having sex or any other sexual statements. During an interview, a facility nurse stated she interviewed all employees after the resident reported someone had sex with her and no one had identified the AP as a suspect. The facility nurse stated the resident called the AP her son but hadn’t heard her refer to him as her brother. The nurse stated she was not aware that multiple staff members had concerns about sexual harassment by the AP. When contacted for an interview, the AP deferred questions to his attorney. In conclusion, the Minnesota Department of Health determined sexual 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.

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 resident was neglected when the facility failed to provide accurate medication administration and wound care management as prescribed. The resident did not receive ordered barrier cream to prevent skin breakdown for a resolved pressure ulcer. As a result, the resident’s pressure ulcer re-opened. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. Although the resident’s medication administration record lacked orders for prescribed barrier cream twice daily, the resident’s services indicated the resident received the barrier cream as prescribed. When interviewed the resident’s family and facility staff indicated the resident had chronic recurring pressure ulcer areas, and there were no concern the resident had not received wound care management as ordered. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted the resident’s family member. The investigation included review of the resident record(s), facility internal investigation, facility incident reports, personnel files, staff schedules, and related facility policy and procedures. Also, the investigator observed the residents pressure ulcer areas. The resident resided in an assisted living facility secure memory care unit with diagnoses including weakness and localized edema. The resident’s assessment indicated the resident was cognitively impaired, but able to make his needs known. The assessment indicated the resident had thin fragile skin and utilized pressure relieving devices. The assessment indicated the resident received medication management and administration services and was being treated for decubitus ulcers on his sacrum and hips. The resident’s orders indicated the resident had utilized mepilex dressings for wound care of the resident’s pressure ulcer areas. The resident’s provider discontinued the mepilex dressing and ordered barrier cream to be applied twice daily and as needed for skin integrity. The facility investigation indicated when nursing placed the order for the resident’s barrier cream it was checked for self-administer instead of scheduled for staff to administer on the medication administration record (MAR). The facility investigation identified the resident received barrier cream as prescribed on the service agreement. The resident’s service/care plan included orders for the barrier cream to be applied twice daily and as needed. The resident’s service delivery of care record indicated the resident received the barrier cream as prescribed. The resident’s progress notes indicated the resident received wound care, wound monitoring, and various interventions to prevent recurring worsening pressure ulcers. When observed the resident appeared to have two small superficial denuded (loss of epidermis caused by prolong moisture and friction) areas covered by barrier cream. The resident denied discomfort and indicated the areas were always in the same spot and would come and go. When interviewed staff stated the resident had barrier cream in his room that was applied twice daily and as needed as indicated in the service agreement. Staff stated they would alert nursing staff if there was any change or worsening of the areas. When interviewed nursing staff stated the resident had chronic recurring pressure ulcer areas that never completely resolved, and they had no concern the resident had not received the barrier cream as prescribed. When interviewed the resident’s family stated they had no concerns regarding the residents wound care not being completed. The family member stated the resident’s pressure ulcers were chronic and recurring over the last few years and never fully healed. 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, attempted. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: N/A Action taken by facility: The facility audited resident orders to ensure accuracy, provided the nurse with additional order entry training, and added the resident’s barrier cream to the MAR to ensure accurate scheduled administration. 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: 05/23/2024 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 _____________________________ 25997 04/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1435 MADISON AVENUE ECUMEN DETROIT LAKES THE COTTA GE DETROIT LAKES, MN 56501 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 April 24, 2024, the Minnesota Department of Minnesota Department of Health is Health initiated an investigation of complaint documenting the State Correction Orders #HL259972100M/#HL259979943C. No correction using federal software. Tag numbers have orders are issued. been 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 is listed in the "Summary Statement of Deficiencies" column. This column also includes the findings which are in violation of the state requirement after the statement, "This Minnesota requirement is not met as evidenced by." Following the evaluators ' findings is the Time Period for Correction. PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH STATES,"PROVIDER'S PLAN OF CORRECTION." THIS APPLIES TO FEDERAL DEFICIENCIES ONLY. THIS WILL APPEAR ON EACH PAGE. 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 LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 D7U511 If continuation sheet 1 of 2 PRINTED: 05/23/2024 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 _____________________________ 25997 04/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1435 MADISON AVENUE ECUMEN DETROIT LAKES THE COTTA DETROIT LAKES, MN 56501 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 Continued From page 1 0 000 ISSUED PURSUANT TO 144G.31 SUBDIVISION 1-3. STATE FORM 6899 D7U511 If continuation sheet 2 of 2