Diamond Willow Assisted Living.

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 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 § 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 An equal opportunity employer . Letter ID: IS7N REVISE 0D9/13/2021 Diamond Willow Assisted Living October 24, 2025 Page 2 pursuant to this survey: St - 0 - 0480 - 144g.41 Subdivision 1 Subd. 1a (a-B) - Min. Req.; Req. Food Servs .- $3,000.00 St - 0 - 0485 - 144g.41 Subdivision 1.A (a) - Min. Req.; Req. Food Servs - $1,000.00 St - 0 - 0510 - 144g.41 Subd. 3 - Infection Control Program - $500.00 St - 0 - 0775 - 144g.45 Subd. 2. (a) - Fire Protection And Physica lEnvironment - $500.00 Therefore ,in accordance with Minn. Stat. §§ 144G0. 1 to 144G9. 999, the total amount you are assesse dis $5,000.00. 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), t he 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: x Identify how the area(s) of noncompliance was corrected related to the resident(s)/ employee(s) 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. To submit a hearing request, please visit: Diamond Willow Assisted Living October 24, 2025 Page 3 https:/ / forms.web.health.state.mn.us/form/ HRDAppealsForm To appea lfines via reconsideration ,please follow the procedure outlined above. Please 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 S, upervisor State Evaluation Team Email: JessieC. henze@state.mn.us Telephone :218-332-5175 Fax :1-866-890-9290 HHH PRINTED: 10/24/2025 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 _____________________________ 23609 09/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 913 OLD HIGHWAY 2 DIAMOND WILLOW ASSISTED LLIVING PROCTOR, MN 55810 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. SL23609016-0 PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On September 22, 2025, through September 25, 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 30 residents; 30 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. An immediate correction order was identified on September 23, 2025, issued for SL323609016-0, THE LETTER IN THE LEFT COLUMN IS tag identification 0485. The licensee took action USED FOR TRACKING PURPOSES AND on September 23, 2025, to mitigate the risk; REFLECTS THE SCOPE AND LEVEL however, the scope and level remains at level ISSUED PURSUANT TO 144G.31 3/Widespread (I). SUBDIVISION 1-3. 0 480 144G.41 Subdivision 1 Subd. 1a (a-b) Minimum 0 480 SS=L requirements; required food services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 01N711 If continuation sheet 1 of 58 PRINTED: 10/24/2025 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: 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 facility neglected the resident when facility staff failed to supervise the resident causing a fall with a wrist fracture. In addition, the facility failed to provide appropriate care and services to maintain the resident’s hygiene and prevent skin breakdown. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. Although the resident fell and sustained a right wrist fracture, staff were following the resident’s plan of care at the time of the fall. In addition, the resident records indicated the resident was independent with toileting and was provided bathing twice a week as the resident allowed. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigation included review of the resident records, facility incident reports, staff schedules, and related facility policy and procedures. Also, the investigator observed the facility, the resident, and the resident’s room. The resident resided in an assisted living memory care unit. The resident’s diagnoses included alcohol induced dementia, and depression. The resident’s service plan included assistance with bathing, dressing, and housekeeping. The resident’s assessment indicated the resident had cognitive impairment, walked independently, and used the bathroom independently. Staff provided verbal ques for bathing and the resident was independent with dressing, however staff were to ensure the resident was wearing clothes appropriate for the weather. The resident’s record indicated one day the resident was outside walking in the grass while holding the hand of a staff member. The resident lost her balance and fell. The following day, the resident’s right wrist was observed to be “slightly” swollen and the resident reported a “little” pain in the wrist. The facility contacted the physician, and an x-ray of the resident’s wrist was ordered. Three days later the x-ray results confirmed the resident’s right wrist was fractured. The resident’s physician ordered a brace, and an appointment was scheduled for the resident to be seen at an orthopedic (branch of medicine dealing with the correction of deformities of bones or muscles) clinic. The resident saw an orthopedic doctor two days later and a cast was applied to the resident’s right wrist. The resident’s record indicated over a two-month period, the resident’s skin was clean, dry, and intact. During an interview, facility leadership stated staff assisted the resident with grooming, bathing and encouraged the resident to change her clothes. At times, the resident refused to bathe and change her clothes, however, the resident would not wear the same clothes longer than two days. Leadership stated the resident had two falls in the last six months and leadership was not aware the resident had any skin breakdown. During an interview, the resident stated she was independent with walking and did not need staff assistance. Staff did help with showers to ensure the resident did not fall. The resident stated her latest fall occurred several weeks ago when she was outside of the facility and fractured her wrist that required a cast. The resident had no concerns with staff providing cares and housekeeping services. Other concerns investigated was a concern the facility and the resident smelled of urine and feces and the environment was filthy. During an onsite visit, the investigator observed the facility, the resident, and the resident’s room. The resident was dressed appropriately and was wearing clean clothes. The resident’s appeared well groomed and clean. The facility and the resident’s room were clean and without odors. 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: Not Applicable. the Action taken by facility: The facility staff were present with the resident outside of the facility when the resident fell. The resident physician and a family member were notified of the fall. The facility scheduled an appointment for the resident and a cast was applied to her right wrist. 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: 01/27/2025 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. WING _____________________________ 23609 01/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 913 OLD HIGHWAY 2 DIAMOND WILLOW ASSISTED LIVING PROCTOR, MN 55810 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 January 13, 2025, the Minnesota Department of Health initiated an investigation of complaint #HL236097003M/#HL236091621C. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 SDLJ11 If continuation sheet 1 of 1

STATE LICENSING COMPLIANCE REPORT Report #: HL236099431C Date Concluded: October 30, 2024 Name, Address, and County of Facility Investigated: Dimond Willow Assisted Living 913 Old Highway 3 Proctor, MN 55810 Facility Type: Assisted Living Facility with Evaluator’s Name: Angela Vatalaro, RN Dementia Care (ALFDC) Special Investigator The Minnesota Department of Health conducted a complaint investigation to determine compliance with state laws and rules governing the provision of care under Minnesota Statutes, 144G. The purpose of this complaint investigation was to review if facility policies and practices comply with applicable laws and rules. No maltreatment under Minnesota Statutes, Chapter 626 was alleged. To view a copy of the correction orders, if any, please visit: https://www.health.state.mn.us/facilities/regulation/directory/provcompselect.html, or call website, please see the attached state form. PRINTED: 10/30/2024 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 _____________________________ 23609 10/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 913 OLD HIGHWAY 2 DIAMOND WILLOW ASSISTED LLIVING PROCTOR, MN 55810 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 October 23, 2024, the Minnesota Department of Health initiated an investigation of complaint #HL236099431C. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 USLF11 If continuation sheet 1 of 1

Finding: Substantiated, facility responsibility 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 the facility failed to ensure the resident received necessary care and services and as a result, the resident developed pressure sores, a urinary tract infection, and weight loss. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was substantiated. The facility was responsible for the maltreatment. The facility failed to ensure staff provided the resident with his care planned needs including catheter care, repositioning, and assist with eating. Due to the lack of care, the resident developed pressure sores, a urinary tract infection, and a 30-pound weight loss. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, unlicensed staff, and family members. The investigator contacted a home care agency and a staffing agency. The investigation included review of the resident record(s), hospital records, pharmacy records, facility internal investigation, facility incident reports, personnel files, staff schedules, and related facility policy and procedures. The investigator observed staff provide direct cares for the residents. The resident resided in an assisted living memory care unit. The resident’s diagnoses included a double below the elbow amputation and diabetes. The resident’s service plan included assistance with wound care, transfers, toileting, hygiene, eating and drinking. The resident’s assessment indicated the resident was totally dependent on staff for assistance, at risk for dehydration and nutritional deficiencies, dependent on staff for catheter cares to prevent infection, and repositioning to prevent pressure ulcers. The resident was alert and oriented to person, place, and time. The resident record indicated the resident had a recurring pressure sore on the coccyx (tailbone area), development of a pressure sore on the right shoulder blade, and a 30-pound weight loss over 8 months before discharge from the facility. The resident’s record indicated every day in one month, there were life sustaining services not provided for the resident. The resident’s wound care services were to be completed by a licensed staff twelve times during the same month and were not completed six of the scheduled times. Also, staff failed to complete the resident’s catheter cares, monitoring catheter output, eating and snack assistance, hygiene and toileting cares daily as assessed, care planned, and required for the resident. Hospital records indicated the resident had catheter complications the first week of that same month and was evaluated at an emergency room. The resident’s catheter bag contained dark red urine and blood. The resident was diagnosed with a severe urinary tract infection, prescribed antibiotics (medication to fight infection) and returned to the facility. Two days later staff told a contracted visiting home care nurse the resident’s antibiotic had not been administered because the order had not been processed by a licensed nurse into the resident’s electronic medication record. The first dose of antibiotic was administered over 48 hours after it was ordered by the emergency room physician. During an interview, a contracted home care licensed staff stated her outside agency was asked to provide supplemental wound care services and catheter management for the resident due to the lack of staff at the resident’s facility. The contracted licensed home care staff stated unlicensed personnel were expected to assist the resident twice daily with cleaning the catheter tube, emptying, and changing the catheter bag. The contracted licensed home care staff stated hygiene and catheter cares were not done and it contributed to the resident’s urinary tract infection, skin breakdown and wound development. The licensed home care staff stated the resident had a coccyx pressure sore that would heal and reopen at various times, and repositioning the resident was important, but was not done. Licensed home care staff stated the lack of repositioning resulted in the development of a new pressure ulcer on the resident’s right shoulder blade. The contracted licensed home care staff stated it was difficult to get wound care and catheter orders processed or supplies ordered for the resident’s cares because the facility had so few staff and often, she would see no staff when visiting the resident. The contracted licensed home care staff stated lack of repositioning, lack of hygiene assistance, poor nutritional intake, and rapid weight loss contributed to a decline in the resident’s emotional and physical health. The contracted licensed home care staff stated she shared concerns about the resident’s inability to access water and the lack of proper cares with a licensed facility nurse and requested a care conference on behalf of the resident. During an interview, a facility licensed staff stated because the facility was unable to provide resident cares the facility contracted with a home care agency and two temporary staffing agencies. The licensed staff stated resident cares suffered because there was never enough staff. Licensed staff stated the resident’s catheter changes and wound cares were managed by an outside agency, and she was grateful for their assistance. Licensed staff stated she had concerns for the health and safety of the residents. During an interview, another licensed staff stated there were a lot of staffing shortages, even after temporary staff were contracted. The licensed staff stated she had not received any training for her role at the facility, and it was “heartbreaking to say”, but the residents did not receive the cares assigned to them. Licensed staff stated repositioning, hygiene and shower services would not be completed for long periods of time due to lack of staff. The licensed staff denied the resident’s wound cares were not completed however, stated if not documented the wound care was not completed. Licensed staff stated the resident would state he felt he was being emotionally and physically neglected. Licensed staff stated the resident told the contracted licensed home health staff he was not being fed but the resident denied saying that during the resident’s care conference. During an interview, the resident stated when he was a resident at the facility, the facility was “always short on help”. The resident stated staff were scheduled to assist with catheter cares twice daily, however, “they didn’t know anything about catheters”. The resident stated he had help from a licensed home care for wounds and catheter care. The resident stated there were hygiene concerns, but staff did not have time to assist with showers, “there were some problems”. The resident stated he would push his call pendant for assistance and “wait hours” because staff were “at another building across the road”. The resident stated he did not care for the food and staff would “forget to come and get me”. The resident stated he had a thirty-pound weight loss while a resident at the facility. In conclusion, the Minnesota Department of Health determined neglect was substantiated. Substantiated: Minnesota Statutes, section 626.5572, Subdivision 19. “Substantiated” means a preponderance of evidence shows that an act that meets the definition of maltreatment occurred. 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: N/A the Action taken by facility: The facility was in the process of hiring individuals to fill leadership roles on campus. 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.

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. HL236099947M/HL236098144C and PLEASE DISREGARD THE HEADING OF HL236098071C THE FOURTH COLUMN WHICH STATES,"PROVIDER'S PLAN OF On February 7, 2024, the Minnesota Department CORRECTION." THIS APPLIES TO of Health conducted a complaint investigation at FEDERAL DEFICIENCIES ONLY. THIS the above provider, and the following correction WILL APPEAR ON EACH PAGE. orders are issued. At the time of the complaint investigation, there were 38 residents receiving THERE IS NO REQUIREMENT TO services under the provider's Assisted Living with SUBMIT A PLAN OF CORRECTION FOR Dementia Care license. VIOLATIONS OF MINNESOTA STATE STATUTES. The following correction order is issued for HL236099947M/HL236098144C, tag The letter in the left column is used for identification 2360. tracking purposes and reflects the scope and level issued pursuant to 144G.31 No correction orders are issued for subd. 1, 2, and 3. #HL236098071C. 02360 144G.91 Subd. 8 Freedom from maltreatment 02360 Residents have the right to be free from physical, LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 Y85211 If continuation sheet 1 of 2 PRINTED: 03/13/2024 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 23609 B. WING _____________________________ 02/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 913 OLD HIGHWAY 2 DIAMOND WILLOW ASSISTED LLIVING PROCTOR, MN 55810 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 02360 Continued From page 1 02360 sexual, and emotional abuse; neglect; financial exploitation; and all forms of maltreatment covered under the Vulnerable Adults Act. This MN Requirement is not met as evidenced by: The facility failed to ensure one of one resident No plan of correction is required for this reviewed (R1) was free from maltreatment. tag. 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. STATE FORM 6899 Y85211 If continuation sheet 2 of 2

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. HL236099947M/HL236098144C and PLEASE DISREGARD THE HEADING OF HL236098071C THE FOURTH COLUMN WHICH STATES,"PROVIDER'S PLAN OF On February 7, 2024, the Minnesota Department CORRECTION." THIS APPLIES TO of Health conducted a complaint investigation at FEDERAL DEFICIENCIES ONLY. THIS the above provider, and the following correction WILL APPEAR ON EACH PAGE. orders are issued. At the time of the complaint investigation, there were 38 residents receiving THERE IS NO REQUIREMENT TO services under the provider's Assisted Living with SUBMIT A PLAN OF CORRECTION FOR Dementia Care license. VIOLATIONS OF MINNESOTA STATE STATUTES. The following correction order is issued for HL236099947M/HL236098144C, tag The letter in the left column is used for identification 2360. tracking purposes and reflects the scope and level issued pursuant to 144G.31 No correction orders are issued for subd. 1, 2, and 3. #HL236098071C. 02360 144G.91 Subd. 8 Freedom from maltreatment 02360 Residents have the right to be free from physical, LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 Y85211 If continuation sheet 1 of 2 PRINTED: 03/13/2024 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 23609 B. WING _____________________________ 02/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 913 OLD HIGHWAY 2 DIAMOND WILLOW ASSISTED LLIVING PROCTOR, MN 55810 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 02360 Continued From page 1 02360 sexual, and emotional abuse; neglect; financial exploitation; and all forms of maltreatment covered under the Vulnerable Adults Act. This MN Requirement is not met as evidenced by: The facility failed to ensure one of one resident No plan of correction is required for this reviewed (R1) was free from maltreatment. tag. 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. STATE FORM 6899 Y85211 If continuation sheet 2 of 2

Finding: Substantiated, facility and individual responsibility 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 alleged perpetrator, (AP)1, failed to safely transfer the resident as indicated in the resident’s plan of care, the resident fell, and sustained a proximal right femur (hip) fracture. In addition, AP2 neglected the resident when AP2 failed to safely transfer the resident as indicated in the resident’s plan of care, the resident fell again with pain in her right hip. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was substantiated. AP1 and the facility were responsible for the maltreatment. AP1 failed to follow the residents plan of care which instructed staff to use a transfer belt and leg brace with transfers. The resident fell and sustained a right femur fracture requiring surgical repair and hospitalization. AP2 failed to follow the resident’s plan of care for safe transfers. The resident fell and complained of pain. However, the facility failed to ensure AP2 had completed training and competency prior to providing care independently to the resident. An equal opportunity employer. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigation included review of the resident’s medical records, facility communication notes, physician notes, radiology reports, AP’s employment and training records, and facility policy and procedures. The investigator completed onsite observation of staff assisting residents with cares. The resident resided in an assisted living facility with diagnoses including early onset Alzheimer’s Disease, dementia, contracture of right hand, stroke, and hemiplegia (paralysis on one side of the body). The resident’s assessment indicated the resident was cognitively impaired but able to communicate her needs and was usually understood. A fall risk assessment indicated the resident was at a risk for falls related to decreased coordination, problems with balance while standing, right sided hemiplegia, impaired cognition, confusion/forgetfulness, anxiety, and poor decision-making ability. The assessment indicated the resident required assistance from one to two staff with transfers using a transfer belt for stability. The assessment instructed staff to provide toileting every two to three hours, use proper footwear, and ensure appropriate assistance was provided to the resident with transfers. The residents service/care plan indicated the resident was unable to walk due to hemiplegia affecting the right side of her body. The residents service/care plan indicated she required assistance from one to two staff with transfers using a transfer belt and leg brace for stability. The care plan indicated the resident required one to two assistance using a transfer belt with showers and instructed staff to apply the resident’s leg brace upon waking. A fall incident report completed by AP1 at the time of the incident indicated when transferring the resident out of the bathtub the resident had bare feet and slipped on the wet floor. The report indicated the resident had pain in her right knee and the provider was notified with additional pain management ordered. A facility report indicated the resident fell when AP1 failed to use a transfer belt or leg brace as indicated in the resident’s plan of care. The report indicated the floor was wet, and the resident’s wheelchair brakes were not locked at the time of the incident. A provider communication indicated the facility notified the provider of the residents fall and knee pain. The provider ordered an X-ray of the resident’s right knee to be completed onsite due to the resident’s advanced dementia. A radiology report indicated there was no fracture of the resident’s right knee. The progress notes indicated the following day the resident reported pain in her right hip, instead of the right knee as identified initially. The progress notes and provider communication indicated the facility updated the provider with orders received for X-rays of the resident’s hip and femur. A radiology report indicated the resident sustained a proximal femur (hip) fracture. The resident record indicated the resident was transferred to the emergency department and admitted to the hospital for surgical repair. The resident was readmitted to the facility six days later. When interviewed AP1 stated she had provided care to the resident before, knew how to apply a transfer belt, and knew how to find the resident’s care plan. AP1 stated she did not look for a transfer belt or review the resident’s plan of care before providing care to the resident. AP1 stated she thought she could do it on her own. When interviewed the nurse who responded after the incident occurred stated AP1 failed to use a transfer belt, proper footwear, and did not ask for assistance with transferring the resident. The nurse indicated AP1 completed training and the nurse observed AP1 providing care to residents with no concerns of AP1’s competency prior to the incident. When interviewed another staff stated she trained AP1 prior to the incident. The staff stated she had reviewed the resident’s plan of care with AP1, and instructed AP1 on using a transfer belt, and applying the resident’s leg brace for transfers. When interviewed a registered nurse stated she had completed skills and competency with AP1 prior to the incident. The nurse stated AP1 demonstrated skills and competency with safe transfer techniques using a transfer belt and accessing the resident’s plan of care. When interviewed facility leadership stated when she talked to AP1 after the incident occurred, AP1 knew the resident should have had a transfer belt on at the time of the incident. When interviewed another registered nurse stated she provided re-education to AP1 after the incident occurred. The nurse stated AP1 verbalized feeling comfortable with the training she had received prior to the incident and expressed feeling comfortable with her duties. The nurse stated AP1 knew the resident should have had on proper footwear, leg brace, and a transfer belt at the time of the incident. AP1’s training records indicated she had completed training, competency, and online training modules which included safe transfers using a transfer belt, falls prevention, and bathing/showering skills prior to the incident. Approximately three months later, a fall incident report indicated the resident fell when AP2 assisted the resident to the toilet without a transfer belt, proper footwear, or the resident’s leg brace. A review of AP2’s personnel files indicated she was newly hired at the time of the incident. When interviewed AP2 stated she was training at the time of the incident. AP2 stated staff instructed her to go help the resident to the bathroom alone. AP2 stated she had not reviewed the residents plan of care, and did not use a transfer belt, proper footwear, or leg brace at the time of the incident. When interviewed a registered nurse stated she went to the facility after the fall incident with AP2. The nurse stated the residents plan of care was not followed at the time of the incident and AP2 did not use a transfer belt, proper footwear, or the resident’s leg brace. The nurse stated AP2 was in training at the time of the incident and had not yet completed skills and competency. The nurse stated after the incident occurred AP2 was removed from her duties and completed the skills and competencies checklist including safe transfers and toileting at that time. The nurse stated when she talked to staff after the incident occurred, staff stated they were busy and instructed AP2 to go help the resident to the bathroom alone. The nurse stated AP2 should not have been working independently at any point prior to her training and competency sign off. The nurse stated the resident had pain after the incident and was evaluated in the emergency department with no injury noted. When interviewed the resident’s family member stated the facility failed to ensure the resident’s plan of care was consistently followed. The family member stated they had reported their concerns to the facility but continued to witness the resident without her leg brace on numerous occasions. In conclusion, the Minnesota Department of Health determined neglect was substantiated. Substantiated: Minnesota Statutes, section 626.5572, Subdivision 19. “Substantiated” means a preponderance of evidence shows that an act that meets the definition of maltreatment occurred. Neglect: Minnesota Statutes, section 626.5572, subdivision 17 Neglect means neglect by a caregiver or self-neglect.