Mother of Mercy.
Mother of Mercy is Grade C, ranked in the top 49% of Minnesota memory care with 1 MDH citation on record; last inspected Feb 2025.
A large home, reviewed on public record.
Ranked against 142 Minnesota facilities.
ALF memory care · 36-month window. Higher percentile = better. Source: Minnesota Dept. of Health · Health Regulation Division.
FACILITY WATCH · BETA
Mother of Mercy has 1 citation on record. Know the moment anything changes.
New findings, complaint investigations, or status changes — emailed to you free.
Citation history, plotted month by month.
1 deficiencie on record. Each bar is a month with a citation.
Finding distribution
1 total · 36 monthsScope × Severity (CMS A–L)
Questions to ask before you visit.
A short pre-tour checklist tailored to Mother of Mercy's record and state requirements.
The facility holds an Assisted Living Facility with Dementia Care license under Minnesota Statutes chapter 144G — can you walk us through the specific dementia supports and programming that qualify Mother of Mercy for this designation, and provide any written policies that describe memory care services?
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MDH records show 5 inspections on file with 0 deficiencies cited — can you share the most recent MDH inspection report from February 21, 2025, and explain how the facility maintains compliance with state dementia care requirements?
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Three complaints were filed with the Minnesota Department of Health during the inspection period on record — were any of those complaints substantiated, and can you provide documentation of any corrective actions the facility implemented in response?
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Every MDH visit, verbatim.
4 inspections in the public record, most recent first. Click any row to expand — cited rows open automatically.
2025-03-21Complaint InvestigationNo findings
Plain-language summary
A complaint investigation found no substantiated neglect after a resident fell and was later diagnosed with a hip fracture. The resident had not received morphine before the fall, and after the fall the facility promptly notified the on-call nurse, family, and hospice provider; a hospice nurse assessed the resident the same day and recommended pain medication, and the facility continued coordinating care with hospice until the resident was transferred to the hospital the next day for evaluation. The Minnesota Department of Health determined no further action was needed.
Full inspector notes
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 morphine, an opioid pain medication, was administered causing the resident to fall. The resident was not assessed by an in-person nurse until the next day. The resident had a fractured hip. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. The resident had not received morphine prior to the fall. However, after the resident’s fall, the facility provided the prescribed morphine due to the resident’s complaints of discomfort, notified and coordinated care with the hospice provider, who assessed the resident the day of the fall and notified the medical provider. Despite the efforts to treat the resident’s pain did not resolve so the resident was transferred to the hospital where she was diagnosed with a hip fracture the following day. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted law enforcement, and the family member. The investigation included review of the resident record, hospice records, facility internal investigation, facility incident reports, staff schedules, law enforcement report, and related facility policy and procedures. Also, the investigator observed resident to facility staff interactions during an onsite visit. The resident resided in an assisted living memory care unit. The resident’s diagnoses included history of a stroke, transient ischemic attacks (a temporary blockage of blood flow to the brain), syncope and collapse, and dementia. The resident’s service plan included assistance with toileting. The resident’s assessment indicated the resident was alert to person only, was resistant to cares, especially toileting and bathing, and ambulated with the assistance of a walker and one facility staff member. The resident was also receiving hospice care. A concern arose the resident was overmedicated with morphine, was not assessed after a subsequent fall, and sustained a hip fracture that was not diagnosed until the following day. A facility incident report indicated the resident had an unwitnessed fall in her room. The same document indicated vital signs were taken by a facility staff member and the facility nurse and hospice provider were notified. The resident complained of back pain after the fall. The resident’s progress notes indicated the unlicensed caregiver had checked on the resident ten minutes before the fall and the resident was sleeping in her chair. After the resident had fallen the unlicensed caregiver notified the facility nurse on-call and hospice after the fall. Hospice documentation confirmed notification of the resident’s fall and that a hospice nurse would be visiting and gave an estimated time of the nurse’s arrival to be 45 minutes. The hospice nurse visit note indicated an assessment was completed where the resident initially denied pain, but did report pain with lifting her left leg and turning her torso to the left. The hospice nurse recommended the facility unlicensed caregivers give morphine every four hours through the night as needed to keep the resident comfortable. The same documentation indicated the resident’s family was updated and the medical provider was contacted with no additional orders obtained. The resident’s medication administration record (EMAR) did not indicate the resident received morphine before the fall but was administered after the fall for the resident’s complaints of pain. The following day the progress notes indicated the facility reached out to the hospice provider as the resident continued to have pain despite receiving morphine for pain. The facility continued to update hospice and hospice communicated with the resident’s family. Later that same day, the resident was sent to the hospital for further evaluation and a hip fracture was identified. During an interview, the on-call nurse stated the unlicensed caregivers contacted her at the time of the fall. At the time, the family was contacted as was the hospice provider. 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: No, due to cognitive impairment. Family/Responsible Party interviewed: Yes Alleged Perpetrator interviewed: Not Applicable the Action taken by facility: No action required 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: 03/28/2025 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 _____________________________ 30461 03/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 230 CHURCH AVENUE MOTHER OF MERCY SENIOR LIVING ALBANY, MN 56307 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, 2025, the Minnesota Department of Health initiated an investigation of complaint #HL304616541C/#HL304618802M. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 4DIT11 If continuation sheet 1 of 1
2025-02-21Annual Compliance VisitNo findings
Plain-language summary
A standard inspection of Mother of Mercy Senior Living was conducted February 18–20, 2025, covering 47 residents in the facility's dementia care program. The inspection resulted in state correction orders for violations of Minnesota assisted living statutes; no immediate fines were assessed. The facility must document in its records how it has corrected the violations and made changes to prevent future noncompliance.
Full inspector notes
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: An equal opportunity employer. Letter ID: IS7N REVISED 09/13/2021 Mother of Mercy Senior Living March 21, 2025 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). 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, Kelly Thorson, Supervisor State Evaluation Team Email: Kelly.Thorson@state.mn.us Telephone: 320-223-7336 Fax: 1 -866-890-9290 HHH PRINTED: 03/21/2025 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 _____________________________ 30461 02/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 230 CHURCH AVENUE MOTHER OF MERCY SENIOR LIVING ALBANY, MN 56307 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 License issued pursuant to a survey. Providers. The assigned tag number appears in the far-left column entitled "ID Determination of whether violations are corrected Prefix Tag." The state Statute number and requires compliance with all requirements the corresponding text of the state Statute provided at the Statute number indicated below. out of compliance is listed in the When Minnesota Statute contains several items, "Summary Statement of Deficiencies" failure to comply with any of the items will be column. This column also includes the considered lack of compliance. findings which are in violation of the state requirement after the statement, "This INITIAL COMMENTS: Minnesota requirement is not met as evidenced by." Following the surveyors' SL30461016-0 findings is the Time Period for Correction. On February 18, 2025, through February 20, PLEASE DISREGARD THE HEADING OF 2025, the Minnesota Department of Health THE FOURTH COLUMN WHICH conducted a full survey at the above provider. At STATES,"PROVIDER'S PLAN OF the time of the survey, there were 47 residents CORRECTION." THIS APPLIES TO whom received services under the Assisted Living FEDERAL DEFICIENCIES ONLY. THIS Facility with 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. 0 470 144G.41 Subdivision 1 Minimum requirements 0 470 SS=F (11) develop and implement a staffing plan for LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 QULH11 If continuation sheet 1 of 33 PRINTED: 03/21/2025 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 _____________________________ 30461 02/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 230 CHURCH AVENUE MOTHER OF MERCY SENIOR LIVING ALBANY, MN 56307 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) 0 470 Continued From page 1 0 470 determining its staffing level that: (i) includes an evaluation, to be conducted at least twice a year, of the appropriateness of staffing levels in the facility; (ii) ensures sufficient staffing at all times to meet the scheduled and reasonably foreseeable unscheduled needs of each resident as required by the residents' assessments and service plans on a 24-hour per day basis; and (iii) ensures that the facility can respond promptly and effectively to individual resident emergencies and to emergency, life safety, and disaster situations affecting staff or residents in the facility; (12) ensure that one or more persons are available 24 hours per day, seven days per week, who are responsible for responding to the requests of residents for assistance with health or safety needs. Such persons must be: (i) awake; (ii) located in the same building, in an attached building, or on a contiguous campus with the facility in order to respond within a reasonable amount of time; (iii) capable of communicating with residents; (iv) capable of providing or summoning the appropriate assistance; and (v) capable of following directions; This MN Requirement is not met as evidenced by: Based on interview and record review, the licensee failed to ensure the clinical nurse supervisor (CNS) developed and implemented a staffing plan to determine staffing levels to meet the needs of all residents, which included reviewing the staffing plan at least twice per year. This had the potential to affect all residents, staff, and visitors. This practice resulted in a level two violation (a STATE FORM 6899 QULH11 If continuation sheet 2 of 33 PRINTED: 03/21/2025 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.
2024-11-07Complaint Investigation1 · Substantiated Finding
Plain-language summary
A complaint investigation substantiated that the facility neglected a resident by failing to ensure a scheduled pain medication (Tramadol) was available as ordered, resulting in the resident missing four doses over two days and being transported to the emergency department with severe pain and withdrawal symptoms. The facility sent multiple refill requests to the pharmacy but did not follow up when the medication was not received, and did not communicate the medication shortage to the resident's doctor during a visit on September 10. The investigation found the facility was responsible for the maltreatment.
“MDH substantiated maltreatment or licensing violation finding”
Full inspector notes
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 they failed to ensure Tramadol (a controlled drug pain medication) was available to administer as ordered. The resident was brought to the emergency department (ED) with increased pain after several doses of Tramadol were missed. 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 the resident’s scheduled Tramadol was available. After the resident did not receive approximately four doses of Tramadol, the resident experienced severe pain and withdrawal symptoms and was transported to the hospital for pain control. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted the resident’s family member and case manager. The investigation included review of the resident record(s), hospital records, pharmacy records, clinic records, facility incident reports, personnel files, staff schedules, and related facility policy and procedures. Also, the investigator observed resident’s and staff at the facility. The resident resided in an assisted living facility with diagnoses including anxiety, chronic back pain, fibromyalgia, and back pain. The resident’s assessment and plan of care indicated the resident utilized Tramadol along with Tylenol for chronic pain in her back and hips. The assessment and plan of care indicated the resident received medication management and administration services at the facility and indicated medications would be given according to the providers orders. The assessment and plan of care indicated the licensed nurse was responsible for monitoring medication supplies and reordering as needed. The resident record indicated the facility utilized the electronic medical record system to reorder medications and fax refill requests to the pharmacy. The record indicated the facility faxed a request to refill the resident’s Tramadol to the pharmacy on September 6, (5 days prior to the resident running out of the medication). Another request was sent on September 9, (3 days later), and again (2 days later, the day the resident ran out of Tramadol) that fax included a note to the pharmacy notifying them the resident would completely run out of all Tramadol at 5:00 p.m. that day. The record indicated the request was forwarded to the provider from the pharmacy at 11:22 a.m. The record indicated the resident’s Tramadol refill was not authorized by the provider for a refill the following day at 1:20 p.m. (after the resident had missed 4 doses of the medication and was brought to the ED with increased pain). Although the facility faxed refill requests there was no indication the pharmacy received or responded to the request nor did the facility follow up with the pharmacy to ensure the resident had the medication available. A provider rounding form and after visit summary (AVS) dated September 10, (the day before the resident’s medication ran out) indicated the resident was seen by her provider at the facility on rounds. There was no indication the facility communicated the resident needed a refill of Tramadol. No medication orders were placed. The resident’s medication administration record (MAR) indicated she was prescribed scheduled Tramadol (4 times daily) 100 milligrams (mg) at 8:00 a.m., and 50 mg at 12:00 p.m., 5:00 p.m., and 10:00 p.m. The MAR indicated the resident missed 4 scheduled doses of Tramadol over 2 days. On September 11, at 10:00 p.m. unlicensed personnel (ULP) was unable to give the Tramadol as ordered, and documented “waiting for the medication from pharmacy.” On September 12, at 8:00 a.m. and 12:00 p.m. another ULP documented the resident’s Tramadol was unable to be given because it was “out of stock” and indicated the nurse was notified. At 5:00 p.m. another ULP documented the Tramadol unable to be given, and indicated the resident was given a dose of as needed (PRN) Tylenol at 5:07 p.m. The ULP documented the Tylenol was not effective at 6:49 p.m. A provider rounding form and AVS dated September 12, indicated the facility failed to communicate to the resident’s provider that the resident needed a Tramadol refill and had not received scheduled doses of her Tramadol as ordered due to being out of the medication. The resident’s progress notes indicated on September 6, at 2:51 p.m. a Tramadol refill request was sent to the pharmacy. 3 days later a progress note indicated the facility had not received the resident’s Tramadol and another fax was sent to the pharmacy. 2 days later a progress note (the day the resident ran out of Tramadol) indicated the facility still had not received the resident’s Tramadol, another fax was sent to the pharmacy, and a nurse called the pharmacy and left a voicemail asking when they could expect the Tramadol. The note indicated the nurse later received communication from the pharmacy that the resident was out of refills and the provider was contacted. There was no indication the facility communicated with the pharmacy prior to the resident running out of Tramadol when the medication refill requested was not received. On September 12, at 6:39 p.m. a progress note indicated the on-call nurse received a call from the resident’s family member about the resident’s Tramadol. The family was informed they were waiting for the provider to authorize a refill of the medication and the nurse would notify the family when the medication arrived. At 8:35 p.m. the on-call nurse received a call the family member was taking the resident to the ED because the resident stated she was going to die without the Tramadol. The progress notes lacked any documentation of the resident being monitored for increased pain, adverse effects, or possible withdrawal symptoms when the resident’s Tramadol was not available to be administered. The progress notes failed to indicate the resident’s provider was notified of the medication error – omission or need for a refill of Tramadol. The resident’s ED/hospital medical record indicated on September 12, the resident reported her chronic low back pain was worsened because she was not getting her tramadol at the facility. The record indicated a dose of Tramadol was given in the ED with the resident reporting feeling significant improvement of her symptoms and denied pain after receiving a dose of Tramadol in the ED. The record indicated the resident had chronic pain syndrome, was chronically on tramadol, and the ED provider had concern for withdrawals on admission with worsening pain from the resident not receiving Tramadol as ordered at the facility. An incident report of the resident’s Tramadol medication error resulting in omission of 4 doses of the resident’s Tramadol over 2 days and facility investigation of the incident was requested, none was provided. During email communication and interviews facility nursing leadership verified the facility had not communicated the resident needed a Tramadol refill to the resident’s provider prior to the resident running out of the medication, or when the providers were at the facility to see the resident on rounds. Nursing leadership verified the provider was not notified of the medication error omission after the resident ran out of Tramadol. Nursing leadership indicated staff reported the resident had increased pain, but the record lacked documentation this occurred and what action was taken for the resident. Nursing leadership indicated the resident was assessed and monitored by nursing staff with no signs of adverse effects or withdrawal symptoms after the omission of scheduled Tramadol occurred. However, the resident record had no documentation assessment or monitoring occurred. When interviewed one ULP staff stated the resident reported she didn’t feel good, could not eat, was assisted to go to bed early, expressed having severe back pain, felt very cold, and stated she “felt like she was going to die” because she had not received Tramadol. The ULP stated the resident’s family member felt the resident could not wait any longer for the Tramadol and brought the resident to the ED. When interviewed the resident’s family member stated the resident called and stated she had not been receiving her Tramadol and was in so much pain.
2024-03-07Complaint InvestigationNo findings
Plain-language summary
On February 22, 2024, Minnesota Department of Health investigated a complaint against Mother of Mercy Senior Living in Albany. No violations were found and no correction orders were issued.
Full inspector notes
PRINTED: 03/07/2024 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 30461 B. WING _____________________________ 02/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 230 CHURCH AVENUE MOTHER OF MERCY SENIOR LIVING ALBANY, MN 56307 (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) 0 000 Initial Comments 0 000 On February 22, 2024, the Minnesota Department of Health initiated an investigation of complaints #HL304618547C . No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 UPVR11 If continuation sheet 1 of 1
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