Hawley Senior Living.

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 _____________________________ 30455 09/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 923 5TH STREET HAWLEY SENIOR LIVING HAWLEY, MN 56549 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****** ASSISTED LIVING PROVIDER FOLLOW UP SURVEY INITIAL COMMENTS SL30455016-1 On September 18, 2025, 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 June 25, 2025. As a result of the follow-up survey, the licensee is in substantial compliance. {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 0MD912 If continuation sheet 1 of 4 PRINTED: 10/03/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ R B. WING _____________________________ 30455 09/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 923 5TH STREET HAWLEY SENIOR LIVING HAWLEY, MN 56549 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) {0 480} 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 0MD912 If continuation sheet 2 of 4 PRINTED: 10/03/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ R B. WING _____________________________ 30455 09/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 923 5TH STREET HAWLEY SENIOR LIVING HAWLEY, MN 56549 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) {0 510} Continued From page 2 {0 510} {0 510} 144G.41 Subd. 3 Infection control program {0 510} SS=D (a) All assisted living facilities must establish and maintain an infection control program that complies with accepted health care, medical, and nursing standards for infection control. (b)The facility's infection control program must be consistent with current guidelines from the national Centers for Disease Control and Prevention (CDC) for infection prevention and control in long-term care facilities and, as applicable, for infection prevention and control in assisted living facilities. (c) The facility must maintain written evidence of compliance with this subdivision. This MN Requirement is not met as evidenced by: Not reviewed during this survey. {01890} 144G.71 Subd. 20 Prescription drugs {01890} SS=F A prescription drug, prior to being set up for immediate or later administration, must be kept in the original container in which it was dispensed by the pharmacy bearing the original prescription label with legible information including the expiration or beyond-use date of a time-dated drug. This MN Requirement is not met as evidenced by: Not reviewed during this survey. {02320} 144G.91 Subd. 4 (b) Appropriate care and {02320} SS=D services (b) Residents have the right to receive health STATE FORM 6899 0MD912 If continuation sheet 3 of 4 PRINTED: 10/03/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ R B. WING _____________________________ 30455 09/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 923 5TH STREET HAWLEY SENIOR LIVING HAWLEY, MN 56549 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) {02320} Continued From page 3 {02320} care and other assisted living services with continuity from people who are properly trained and competent to perform their duties and in sufficient numbers to adequately provide the services agreed to in the assisted living contract and the service plan. This MN Requirement is not met as evidenced by: Not reviewed during this survey. STATE FORM 6899 0MD912 If continuation sheet 4 of 4 P r o t e c t i n g , M a i n t a i n i n g a n d I m p r o v i n g t h e H e a l t h o f A l l M i n n e s o t a n s Electronically Delivered August 13, 2025 Licensee Hawley Senior Living 923 5th Street Hawley, MN 56549 RE: Project Number(s) SL30455016 Dear Licensee: The Minnesota Department of Health (MDH) completed a survey on June 25, 2025, for the purpose of evaluating and assessing compliance with state licensing statutes. At the time of the survey, MDH noted violations of the laws pursuant to Minnesota Statute, Chapter 144G, Minnesota Food Code, Minnesota Rules Chapter 4626, Minnesota Statute 626.5572 and/or Minnesota Statute Chapter 260E. STATE 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 3: a fine of $3,000 per incident, in addition to any enforcement mechanism authorized in § 144G.20; Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.

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 the resident when staff failed to address a change in the resident’s condition after the resident fell and hit her head, resulting in a delay of care. The resident was observed to be not acting the same and vomited after the fall, but emergency medical services were not called until seven hours later. The resident was brought to the emergency room. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was inconclusive. Although staff failed to follow facility policy and procedure when they did not notify the registered nurse (RN) with a change in condition after the resident fell, it is unable to be determined if the actions or inactions of the staff members contributed to the resident’s condition. There was not a preponderance of evidence to support that the actions of the facility staff met the definition of neglect. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted law enforcement. The investigation included review of the resident record, hospital records, facility incident reports, personnel files, staff schedules, law enforcement report, and related facility policy and procedures. Also, the investigator observed care and services at the facility. The resident resided in an assisted living facility. The resident’s diagnoses included dementia. The resident’s service plan included assistance with transfers and all activities of daily living. The resident’s assessment indicated the resident required assistance of two staff members for transfers. Facility documentation indicated at 6:07 p.m., the on-call RN was called after the resident fell and hit her head. Staff were educated to begin neuro checks (a neurological assessment that determines how a person's nervous system is working), the resident's daughter was called, and a fax was sent to the primary care provider. Neuro checks were initiated immediately after the fall by ULP at the facility. The first three neuro checks done 15 minutes apart indicate the resident’s pupil reaction was a 2, which was sluggish, an abnormal finding. The ULP failed to immediately notify the RN. 90 minutes after the fall, the resident’s oxygen was 87% (normal is 95% to 100%, a level below 92% could indicate hypoxia). The ULP failed to notify the RN of the abnormal oxygen reading. The resident's blood pressure was 160/110 (normal is 120/80, a reading greater than 140/90 would be stage two high blood pressure). The ULP failed to notify the RN of the abnormal blood pressure. The ULP recorded additional abnormal vital sign readings four more times over the next four hours and failed to notify the RN. When the night shift ULP took over the resident’s care, she recorded abnormal vital signs again and contacted the RN at 12:38 a.m. to report low oxygen levels, a high blood pressure, and that the resident’s eyes were red and glossy and not responding to light. The on-call RN directed staff to call 911. Ambulance records indicated 911 was called at 12:45 a.m. and the ambulance arrived at 1:11 a.m. The police report indicated responding officers were told the resident had fallen out of her wheelchair around 6:00 p.m. and struck her head on the floor. The responding officer "observed a large abrasion" on the resident's left side of her forehead and that staff reported the resident was "not acting the same" as she usually did after the fall. Staff reported to police that the resident's eyes have been monitored since the fall and have shown to have "difficulty dilating properly." The resident was noted to have vomited at least once since falling. The responding officer "inquired to why medical was not contacted until almost seven hours later. She stated they just started their shift at 2300 hours and did not know why staff earlier did not contact EMS. She further stated those records were located in the office and it was currently locked, inaccessible." Hospital records indicated the resident was diagnosed with a head contusion (an injury to the head) and after being evaluated in the emergency room, discharged back to the facility the next day. During an interview the registered nurse (RN) stated she initially didn't have any concerns about the resident's transfer to the emergency room but confirmed after reviewing the neuro check sheet, staff should have called the nurse as soon as they noticed a change and confirmed there was a delay of care. During an interview, the ULP working when the resident fell stated as soon as the resident fell and threw up, she immediately called the on-call RN and told her she felt the resident needed to be sent into the emergency room. The ULP stated the on-call RN told her they [the emergency room] "weren't going to do anything for rugburn" and told her to do vitals and start neuro checks. The ULP stated she couldn't find a neuro check sheet at the facility, so she found one off Google and printed it off. The ULP stated there was not a place to document oxygen, but she thought oxygen would be important to monitor so she added a line for it. The ULP stated she had not been trained on how to complete neuro checks previously. The ULP stated she was aware the resident had some out-of-range vital signs but did not call the on-call RN back because the nurse was crabby when she called earlier, and she felt she wouldn't take it seriously. The ULP stated she didn't know the ranges for what abnormal or normal vital signs would be but their blood pressure monitor would alert if it was high. The ULP stated she knew the resident's oxygen was low, but since it came back up, she continued to just record the vital signs. The ULP stated she wanted to send the resident in right after she threw up but didn't feel the on-call RN listened to her concerns and she didn't call her back because she felt like she would be a bother if she called her again. During an interview, ULP working on the night shift stated she didn’t recall hearing anything in shift report about concerns with the resident's vital signs and was just told to do neuro checks. The ULP stated she noticed on the neuro sheet that the resident had previous abnormal vital signs but wasn't sure what the prior shift had done about it. Another ULP working the night shift stated she was asked by the other night shift ULP to verify the resident’s abnormal vital signs and noticed her blood pressure was elevated, her oxygen was low, and her pupils weren't responding normally. The ULP stated she knew the resident fell on the prior shift, so they decided to call the on-call nurse. The ULP stated when emergency responders arrived, they asked why this was the first time they were being called if the resident had been having abnormal vital signs for a few hours. ULP-D stated she wasn't sure what was done on the prior shift but they had noticed abnormal vital signs, so they called the nurse. During an interview, the on-call RN stated she was notified of the resident's fall shortly after it happened, and she advised the ULP to initiate neuro checks. The on-call RN stated vitals initially reported to her were within normal limits. The on-call RN stated she was not updated of any concerns until the night shift staff called her to report their concerns and based on their report, she felt the resident should be seen in the emergency room, so she walked the staff through to process of sending the resident in and calling 911. 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.

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 the resident when staff failed to address a change in the resident’s condition after symptoms of a stroke were observed resulting in a delay in care and the resident was admitted to the hospital for a stroke. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was inconclusive. Although a single unlicensed staff member failed to timely report an observation of slurred speech, resulting in failure to provide care according to the standard of practice, the incident was an error in therapeutic conduct. When additional symptoms were identified later in the morning, emergency medical services were contacted, and the resident was sent to the hospital for evaluation and treatment. The resident was diagnosed with a stroke, treated, and returned to her baseline health condition. An equal opportunity employer. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator also contacted law enforcement. The investigation included review of the resident’s medical record, hospital records, employee training records, staff schedules, and the police report. The resident resided in an assisted living with dementia care facility. The resident’s diagnoses included cognitive impairment, type two diabetes, and a history of a stroke. The resident’s service plan included assistance with dressing, grooming, bathing, behavior management, medication administration, and RN supervision of monthly INR (international normalized ration, a lab value that looks to see how well your blood clots) checks. The resident’s assessment did not mention the resident having difficulty talking or having slurred speech when waking in the morning. The resident’s record indicated at 12:05 p.m., staff called the on-call RN to report “resident is having left sides droop. Weakness not feeling well being sent 911 [sic].” The police report indicated 911 was called at 12:05 p.m. Law enforcement responded to the 911 call along with emergency medical services (EMS). The police report indicated the resident had slurred speech around 7:10 a.m. but went back to bed. When the resident got up at 11:30 a.m., slurred speech and facial drooping were noted and 911 was contacted. The resident’s hospital admission documentation indicated the resident woke up at 7:30 a.m. and was noted by staff to have slurred speech. “Staff put her back to bed because they thought she was sleepy.” When the resident woke up at 11:30 a.m., “she still had slurred speech, so the resident was sent to the emergency room.” Another note from a hospital provider indicated the resident arrived at the emergency room with “slurred speech and a right facial droop that improved before arrival at the ED…staff noticed the change in her speech when they woke her at 7:10 but associated it with waking her from a deep sleep and her speech had not improved when they reevaluated it at 11:30.” The resident had an MRI (imaging) scan completed and was diagnosed with a stroke. The resident was hospitalized for two days, returned to her baseline condition, and was readmitted to the facility. During an interview, the clinical nurse supervisor (CNS) stated the staff member who noted the initial slurred speech was an unlicensed staff member and "she probably handled it to the best of her knowledge, I would bet she didn't think stroke." During an interview, the unlicensed direct care staff member stated she had gone in to give the resident her medications between 7:00 a.m. and 7:30 a.m. on the morning of the incident. The resident was sleeping in the chair and the staff member woke the resident up and asked her if she would like to take her medications. The resident stated she wanted to receive her medications. The staff member stated the resident's voice was "kinda off" during this exchange, but the staff member attributed it to having just woken the resident up and "left it at that." The staff member stated she checked back on the resident about an hour and a half later, and the resident was in bed. At that time, the staff member noticed the resident’s "speech was more slurred" and there was "a little bit of droopiness." The staff member then called another employee to take a second look. The other employee described her observations of the resident as "stroke like symptoms." The staff member got the on-call phone and called 911. The staff member stated she did not recall being trained on identifying stroke symptoms. When asked further about the resident’s voice being "off" around 7:00 a.m., the staff member described it as "just a little slurred." During an interview, the on-call registered nurse (RN) stated she was first notified of the slurred speech and facial droop at 12:06 p.m. and was not aware if stroke symptoms were first observed around 7:00 a.m. The RN stated since 911 was called, she did not ask any additional questions about the onset of symptoms and did not complete any further investigation of the incident. 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; due to cognitive impairment 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: The responsible party will be notified of their right to appeal the maltreatment finding. The facility was found to be in noncompliance. To view a copy of the Statement of Deficiencies and/or correction orders, please visit: https://www.health.state.mn.us/facilities/regulation/directory/provcompselect.html If you are viewing this report on the MDH website, please see the attached Statement of Deficiencies. You may also call 651-201-4200 to receive a copy via mail or email. cc: The Office of Ombudsman for Long Term Care The Office of Ombudsman for Mental Health and Developmental Disabilities Clay County Attorney Hawley City Attorney Hawley Police Department Minnesota Board of Nursing PRINTED: 01/29/2025 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. WING _____________________________ 30455 01/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 923 5TH STREET HAWLEY SENIOR LIVING HAWLEY, MN 56549 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 AMENDED ASSISTED LIVING PROVIDER using federal software. Tag numbers have CORRECTION ORDER 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 complaint investigation. Prefix Tag." The state Statute number and the corresponding text of the state Statute Determination of whether a violation is 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 a Minnesota Statute contains several findings which are in violation of the state items, failure to comply with any of the items will requirement after the statement, "This be considered lack of compliance. Minnesota requirement is not met as evidenced by." Following the surveyors' INITIAL COMMENTS: findings is the Time Period for Correction.