River Oaks Columbia Heights.

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 . . ." IMPOSITION OF FINES In accordance with Minn. Stat. § 144G.31, 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: Level 1: no fines or enforcement; Level 2: a fine of $500 per violation, in addition to any enforcement mechanism authorized in § 144G.20; Level 3: a fine of $1,000 per incident, in addition to any enforcement mechanism authorized in § 144G.20; Level 4: a fine of $3,000 per incident, in addition to any enforcement mechanism authorized in § 144G.20; Level 5: a fine of $5,000 per violation, in addition to any enforcement mechanism authorized in § 144G.20. Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, the following fines are assessed An equal opportunity employer. Letter ID: IS7N REVISE D09/13/2021 River Oaks Columbia Heights February 6, 2026 Page 2 pursuant to this survey: St - 0 - 0775 - 144g.45 Subd. 2. (a) - Fire Protection And Physical Environment - $500.00 St - 0 - 1290 - 144g.60 Subdivision 1 - Background Studies Required - $1,000.00 The refor e, in accor danc e wit h Minn. Sta t. §§ 144G.01 to 144G.999 9, the total amount you are assessed is $. You will be invoiced approximately 30 days after receipt of this notice, subject to appeal . 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: 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 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 appe al fi nes via re cons iderat ion , pl ease follow the procedu r e outl ined abo ve. Plea se no te tha t you River Oaks Columbia Heights February 6, 2026 Page 3 may re que st a rec onside rati on or a hearing, bu t not bot h. If you wish to cont est ta gs with out fine s 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 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, Kelly Thorson, Supervisor State Evaluation Team Email: KellyT. horson@state. mn.us Telephone: 320-223-7336 Fax: 1-866-890-9290 CLN PRINTED: 02/ 06/ 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 _____________________________ 21871 01/ 07/ 2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 900 42ND AVENUE NE RIVER OAKS COLUMBIA HEIGHTS COLUMBIA HEIGHTS, MN 55421 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. SL21871016- 0 PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On January 5, 2026, through January 7, 2026, the STATES, "PROVIDER' S PLAN OF survey at the above provider and the following FEDERAL DEFICIENCIES ONLY. THIS correction orders are issued. At the time of the WILL APPEAR ON EACH PAGE. survey, there were 62 residents; 62 receiving services under the Assisted Living Facility with THERE IS NO REQUIREMENT TO Dementia Care license. SUBMIT A PLAN OF CORRECTION FOR VIOLATIONS OF MINNESOTA STATE An immediate correction order was identified on STATUTES. January 6, 2026 issued for SL21871016, tag identification 1290. THE LETTER IN THE LEFT COLUMN IS USED FOR TRACKING PURPOSES AND During the survey, the licensee took action to REFLECTS THE SCOPE AND LEVEL mitigate the immediate risk. However, ISSUED PURSUANT TO 144G. 31 noncompliance remained, and the scope and SUBDIVISION 1-3. level remain unchanged. 0 480 144G. 41 Subdivision 1 Subd. 1a (a-b) Minimum 0 480 SS= F requirements; required food services LABORATORY DIRECTOR' S OR PROVIDER/ SUPPLIER REPRESENTATIVE' S SIGNATURE TITLE (X6) DATE STATE FORM 6899 WQYJ11 If continuation sheet 1 of 37 PRINTED: 02/ 06/ 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: 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 the facility failed to address a change in condition. The resident had significant weight gain resulting in decreased mobility, heart health, and breathing concerns. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. The resident had gained weight continuously over six months after admitting to the facility. The facility notified the resident’s primary care provider and psychiatrist. The primary care provider ordered blood tests, made referrals to outside specialists, and notified psychiatry for medication adjustments. The investigator conducted interviews with facility staff members, including administrative staff and nursing staff. The investigator contacted the resident’s primary care provider. The investigation included review of the resident records, staff schedules, and related facility policy and procedures. Also, the investigator toured the facility and observed interactions between facility staff and residents. The resident resided in an assisted living facility. The resident’s diagnoses included attention-deficit hyperactivity disorders, depression, post-traumatic stress disorder, conversion disorder, borderline personality disorder, and anxiety. The resident’s service plan included assistance with management of repetitive behaviors, medication administration, and monthly weights. The resident’s assessment indicated the resident was alert, oriented and was independent with activities of daily living. The resident’s medical record indicated the resident gained 72 pounds in a four-month span. The primary care provider ordered tests and no known cause for the weight gain could be determined. The resident’s medical record indicated the resident’s Abilify (antipsychotic) medication was discontinued due to being a possible contributing factor for the resident’s weight gain. During an interview, leadership stated the resident’s primary care provider was notified of the resident’s weight gain approximately 14 days after the resident admitted to the facility. The primary care provider ordered blood tests in an attempt to find out why the resident gained weight, and the resident was started on Lasix (loop diuretic) for swelling in her legs. The resident’s Abilify medication was discontinued because providers thought the medication may have been a factor in the resident’s weight gain. In house providers continue to monitor the resident’s weight gain. During an interview, a primary care provider stated the resident’s weight gain was a concern. Several blood tests and referrals to several specialists were made. Test results indicated it was actual weight gain and was not fluid retention related issues. The primary care provider stated weight gain is a side effect of antipsychotic medications, and the psychiatrist was notified. The psychiatrist made adjustments to the resident’s antipsychotic medications. During an interview, the resident stated it is unknown why she gained weight. 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. Action taken by facility: The facility notified the resident’s primary care provider of the resident’s weight gain. 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: 10/21/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ C B. WING _____________________________ 21871 10/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 900 42ND AVENUE NE RIVER OAKS COLUMBIA HEIGHTS COLUMBIA HEIGHTS, MN 55421 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 On October 2, 2025, the Minnesota Department of Health initiated an investigation of complaint HL218715182M/HL218711800C. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 PJ5W11 If continuation sheet 1 of 1

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 they failed to provide the resident supervision when the resident eloped from the facility by breaking and climbing out a window in the resident’s room. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. Facility staff could not anticipate the resident breaking and climbing out the window in her room. Staff immediately responded to the resident and with the assistance of law enforcement stayed with the resident until emergency medical services arrived. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted the resident’s case worker. The investigation included review of the resident records, hospital records, facility internal investigation, facility incident reports, and the law enforcement report. Also, the investigator observed the locked memory care unit and locked fenced courtyard area. The resident resided in an assisted living memory care unit. The resident’s diagnoses included dementia and anxiety disorder. The resident’s service plan included assistance with medication management services. The resident’s assessment indicated the resident was oriented to person, place, required redirection and reminders often, and walked independently without assisted devices. The facility’s investigation indicated earlier in the day, the resident was agitated and tried to “escape” out of a patio area. Facility staff provided the resident as needed medication for agitation and brought the resident to her room to calm. Approximately one hour later, the resident broke the window in her room and climbed out. Staff immediately called 911, followed the resident, and controlled traffic as the resident crossed a busy street. Staff stayed with the resident until law enforcement arrived. The law enforcement report indicated law enforcement arrived at a gas station shortly after the facility called and found the resident surrounded by facility staff members. The resident had a laceration (cut) on her right wrist and small cuts on her left arm and wrist. The resident denied living at the facility and said she did know why facility staff were following her. The resident was transported to a hospital for an evaluation. In the resident’s room, it appeared the resident used a stand to a lamp and broke her ground level window. The resident’s hospital record indicated the resident arrived at the hospital agitated and confused. The resident was evaluated by physiatry and admitted to a locked unit and placed on a 72-hour hold. The resident had superficial scratches to her right hand and left arm. The resident had a laceration on her right forearm that was closed with stiches. Seven days later, the resident discharged to another inpatient unit at a different hospital. During an interview, unlicensed personnel (ULP) stated the day of the incident, the staff member who was working in memory care came out yelling, “help, help, I need help.” The resident had just broken the window in her room, climbed out, and was running across the street. The ULP stated staff contacted 911 for assistance. The ULP and kitchen staff ran outside and controlled traffic as the resident crossed a busy street. The ULP stated at a gas station, staff stayed with the resident until law enforcement arrived. During investigative interviews, multiple nurses stated staff were trained and provided interventions for the resident’s known agitation and exit seeking behaviors. The resident had no previous incidents of breaking a window to leave. Staff interventions for agitation included redirection and distraction. At times, staff were directed to bring the resident to her room to calm. One nurse stated the resident’s as needed medication for agitation increased during her stay. During an interview, leadership stated earlier in the shift the resident was agitated and wanted to leave. Staff distracted her, shut memory care window blinds, and had the resident sit in her room attempting to calm her. While in her room, the resident broke the window and climbed out. Leadership stated the memory care staff heard the noise of the window breaking and called another staff member not in memory care for help. Facility staff members rushed outside to assist the resident. The resident had a history of agitation however, the resident had no previous attempts of breaking a window to leave the facility. Leadership stated staff interventions for the resident’s agitation included distraction and at times various facility staff members provided one-on-one to calm her. These interventions had previously been effective. Leadership stated throughout the resident’s stay at the facility, they also increased doses of the resident’s as needed medication for agitation. The resident did not return to the facility after the incident. 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. Unable to reach and due to cognition. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Not Applicable. Action taken by facility: The facility staff provided medication and interventions for the resident’s agitation. While the resident crossed the street, staff controlled the traffic, called 911, and stayed with the resident until law enforcement arrived. 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: 03/22/2024 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 _____________________________ 21871 02/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 900 42ND AVENUE NE CREST VIEW ON 42ND COLUMBIA HEIGHTS, MN 55421 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 7, 2024, the Minnesota Department of Health initiated an investigation of complaint #HL218714531C/#HL218717708M, #HL218716422C/HL218718825M, #HL218716844C/HL218719165M. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 PKY411 If continuation sheet 1 of 1

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. Furthermore, the follow-up survey determined your facility had not corrected all of the state correction orders issued pursuant to the June 30, 2023, initial survey. In accordance with Minn. Stat. § 144G.31, Subd. 4 (a), state correction orders issued pursuant to the last survey completed on October 25, 2023, found not corrected at the time of the follow-up survey follow-up survey and subject to a penalty assessment are as follows: 0630-Compliance With Requirements For Reporting Ma-144g.42 Subd. 6 (b) 0660-Tuberculosis Prevention And Control-144g.42 Subd. 9 1760-Documentation Of Administration Of Medication-144g.71 Subd. 8 - $500.00 1890-Prescription Drugs-144g.71 Subd. 20 1940-Individualized Treatment Or Therapy Managemen-144g.72 Subd. 3 - $500.00 1950-Administration Of Treatments And Therapy-144g.72 Subd. 4 - $500.00 The details of the violations noted at the time of this follow-up survey completed on October 25, 2023, (listed 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. An equal opportunity employer. Letter ID: 292I_Revised 04/14/2023 Crest View on 42nd November 13, 2023 Page 2 Also, at the time of this follow-up survey completed on October 25, 2023, we identified the following violation(s): 1440-Supervision Of Staff Providing Delegated Nurs-144g.62 Subd. 4 1880-Storage Of Medications-144g.71 Subd. 19 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. Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, t he total amount you are assessed is $1,500.00. You will be invoiced approximately 30 days after receipt of this notice, subject to appeal DOCUMENTATION OF ACTION TO COMPLY Per Minn. Stat. § 144G.30, Subd. 5(c), the licensee must document actions taken to comply with the correction orders within the time period outlined on the state form; however, plans of correction are not required to be submitted for approval. The correction order documentation should include the following: Identify how the area(s) of noncompliance was corrected related to the 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). IMPOSITION OF FINES: Level 1: no fines or enforcement. Level 2: a fine of $500 per violation, in addition to any enforcement mechanism authorized in § 144G.20 for widespread violations; Level 3: a fine of $3,000 per violation per incident, in addition to any enforcement mechanism authorized in § 144G.20. Level 4: a fine of $5,000 per incident, in addition to any enforcement mechanism authorized in § 144G.20. 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 the MDH within 15 calendar days of the correction order receipt date. A state correction order under Minn. Stat. § 144G.91, Subd. 8, Free from Maltreatment is associated Crest View on 42nd November 13, 2023 Page 3 with a maltreatment determination by the Office of Health Facility Complaints. If maltreatment is substantiated, you will receive a separate letter with the reconsideration process under Minn. Stat. § 626.557. Please email reconsideration requests to: Health.HRD.Appeals@state.mn.us. Please attach this letter as part of your reconsideration request. Please clearly indicate which tag(s) you are contesting and submit information supporting your position(s). Please address your cover letter for reconsideration requests to: Reconsideration Unit 85 East Seventh Place St. Paul, MN 55164-0970 REQUESTING A 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 MDH 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. Requests for hearing may be emailed to: Health.HRD.Appeals@state.mn.us. To appeal fines via reconsideration, please follow the procedure outlined above. P lease note that you may request a reconsideration o r a hearing, but not both. You are encouraged to retain this document for your records. It is your responsibility to share the information contained in the letter and/or state form with your organization’s Governing Body. Sincerely, Maria King, RN Division Director HHH PRINTED: 11/13/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ R B. WING _____________________________ 21871 10/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 900 42ND AVENUE NE CREST VIEW ON 42ND COLUMBIA HEIGHTS, MN 55421 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 License In accordance with Minnesota Statutes, section Providers. The assigned tag number 144G.08 to 144G.95, these correction orders are appears in the far-left column entitled "ID issued pursuant to a survey. Prefix Tag." The state Statute number and the corresponding text of the state Statute Determination of whether violations are corrected out of compliance is listed in the requires compliance with all requirements "Summary Statement of Deficiencies" provided at the Statute number indicated below. column. This column also includes the When Minnesota Statute contains several items, findings which are in violation of the state failure to comply with any of the items will be requirement after the statement, "This considered lack of compliance. Minnesota requirement is not met as evidenced by." Following the surveyors' INITIAL COMMENTS: findings is the Time Period for Correction. SL21871015-1 PLEASE DISREGARD THE HEADING OF On October 23, 2023, through October 25, 2023, THE FOURTH COLUMN WHICH the Minnesota Department of Health conducted a STATES,"PROVIDER'S PLAN OF licensing order follow-up related to correction CORRECTION." THIS APPLIES TO orders issued for SL21871015-0, and the FEDERAL DEFICIENCIES ONLY. THIS following correction orders are issued/re-issued. WILL APPEAR ON EACH PAGE. At the time of the survey, there were 52 active residents; all of whom were receiving services THERE IS NO REQUIREMENT TO under the Assisted Living with Dementia Care SUBMIT A PLAN OF CORRECTION FOR license. 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 subd. 1, 2, and 3. {0 480} 144G.41 Subd 1 (13) (i) (B) Minimum {0 480} SS=F requirements (13) offer to provide or make available at least the LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 85K812 If continuation sheet 1 of 24 PRINTED: 11/13/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ R B.