Cedar Court.

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 CORRECTIO NORDERS 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 t he violati ons ; however, no immediate fines are assessed for this survey of your facility. DOCUMENTATIO ONF ACTION TO COMPLY In accorda nce with Min n. Stat. § 144G.30, Sub d. 5(c), th e lic ens ee mus t docum ent ac tions taken t o 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: An equal opportunity employer. Letter ID: IS7N REVISE D09/13/2021 Cedar Court March 9, 2026 Page 2 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 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 conv enien ce at thi s link: https: / / forms. office.com/ g/ Bm5uQEpHVa. Your inpu t is import ant 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 CLN PRINTED: 03/ 09/ 2026 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 _____________________________ 30231 02/ 19/ 2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 810 WEST MAIN STREET CEDAR COURT ADAMS, MN 55909 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 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. " The issued pursuant to a survey. 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. SL30231016- 0 PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On February 17, 2026, through February 19, STATES, "PROVIDER' S PLAN OF 2026, 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 33 residents; 28 receiving services under the Assisted Living THERE IS NO REQUIREMENT TO Facility with Dementia Care license. SUBMIT A PLAN OF CORRECTION FOR VIOLATIONS OF MINNESOTA STATE STATUTES. THE LETTER IN THE LEFT COLUMN IS USED FOR TRACKING PURPOSES AND REFLECTS THE SCOPE AND LEVEL ISSUED PURSUANT TO 144G. 31 SUBDIVISION 1-3. 0 550 144G. 41 Subd. 7 Resident grievances; reporting 0 550 SS= F maltreatment LABORATORY DIRECTOR' S OR PROVIDER/ SUPPLIER REPRESENTATIVE' S SIGNATURE TITLE (X6) DATE STATE FORM 6899 TZOM11 If continuation sheet 1 of 16 PRINTED: 03/ 09/ 2026 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 _____________________________ 30231 02/ 19/ 2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 810 WEST MAIN STREET CEDAR COURT ADAMS, MN 55909 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) 0 550 Continued From page 1 0 550 All facilities must post in a conspicuous place information about the facilities' grievance procedure, and the name, telephone number, and email contact information for the individuals who are responsible for handling resident grievances. The notice must also have the contact information for the Office of Ombudsman for Long- Term Care and the Office of Ombudsman for Mental Health and Developmental Disabilities and must have information for reporting suspected maltreatment to the Minnesota Adult Abuse Reporting Center. The notice must also state that if an individual has a complaint about the facility or person providing services, the individual may contact the Office of Health Facility Complaints at the Minnesota Department of Health. This MN Requirement is not met as evidenced by: Based on observation, interview, and record review the licensee failed to post in a conspicuous place, information about the licensee' s grievance procedure with the required content as well as the required information related to the contact information for the state and applicable regional Office of Ombudsman for Long- Term Care and the Office of Ombudsman for Mental Health and Developmental Disabilities. This had the potential to affect all residents, staff, and visitors. 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, but was not likely to cause serious injury, impairment, or death) , and is 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 STATE FORM 6899 TZOM11 If continuation sheet 2 of 16 PRINTED: 03/ 09/ 2026 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: Substantiated, 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 alleged perpetrator (AP) abused the resident when she rough handled the mechanical lift sling while she transferred him causing him to cry out in pain from pinching and causing the resident to use foul language. After she completed the transfer, the AP withheld the resident’s oxygen and threw his personal items of his around his room. As a result, the resident suffered physical pain and emotional distress. Investigative Findings and Conclusion: The Minnesota Department of Health determined abuse was substantiated. The AP was responsible for the maltreatment. The AP failed to remove the resident’s mechanical lift sling properly causing the sling to pinch the resident and he experienced scrotal pain. The AP refused to give the resident his oxygen and blanket after the transfer occurred; then pushed the resident’s table which caused items to go onto the floor, and across the room. The AP then left the resident. Photo images of the resident’s room also showed multiple items scattered around. The resident suffered physical pain and emotional distress as a result. 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 internal investigation, facility incident reports, personnel files, staff schedules, and related facility policy and procedures. Also, the investigator toured the facility observed mechanical lift transfers, medication administration, wound care, staffing levels, and documentation processes. The resident resided in an assisted living memory care unit. The resident’s diagnoses included myotonic muscular dystrophy (muscle weakness, and stiffness). The resident’s service plan included assistance with bathing, dressing, grooming, toileting, medication management, and mobility. The resident’s nursing assessment indicated he was unable to walk and required a mechanical lift (Hoyer) with assistance of two staff members to transfer and an electric wheelchair for mobility. The assessment indicated the resident’s behavior included using profanity. The resident received hospice care (end of life). The resident wore oxygen at bedtime. The facility’s internal investigation indicated unlicensed personnel (ULP) #1 helped the AP with the resident’s mechanical lift transfer. ULP #1 reported they toileted the resident and then transferred him to his recliner when she left the room to return assisting her resident. ULP #2 saw the AP come out of the resident’s room 10 minutes after ULP #1 left and the AP slammed the door as she walked outside. The resident then put on his call light and ULP #2 answered. ULP #2 reported there was cups and water on the floor and the resident’s side table items were also on the floor. ULP #2 said the resident was distressed, his blanket was on the floor where he could not reach it. ULP #2 said the resident reported the AP was rough, pushed all of his tray table items to the floor, refused to give him his blanket and oxygen cannula, and the AP walked out of the room. ULP #2 said the resident said he never wanted the AP to come near him [again]. ULP #1 said she learned after she left, the AP pulled the sling underneath the resident too hard, and it upset the resident. Nurse interviewed the resident, who reported the AP was forceful and rough while using the sling. He asked the AP to stop and she did not. He cried out in pain when the sling pinched his scrotum and he then swore at the AP. The resident reported the AP got angry, put the resident’s oxygen tubing out of reach and threw the resident’s blankets and belongings. The AP was suspended. Photo images of the resident’s room showed a water cup on the floor, across from the resident, just inside the entrance from his room. Another photo showed a cup on the windowsill, behind the resident, tipped over, with water on the windowsill. There were personal items on the floor under the window such as small pink basket, paper, and a Kleenex box (behind the resident, out of his reach). During an interview, ULP #1 said she helped the AP transfer the resident out of his wheelchair, to the commode, then into his reclining lounge chair. ULP #1 said the resident slept in his reclining lounge chair during the night. ULP #1 said, after she helped get the resident into the reclining chair, she left the room. ULP #1 said the AP was in the process of removing the sling from under the resident and his room was in order when she left. ULP #1 said everything seemed “OK.” ULP #1 said she was with another resident when she saw the AP walk outside (the facility) and “slam” a door. ULP #1 said she asked the AP what was wrong, and she told her the resident called her a name which made her upset. ULP #1 said she then went into the resident’s room and saw his table tipped over, and things scattered around his room. ULP #1 said ULP #2 was in the room, talking to the nurse on the phone. ULP #1 said the resident’s bedside table was on the ground. ULP #1 said the resident’s cups and other personal items scattered around the floor. ULP #1 said the nurse told ULP #2, to send the AP home. ULP #1 said she went and told the AP to go home. ULP #1 said the resident was upset. During an interview, ULP #2 said she was just down the hall from the resident’s room and saw the AP leave his room then “slam” a door into the wall as she went outside. ULP #2 said the resident pushed his call pendant and she walked into his room. ULP #2 said the resident was screaming. ULP #2 said she saw cups all over the room, water on the floor. ULP #2 said the resident was sitting in his recliner chair, without pants on and his blanket on the floor. The resident told her he swore at the AP because she “yanked” and “yanked” the sling from under him which pinched his genitals. The resident said the AP pushed his table and everything “went flying.” The resident said the AP threw his oxygen tubing and blanket to the ground, and walked out. ULP #2 said the resident was “panting” and told her he could not breath. The resident told ULP #2 he never wanted the AP in his room again. ULP #2 described the resident as being “very upset,” trembling, and shaking. ULP #2 said she called the facility nurse, who told her to send the AP home. ULP #2 said ULP #1 helped her clean the resident’s room. ULP #2 said she took photos of the resident’s room and audio recordings. During an interview, a facility nurse said she received a phone call from ULP #2 who told her what occurred. The nurse said while she spoke to ULP #2, the AP called. The nurse said the AP was defensive and told her the resident yelled at her and called her names. The nurse said the AP told her she pulled out the sling from under him “nicely” and did not cause the disarray in his room. During an interview, a manager said she spoke to the resident the night of the incident and he was crying, distressed, and afraid. The manger said ULP #1 and ULP #2 helped calm the resident. The manager said she also tried to calm the resident and provide reassurance to him this would not happen again. The manager said she briefly spoke to the AP, but she was very vague about what occurred. The manager said the AP told her she did not come into work so the resident could “disrespect” her and she was not going to allow the resident to talk to her the way he did. The manger said the AP did not provide further details. The AP’s employee file indicated she started working for the facility less than one month before the incident. The AP received education on vulnerable adults, dementia, and resident mental illness. The facility provided the AP education on their standards of behavior including professional conduct. Audio footage was unavailable.

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 the resident used a lighter to ignite a cigarette and caught his clothes on fire. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was inconclusive. Due to incomplete and conflicting accounts of the incident, it could not be determined if maltreatment occurred. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigation included review of the resident record, hospital records, facility incident reports, personnel files, staff schedules, related facility policy and procedures. Also, the investigator observed interactions between staff and residents. The resident resided in an assisted living memory care unit. The resident’s diagnoses included muscular dystrophy. The resident’s care plan included assistance with dressing, grooming, behavior management, and supervision of lighter use. The resident’s assessment indicated the resident was alert with no cognitive impairment. The resident refused assistance with smoking. Documentation indicated the resident used a lighter to light a cigarette outside when he caught his hooded sweatshirt on fire. The resident needed assistance to smother the fire to protect himself. The resident’s medical record indicated the resident caught his clothes on fire, the medical provider was updated, and the resident was ordered to not use a lighter without supervision. During an interview, a staff member stated the resident was outside smoking and when a staff member let the resident inside, staff noted a burn spot on the hood of the resident’s sweatshirt. A staff member stated facility management was notified and advised to increase monitoring of the resident however his care plan was not updated and increased monitoring was not done. During an interview the facility nurse stated the resident was not compliant with the facility rules and refused staff supervision and would leave the facility if staff tried to supervise him. The facility nurse stated she was not sure when the incident occurred. The laundry staff reported the burn in the hooded sweatshirt, and she interviewed staff, but no staff knew what happened. The facility nurse stated the resident’s care plan included a behavior section, but that section did not indicate specific smoking instructions for staff. A facility nurse stated staff were educated on resident smoking concerns however stated the education was not documented. During an interview, the resident stated the facility had attempted interventions, but the staff had other residents to care for and they did not need to watch him smoke. The resident stated the incident was a small incident and he did not get burned. During an interview, an outside agency staff member involved in the resident’s care stated the resident had two incidents with smoking, one included his hooded sweatshirt getting burnt and one when he burnt his hand. An outside agency staff member stated the facility had guidelines in place for the resident including to not smoke in the facility and locking up lighters in the medication cart but she was not aware of additional interventions put in place to prevent reoccurrence. During an interview, the resident’s responsible party stated when the resident’s hood was smoldering the resident tapped the smoldering out. The responsible party stated the facility had to give him the lighter and knew when he would go outside to smoke. The responsible party did not believe the resident would refuse supervision while he smoked. 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: Yes. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Not Applicable. the Action taken by facility: The facility updated the provider regarding the incident. Action taken by the Minnesota Department of Health: 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 PRINTED: 07/16/2025 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 _____________________________ 30231 05/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 810 WEST MAIN STREET CEDAR COURT ADAMS, MN 55909 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****** ASSISTED LIVING PROVIDER CORRECTION ORDER In accordance with Minnesota Statutes, section 144G.08 to 144G.95, these correction orders are issued pursuant to a complaint investigation. Determination of whether a violation is corrected requires compliance with all requirements provided at the statute number indicated below. When a Minnesota Statute contains several items, failure to comply with any of the items will be considered lack of compliance. INITIAL COMMENTS: #HL302312454C/#HL302311545M On May 14, 2025, the Minnesota Department of Health conducted a complaint investigation at the above provider, and the following correction orders are issued. At the time of the complaint investigation, there were 47 residents receiving services under the provider's Assisted Living with Dementia Care license. The following correction order is issued/orders are issued for ##HL302312454C/#HL302311545M, tag identification 2310. 02310 144G.91 Subd. 4 (a) Appropriate care and 02310 SS=H services (a) Residents have the right to care and assisted living services that are appropriate based on the resident's needs and according to an up-to-date service plan subject to accepted health care LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 99RN11 If continuation sheet 1 of 5 PRINTED: 07/16/2025 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 _____________________________ 30231 05/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 810 WEST MAIN STREET CEDAR COURT ADAMS, MN 55909 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) 02310 Continued From page 1 02310 standards. This MN Requirement is not met as evidenced by: Based on observation, interview, and document Minnesota Department of Health is review, the licensee failed to ensure appropriate documenting the State Correction Orders care and services were provided for two of two using federal software. Tag numbers have residents (R1 and R2) who were reviewed for been assigned to Minnesota State safe smoking. The licensee failed to assess and Statutes for Assisted Living Facilities. The implement interventions following incidents of assigned tag number appears in the unsafe smoking. This had the potential to affect far-left column entitled "ID Prefix Tag." The all the residents, staff, and visitors of the facility. state Statute number and the corresponding text of the state Statute out This practice resulted in a level three violation (a of compliance is listed in the "Summary violation that harmed a resident's health or safety, Statement of Deficiencies" column.

STATE LICENSING COMPLIANCE REPORT Report #: HL302315064C Date Concluded: March 14, 2024 Name, Address, and County of Facility Investigated: Cedar Court 810 West Main Street Adams, MN 55909 Mower County Facility Type: Assisted Living Facility with Evaluator’s Name: Kevin Sedivy Dementia Care (ALFDC) Engineer Specialist 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, Chapter 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 MDH website, please see the attached state form. PRINTED: 03/22/2024 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 _____________________________ 30231 03/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 810 WEST MAIN STREET CEDAR COURT ADAMS, MN 55909 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 March 11, 2024, the Minnesota Department of Health initiated an investigation of complaint HL302316938C and HL302315064C. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 FOVQ11 If continuation sheet 1 of 1