Woodstone Senior Living.

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 necessary to ensure the health, safety, and welfare of residents in your care. 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 . . ." In accordance with Minn. Stat. § 144G.31 Subd. 4, MDH may assess fines based on the level and scope of the violations; h owever, no immediate fines are assessed for this survey of your facility. 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 An equal opportunity employer. Letter ID: IS7N REVISED 09/13/2021 Woodstone Senior Living June 17, 2025 Page 2 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 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. If you have any questions, please contact me. Sincerely, Jodi Johnson, Supervisor State Evaluation Team Email: jodi.johnson@state.mn.us Telephone: 507-344-2730 Fax: 1 -866-890-9290 JMD PRINTED: 06/17/2025 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 _____________________________ 29913 05/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2020 MEYER DRIVE WOODSTONE SENIOR LIVING NEW ULM, MN 56073 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 SL29913016-0 Time Period for Correction. On May 5, 2025, through May 7, 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 29 residents; 29 receiving CORRECTION." THIS APPLIES TO services under the Assisted Living Facility with FEDERAL DEFICIENCIES ONLY. THIS Dementia Care license. 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 ISSUED PURSUANT TO 144G.31 SUBDIVISION 1-3. 01890 144G.71 Subd. 20 Prescription drugs 01890 SS=F A prescription drug, prior to being set up for LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 SUC311 If continuation sheet 1 of 4 PRINTED: 06/17/2025 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 _____________________________ 29913 05/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2020 MEYER DRIVE WOODSTONE SENIOR LIVING NEW ULM, MN 56073 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) 01890 Continued From page 1 01890 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: Based on observation, interview, and record review, the licensee failed to ensure medications were labeled correctly for one of two residents (R2). In addition, the licensee failed to ensure medications were not expired for licensee's house medication supply. This had the potential to affect all the licensee's current residents. This practice resulted in a level two violation (a violation that did not harm a resident's health or safety but had the potential to have harmed a resident's health or safety) and was issued at a widespread scope (when problems are pervasive or represent a systemic failure that has affected or has the potential to affect a large portion or all the residents). Findings include: FAILED TO ENSURE MEDICATIONS WERE LABELED On May 6, 2025, at 7:37 a.m., ULP-F prepared morning medications along with over the counter (OTC) medications: -Hair skin and nails by mouth once daily; -Optimal vision by mouth daily; and -Provex Plus 250 (milligrams) mg by mouth daily. R2's OTC medications prepared by unlicensed personnel (ULP)-F lacked the original prescription label or any identification on R2's OTC's pill STATE FORM 6899 SUC311 If continuation sheet 2 of 4 PRINTED: 06/17/2025 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 _____________________________ 29913 05/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2020 MEYER DRIVE WOODSTONE SENIOR LIVING NEW ULM, MN 56073 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) 01890 Continued From page 2 01890 bottles as stated above. On May 6, 2025, at 7:43 a.m., the surveyor asked ULP-F how she knew she was using R2's pill bottles. ULP-F stated each OTC medication bottle should have a name or a room number on it, and ULP-F marked each pill bottle with R2's room number on it. EXPIRED MEDICATIONS The licensee's medication cart contained expired medications. On May 6, 2025, at 8:25 a.m., the medication cart was inspected along with ULP-F.

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 follow the resident’s plan of care and served food that was not a part of the resident’s prescribed diet. In addition, the facility neglected the resident when the alleged perpetrator (AP), a registered nurse (RN), failed to report, assess, and monitor a change in condition. The resident was admitted to the hospital with aspiration pneumonia and died approximately two weeks later. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was inconclusive. The on-call registered nurse (RN)/alleged perpetrator (AP) failed to appropriately assess the resident’s change in condition and failed to respond to reports of oxygen saturation levels below normal ranges. The resident experienced low oxygen saturation levels around 70% to 80% (normal range is 90%-100%) for almost 24 hours. Unlicensed personnel (ULP) reported abnormal oxygen saturation levels to the on-call RN, but a physician was not updated, and no action was taken. An equal opportunity employer. However, the resident’s daughter requested staff to call the facility nurse later that day, who directed the resident be sent to the emergency room. The resident was hospitalized with aspiration pneumonia and a COPD exacerbation and returned to the facility on hospice services. The resident died approximately two weeks later of aspiration pneumonia. The resident was hospitalized two weeks prior to this incident for aspiration pneumonia after experiencing abnormal oxygen saturation levels. Since the resident had two prior hospital admissions with aspiration pneumonia as the admitting diagnosis, it is unable to be determined if the delay in care from the on-call RN directly led to the resident’s death. Additionally, the resident was fed food that was not part of his prescribed diet, however he began to show symptoms of aspiration pneumonia prior to being served the incorrect diet. Dietary staff was appropriately trained on preparing modified diets and re-trained following the incident. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator also contacted the hospital. The investigation included review of the resident’s hospital medical records, death certificate, and facility records including the service plan, recent assessments, progress notes, and care plan. The resident resided in an assisted living with dementia care facility. The resident’s diagnoses included Alzheimer’s dementia with behavioral disturbance, congestive heart failure, and chronic obstructive pulmonary disease (COPD). The resident’s service plan included assistance with dressing, grooming, toileting, behavior management, and medication administration. The resident’s assessment indicated the resident was to have thickened liquids and soft, bite-sized food. The resident had been hospitalized recently with a diagnosis of aspiration pneumonia. Approximately three weeks before the resident’s death, he was sent to the hospital with low oxygen saturation levels and complaints of shortness of breath. The resident was admitted with a diagnosis of aspiration pneumonia and COPD exacerbation. Hospital records indicated the resident had extensive coughing with food intake, required suctioning, and a speech therapy evaluation was ordered by the physician. Speech therapy recommended a level 6 dysphagia diet (soft/bite sized food) with nectar thick liquids. The resident was treated with supplemental oxygen at the hospital but was weaned off the supplement oxygen prior to his discharged back to the facility. Approximately ten days after returning from the hospital, the resident was noted to have a lingering, non-productive cough and became short of breath with transfers and coughing. The facility RN contacted the resident’s home health nurse on a Friday with her concerns and informed the RN the resident’s cough was not improving. A progress note indicated the home care RN replied she “would send a message back to his provider but could not guarantee an answer today due to it being Friday of a holiday.” Two days later, on a Sunday morning, ULP contacted the facility on-call RN after the resident’s oxygen saturation levels ranged from the mid-70s to mid-80s. A facility incident report indicated the resident didn't have an order for oxygen to be applied, so the on-call RN instructed ULP to give PRN (as needed) Tylenol or an inhaler. The resident did not have a physician’s order for Tylenol and the inhaler was out of doses. The on-call RN encouraged ULP to call the resident’s daughter to see if she could bring a different inhaler so they could alternate administration of PRN inhalers and PRN nebulizers. The resident continued to have oxygen saturations in the low 80s and the on-call RN was contacted again. The on-call RN instructed ULP to call her if the resident's oxygen got as low as 75% or if his face, lips, or fingers became blue. The resident's family came into the facility to visit before lunch and commented the resident "looked rough and was debating bringing him in to the ER..." The resident was served corn at lunch, which was not a part of the resident’s prescribed diet. The resident was also served a dish with corn in it again at supper. After supper, the on-call RN was called again, and ULP were advised "family needs to decide if they want him to go in or not when they come in but the PRNs were not helping." The resident’s family came back to the facility after supper with an inhaler for the resident. The family questioned why the resident was not put on oxygen and if the facility had a portable oxygen machine for him. ULP told the resident’s daughter they didn’t have an oxygen machine and “explained what the on-call RN had stated.” The resident’s daughter requested ULP call the facility RN, instead of the on-call RN, for further guidance. The facility RN noted she could “hear the resident's coughing in the background, noting that the PRNs were not helping, and the resident was telling his family "goodbye" and that he “didn't want to fight anymore." The facility RN encouraged the family to take the resident to the hospital. Facility documentation indicated the on-call RN reported she "received numerous phone calls throughout the weekend regarding [the resident] and his coughing but nothing was helping." The on-call RN apologized for not sending the resident in but "didn't know if family wanted him to go in as staff had not related that information about talking to family." During an interview, the on-call RN stated she worked as an on-call nurse for the facility, took call every third weekend, but did not work in the facility and worked at a hospital for her primary job. The on-call RN stated while on call, she did not have access to the resident's electronic medical record and relied solely on what ULP reported over the phone. The on-call RN stated ULP were “usually pretty good” and she knew to ask detailed questions to obtain all the information she needed to triage and assess the issue. The on-call RN stated any information she needed to triage an issue could be obtained verbally and she did not need to access the resident's medical record. The on-call RN trusted the assessment and judgment of the ULP. The on-call RN stated she was updated by the facility RN, before she took over call for the weekend, that the resident was hospitalized two weeks prior for aspiration pneumonia and had a persistent cough. The on-call RN stated it was not unusual for someone with pneumonia to have a lingering cough and besides low oxygen, the resident’s other vital signs were within normal limits. The on-call RN stated since the resident was stable enough to be discharged from the hospital and was not discharged with supplemental oxygen, she initially wasn't too concerned. The on-call RN stated she "didn't know if he was one of those people who didn't maintain his oxygen sats since he recovered, I have in my notes he would be 79% and would improve to 89%, but his temp was still 98. In hindsight, even though he recovered, I should have sent him in.