Westwood Place Inc.

correction orders issued pursuant to the last survey, completed on September 12, 2025, found not corrected at the time of the February 5, 2026, follow-up survey and/ or subject to penalty assessment are as follows: 0810-Fire Protection And Physical Environment- 144g.45 Subd. 2 (b-F) - $1,000.00 1290-Background Studies Required- 144g.60 Subdivision 1 - $1,000.00 1350-Temporary Staff-144g.60 Subd. 5 - $500.00 The details of the violations noted at the time of this follow-up survey completed on February 5, 2026 (listed Westwood Place Inc April 22, 2026 Page 2 above) , are on the attached State Form. Brackets around the ID Prefix Tag in the left hand column, e.g., {2 ----} will identify the uncorrected tags. Also, at the time of this follow-up survey completed on February 5, 2026, we identified the following violation(s): 1500-Required Annual Training-144g.63 Subd. 5 1650-Service Plan, Implementation And Revisions To-144g.70 Subd. 4 (f) 1730-Individualized Medication Management Plan-144g.71 Subd. 5 1760-Documentation Of Administration Of Medication- 144g.71 Subd. 8 1950-Administration Of Treatments And Therapy-144g.72 Subd. 4 1960-Documentation Of Administration Of Treatments- 144g.72 Subd. 5 The details of the violation(s) noted at the time of this follow-up survey are delineated on the attached State Form. Only the ID Prefix Tag in the left hand column without brackets will identify these state correction orders. It is not necessary to develop a plan of correction. Therefo re , in acc ordanc e with Minn. Stat. §§ 144 G.01 to 144G .99 99 , the total amount you are assessed is $2,500.00. 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. § 144G.30, Subd. 5(c), the licensee must document actions taken to comply with the correction orders and immediately correct any reissued orders outlined on the state form; however, plans of correction are not required to be submitted for approval. The correction order documentation should include the following: Identify how the area( s) of noncompliance was corrected related to the resident( s)/ employee( s) · identified in the correction order. Identify how the area( s) of noncompliance was corrected for all of the provider’s · resident( s)/ employees that may be affected by the noncompliance. Identify what changes to your systems and practices were made to ensure compliance with the · specific statute( s). CORRECTIO NORDER RECONSIDERATIO PNROCESS 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 REQUESTIN GA HEARING Alternatively, in accordance with Minn. Stat. § 144G.31, Subd. 5(d), an assisted living provider that has been assessed a fine under this subdivision has a right to a reconsideration or a hearing under this section and chapter 14. Pursuant to Minn. Stat. § 144G.20, Subd. 14 and Subd. 18, a request for a hearing must be in writing and received by the Department of Health within 15 business days of the correction order receipt date. The request must contain a brief and plain statement describing each Westwood Place Inc April 22, 2026 Page 3 matter or issue contested and any new information you believe constitutes a defense or mitigating factor. To submit a hearing request, please visit: https: / / forms. web. health. state. mn. us/ form/ HRDAppealsForm To appea l fines via rec onsiderati o n, ple ase fol lo w the pro cedure outlined abo ve. Please no te tha t you may re quest a rec onsider atio n or a he aring, but no t bo th. If you wish to contes t ta gs witho ut fines in a reconsideration and tags with the fines at a hearing, please submit two separate appeals forms at the website listed above. CONDITIONA LLICENS EISSUED: MD H will extend the conditio nal assisted liv ing wit h dementia care fac ility lice ns e fo r Westwo od Plac e Inc, fo r an additional 60 calendar days from the date of this notice. At an unannounced point in time, within the 60 calendar days, MDH will conduct a follow-up survey, as defined in Minn. Stat. § 144G.30, Subd. 6. Based on the results of the follow-up survey, MDH will determine if Westwood Place Inc is in substantial compliance. The following conditions will continue to be in effect on the conditional assisted living facility with dementia care license: a. No new subs tant iated maltr eatme nt alle ga tions: If any new investigations begin in the conditional license period, and the allegations are substantiated, MDH may pursue additional enforcement actions up to and including immediate temporary suspension and revocation of the license. b. Cons ult ant: Westwood Place Inc will continue to contract with an RN to provide consultation concerning all resident( s) to whom Westwood Place Inc provides lic ensed assiste d liv ing servi c es under the conditio nal lice nse . The cons ultant mus t continue to have access to all resident( s) receiving services from Westwood Place Inc. The consultant will continue to conduct initial and ongoing evaluations of the provider. Direct resident observation may be required based on the consultant’ s judgement or at the discretion of MDH. The RN must continue to not have any affiliation with Westwood Place Inc. Westwood Place Inc is responsible for the expense of the contract with the RN. The main purpose of the consultant is to provide guidance to Westwood Place Inc in an effort to help Westwood Place Inc align their practices with the requirements of Minn. Stat. §§ 144G.01 – 144G.9999 and to provide oral and written reports to MDH noting progress toward substantial compliance and/ or concerns about observations. Westwood Place Inc will continue to develop and implement policies, procedures, and processes specific to the offered services in accordance with the guidance provided by the consultant to ensure ongoing monitoring and substantial compliance with statutory requirements. c. Reports : The RN consultant will continue to provide MDH with regular reports at intervals specified by MDH. Reports will continue on a weekly basis until MDH notifies Westwo od Pla c e Inc and the RN consultant abo ut a change. Eac h repo rt will be elec tr onic ally subm itte d to : HRDConsultantReports. MDH@state. mn. us. The conte nt of the reports will include information such as: i. Progress towards correction of orders; Westwood Place Inc April 22, 2026 Page 4 ii. Observations of staff delivering assisted living services and the level of competency observed; iii. Conversations with residents and family members about satisfaction with assisted living services; iv. Conversations with staff about their level of knowledge about the tasks they perform, the people they serve and the health professionals who delegate to them; v. Overall impressions about the quality of the assisted living services delivered; vi. Overall impressions about the dignity with which the residents and their family members are treated; vii. Concerns; and viii. Any other information requested by the Department or considered important by the RN consultant( s). d. Monit ori ng vis its : MDH may make unannounced monitoring visits to assess the progress of Westwood Place Inc to correct the violations cited during the follow-up survey as well as to determine the overall practice of Westwood Place Inc in meeting the needs of the people it serves. In addition, the Office of Ombudsman for Long-Term Care (OOLTC m) ay also make unannounced monitoring visits to determine the level of satisfaction of those people who receive licensed assisted living services. The OOLTC will share their findings with MDH. e. Foll ow -up surv ey: At the time of the follow-up survey, MDH may pursue additional enforcement actions, up to and including immediate temporary suspension or revocation of the license if MDH identifies any level 4 or 5 violations or widespread care related violations. f. Corr ecti ve Ac ti on Plan: Westwood Place Inc will continue to develop and work within a corrective action plan (CAP). The CAP is a working document that includes at least the following information: i. A statement of the concern ii.

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 by failing to provide thickened liquids as required for his thickened liquid diet. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was inconclusive. While it was true there were occasions the facility may have made medical errors regarding the resident’s thickened liquids order, there is not sufficient evidence this affected the resident’s health or outcome. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigation included review of resident's records, incident reports, and the resident's external medical record. The investigation included an onsite visit, observations, and interactions between residents and facility staff. The resident resided in an assisted secured memory care building. The resident’s diagnoses include chronic respiratory failure and dysphagia (swallowing difficulties). The resident’s service plan included assistance with all activities daily living, medications, meals, and housekeeping. The resident was enrolled in hospice. The medical records indicated the resident had an order for thickened liquids due to swallowing difficulty and risk for aspiration (sucking food or liquid into the airway). The same records indicated the resident was found on multiple occasions with thin liquids in his room, which raised a concern for aspiration pneumonia. About three months prior to this concern the resident had been hospitalized and those records indicated was there for pneumonia, septic shock, and dysphagia with aspiration. While the resident had a diminished appetite, he did drink Pepsi daily as part of his routine. the resident was discharged back after five days later. However, on the day of discharge, he returned to the Emergency Room (ED) later that day due to lethargy. The reason for this hospitalization was failure to thrive, altered mental status, and poor oral intake. During this hospitalization, a video swallow study was done showing silent aspiration with thin liquids, therefore, the resident had been placed on a mechanical soft foods and mildly thick liquid diet regimen. While speech therapy was considered to improve the resident’s swallowing, this was not pursued when the resident enrolled in hospice for comfort cares and returned to the facility. The facility progress notes indicated that caregivers reported the resident was drinking fluids without thickener without issue with no coughing. The same documents indicated that as the resident decline, he was unable to drink thickened liquids on his own and at times the caregivers provided him spoon fed him water. About two months after the resident returned to the facility, Pepsi was found in the resident’s room that was not thickened on three or four occasions, which was brought to the facility’s attention due to the concern for possible silent aspiration. In the weeks following this occurrence the hospice records indicated the resident's lung sounds were consistently diminished or absent during several visits throughout the last month of his stay at the facility. Despite this, his oxygen levels remained stable at 94% - 97% while breathing room air. The resident’s death record indicated he died approximately three months after enrolling in hospice. The same document did not list aspiration pneumonia as a cause of death. During an interview, nurse #1 stated she some staff members were aware of the order for thickened liquid requirement but continued with thin liquids because they felt the resident's passing was imminent and therefore the consistency of the liquid was inconsequential. She stated it was also reported the resident disliked thickened liquids. Nurse #1 stated education on thickened liquids had been provided on multiple occasions, emphasizing that thickened liquids could be added to any beverage but needed to be consumed promptly. Nurse #1 stated she assessed signs of aspiration during visits, included increased lethargy, frothy sputum, clothing stains, coughing, sputum production, dry heaving, and hiccups. While hospice provided the thickener, the responsibility for staff education rested with the facility. During an interview, manager #1 stated the resident was admitted to the facility two years ago and was subsequently discharged to a nursing home due to an increasing level of care. Following his last hospital admission, he returned to the facility under hospice care. Upon discharge from the hospital, the resident was placed on a mechanical soft food and thickened liquid diet. The resident preferred and enjoyed drinking soda {Pepsi] but the if he did not drink it immediately the thickener did not maintain its consistency. Manager #1 stated that when nurse #1 raised the concern the facility looked into it and found the thickened soda lost its consistency after about an hour and that had been unknown previously. During an interview, manager #2 stated once it was discovered the issue with thickened liquids not maintaining its consistency over time, the facility adopted a practice of having the resident drink his thickened beverage, discard what was left and avoid leaving the liquid in his room. During an interview, unlicensed caregiver #1 stated the resident had been on thickened liquids for a couple of months. The information about the thickened liquid was clearly documented in his record and easy to see. During an interview, a kitchen staff member stated when the resident returned from the hospital, he started a thickened liquid, which she used to mix into any beverage he desired. She said she did not prepare the mixture until he was ready to drink it, simply following the directions on the package. 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. The resident was deceased. Family/Responsible Party interviewed: No, attempted but did not reach. Alleged Perpetrator interviewed: Not Applicable. Action taken by facility: The facility finally adopted a practice of having the resident drank it and discarding the remainder promptly. Everyone was told to prevent leaving the liquid in his room and dispose of it immediately after consumption. 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: 04/02/2024 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 _____________________________ 30328 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 209 JEFFERSON AVENUE SW WESTWOOD PLACE INC WATERTOWN, MN 55388 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 February 21, 2024, the Minnesota Department of Health initiated an investigation of complaints #HL303289085M/HL303286687C. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 7CPO11 If continuation sheet 1 of 1