Suite Living Senior Care of Cr.

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 necessar yto ensure the health, safety, and welfare of residents in your care. STATE CORRECTIO ONRDERS 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 Statemen tof Deficiencies "column. This column also includes the findings that are in violation of the state statute after the statement, "This MN Requiremen tis not met as evidenced by . . ." IMPOSITION OF FINES In accordance with Minn. Stat. § 144G3. 1, Subd .4, fines and enforcement actions may be imposed based on the level and scope of the violations and may be imposed immediately with no opportunity to correct the violation first as follows: Leve l1: no fines or enforcement; Leve l2: a fine of $500 per violation, in addition to any enforcement mechanism authorized in § 144G2. 0; Leve l3: a fine of $1,000 per incident, in addition to any enforcement mechanism authorized in § 144G2. 0; An equal opportunity employer . Letter ID: IS7N REVISE 0D9/13/2021 Suite Living Senio rCare of Crysta lLLC Novembe r12, 2025 Page 2 Leve l4: a fine of $3,000 per incident, in addition to any enforcement mechanism authorized in § 144G2. 0; Leve l5: a fine of $5,000 per violation, in addition to any enforcement mechanism authorized in § 144G2. 0. Therefore ,in accordance with Minn. Stat. §§ 144G0. 1 to 144G9. 999, the following fines are assessed pursuant to this survey: St - 0 - 0510 - 144g.41 Subd. 3 - Infection Control Program $500.00 Therefore ,in accordance with Minn. Stat. §§ 144G0. 1 to 144G9. 999, the total amount you are assesse dis $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. § 144G3. 0, Subd .5(c), the licensee must docum ent actions taken to comply with the correction orders within the time period outlined on the state form; however, plans of correction are not required to be submitted for approval. The correction order documentation should include the following: x Identify how the area(s) of noncompliance was corrected related to the resident(s)/ employees( ) identified in the correction order. x Identify how the area(s) of noncompliance was corrected for all of the provider’s resident(s)/ employees that may be affected by the noncompliance. x Identify what changes to your systems and practices were made to ensure compliance with the specific statute(s). CORRECTIO ONRDER RECONSIDERATI OPRNOCESS In accordance with Minn. Stat. § 144G3. 2, Subd .2, you may challenge the correction order(s) issued, including the level and scope ,and any fine assesse dthrough the correction order reconsideration process .The request for reconsideration must be in writing and received by MDH within 15 calendar days of the correction order receipt date. To submit a reconsideration request, please visit: https:/ / forms.web.health.state.mn.us/form/ HRDAppealsForm REQUESTIN AG HEARING Alternatively ,in accordance with Minn. Stat. § 144G3. 1, Subd .5(d), an assisted living provider that has been assesse da fine under this subdivision has a right to a reconsideration or a hearing under this section and chapter 14. Pursuan tto Minn. Stat. § 144G2. 0, Subd .14 and Subd .18, a request for a hearing must be in writing and received by the Department of Health within 15 business days of the correction order receipt date. The request must contain a brief and plain statement describing each Suite Living Senio rCare of Crysta lLLC Novembe r12, 2025 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 lfines via reconside ration, please follow the pr ocedur e outlined above. Plea se note that you may request a reconsideration or a hearing, but not both. If you wish to contest tags without fines in a reconsideration and tags with the fines at a hearing, please submit two separate appeals forms at the website listed above. The MDH Health Regulation Division (HRD )values your feedback about your experience during the survey and/or investigation process .Please fill out this anonymous provider feedback questionnaire at your convenience at this link: https:/ / forms.office.com/g/ Bm5uQEpHV.a Your input is important to us and will enable MDH to improve its processe sand communication with providers . If you have any questions regarding the questionnaire ,please contact Susan Winkelmann at susanw. inkelmann@state.mn.us or call 651-201-5952. You are encouraged to retain this document for your records . It is your responsibility to share the information contained in the letter and state form with your organizations’ Governing Body. If you have any questions ,please contact me. Sincerely, Jess Schoenecke rS, upervisor State Evaluation Team Email: JessS. choenecker@state.mn.us Telephone :651-201-3789 Fax :1-866-890-9290 KKM PRINTED: 11/12/2025 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 _____________________________ 38860 10/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3501 DOUGLAS DRIVE SUITE LIVING SENIOR CARE OF CRYSTAL LLC MINNEAPOLIS, MN 55442 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE PREFIX PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 000 Initial Comments 0 000 ******ATTENTION****** Minnesota Department of Health is documenting the State Licensing ASSISTED LIVING PROVIDER LICENSING Correction Orders using federal software. CORRECTION ORDER Tag numbers have been assigned to Minnesota State Statutes for Assisted In accordance with Minnesota Statutes, section Living with Dementia Care facilities. The 144G.08 to 144G.95, these correction orders are assigned tag number appears in the issued pursuant to a survey. far-left column entitled "ID Prefix Tag." The state Statute number and the Determination of whether violations are corrected corresponding text of the state Statute out requires compliance with all requirements of compliance is listed in the "Summary provided at the Statute number indicated below. Statement of Deficiencies" column. This When Minnesota Statute contains several items, column also includes the findings which failure to comply with any of the items will be are in violation of the state requirement considered lack of compliance. after the statement, "This Minnesota requirement is not met as evidenced by." INITIAL COMMENTS: Following the evaluators' findings is the SL#38860016 Time Period for Correction. On October 20, 2025, through October 23, 2025, PLEASE DISREGARD THE HEADING the Minnesota Department of Health conducted a OF THE FOURTH COLUMN WHICH survey at the above provider, and the following STATES,"PROVIDER'S PLAN OF correction orders are issued. At the time of the CORRECTION." THIS APPLIES TO survey, there were 30 residents; 30 receiving FEDERAL DEFICIENCIES ONLY. THIS services under the Assisted Living Facility with WILL APPEAR ON EACH PAGE. Dementia Care license. 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. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 T3JU11 If continuation sheet 1 of 8 PRINTED: 11/12/2025 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 _____________________________ 38860 10/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3501 DOUGLAS DRIVE SUITE LIVING SENIOR CARE OF CRYSTAL LLC MINNEAPOLIS, MN 55442 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) 0 480 Continued From page 1 0 480 0 480 144G.41 Subdivision 1 Subd.

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 after the resident fell and staff failed to assess or report the fall. Family later took the resident to the hospital where she was diagnosed with a hip fracture. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. The resident had an unwitnessed fall. After the fall, staff assessed the resident and documented the residents fall per protocol. After the resident had complaints of increasing pain, the resident went to the hospital for further evaluation and was diagnosed with a non-operable pelvic fracture. The resident returned to the facility three days later. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted the resident’s family. The investigation included review of the resident records, hospital records, the facility internal investigation, facility incident reports, personnel files, staff schedules, and related facility policy and procedures. Also, the investigator observed staff interactions with residents. The resident resided in an assisted living facility. The resident’s diagnoses included stroke and pelvic fracture. The resident’s services included assistance with activities of daily living (ADLs), meals, medication management, laundry, and housekeeping. The resident’s assessment indicated the resident had visual difficulties and used a power chair for her primary means of mobility. An incident report indicated a staff member working a weekend morning shift found the resident on the floor of her room. The resident said she was trying to get something from a drawer, turned, and lost her balance. The resident did not use her call light for staff assistance. Staff took the resident’s vital signs and notified the nurse on call. The resident complained of hip pain and staff gave her pain medication. There were no apparent injuries. Staff leadership and the resident’s family member were notified. The resident’s progress notes indicated the resident continued to receive Tylenol for hip pain, and the resident stated it was effective in managing her pain. However, after three days the resident complained of increasing hip pain and staff requested an on-site x-ray from her provider. The resident’s provider stated they wanted to see the resident in person and informed the residents family. Two days later a bruise on the resident’s right buttock formed and the family member took her to urgent care for an x-ray. The resident was diagnosed with a right fracture of the pelvis and sacrum. A physical therapy (PT) evaluation indicated the resident was weightbearing as tolerated. The resident was discharged from the hospital after three days and did not complain of pain when sitting. Her care was increased to assist of two for transfers and assist of one for ADLs. The resident and staff were educated about her new care plan. The resident’s hospital record indicated the resident was diagnosed with right-sided superior and inferior pubic rami fractures and a sacral fracture. The orthopedic team was consulted and recommended nonoperative management with weightbearing as tolerated on her right leg. No further orthopedic interventions were planned. The resident’s pain was well-controlled, although it did increase with movement. After three days, the resident returned to the facility. The resident’s care plan indicated after she returned from the hospital, reassurance checks were initiated once per shift. The resident’s care sheets indicated the reassurance checks were completed by staff as directed. When interviewed, an unlicensed staff member said she was curious when she did not see the resident out in the community bright and early in the morning as usual. She checked on the resident in her room and found her on the floor. The resident was not wearing her pendant, so she had been unable to call for help. The staff member assessed the resident, took her vital signs, and asked if she was in pain. At that time, the resident did not complain of pain, nor did she feel she needed further medical intervention. The staff member notified the on-call nurse and stated the resident did not start to complain of pain until after the weekend, when staff noticed a bruise had begun to develop around her right hip. When interviewed, facility leadership stated staff on site followed appropriate protocol after the resident fell, and the resident did not start to complain of much pain until several days later. As the resident complained of increasing pain, and a bruise began to develop around her right hip, nursing attempted to schedule an in-house x-ray for the resident, but the resident’s provider wanted the resident seen in person. The resident’s family member then took the resident to urgent care to obtain an x-ray of her right hip. At that point, the resident was admitted to the hospital with non-operable pelvic fracture. The resident returned from the hospital after a few days and the facility increased her services considering her new diagnosis. 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, attempted. Family/Responsible Party interviewed: Yes, family provided a brief informal statement. Alleged Perpetrator interviewed: Not Applicable the Action taken by facility: The facility assessed the resident after the fall, notified her family, and managed her pain. The facility reported increased pain and bruising to the family, initiating the resident’s visit to urgent care. The resident’s care plan was updated after her hospital stay and staff were trained regarding the resident’s increased needs. 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: 11/26/2024 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 _____________________________ 38860 10/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3501 DOUGLAS DRIVE SUITE LIVING SENIOR CARE OF CRYSTAL LLC MINNEAPOLIS, MN 55442 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 CORRECTION using federal software. Tag numbers have ORDER 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 complaint investigation. state Statute number and the corresponding text of the state Statute out Determination of whether a violation is 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 a Minnesota Statute contains several are in violation of the state requirement items, failure to comply with any of the items will after the statement, "This Minnesota be considered lack of compliance. requirement is not met as evidenced by." Following the evaluators' findings is the INITIAL COMMENTS: Time Period for Correction. #HL388604783C/#HL388604122M PLEASE DISREGARD THE HEADING OF #HL388604237C/#HL388603783M THE FOURTH COLUMN WHICH STATES,"PROVIDER'S PLAN OF On October 4, 2024, the Minnesota Department CORRECTION." THIS APPLIES TO of Health conducted a complaint investigation at FEDERAL DEFICIENCIES ONLY. THIS the above provider, and the following correction WILL APPEAR ON EACH PAGE. orders are issued.

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. The Department of Health documents state correction orders using federal software. Tag numbers are assigned to Minnesota state statutes for Home Care Providers. 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 and enforcement actions based on the level and scope of the violations; however, no immediate fines are assessed for this survey of your facility. DOCUMENTATION OF ACTION TO COMPLY Per Minn. Stat. § 144G.30, Subd. 5(c), t he licensee must document actions taken to comply with the correction orders within the time period outlined on the state form; however, plans of correction are not required to be submitted for approval. The correction order documentation should include the following: Identify how the area(s) of noncompliance was corrected related to the resident(s)/employee(s) identified in the correction order. An equal opportunity employer. Letter ID: 9GJX Revise d04/20/2023 Suite Living Senior Care of Crystal LLC September 28, 2023 Page 2 Identify how the area(s) of noncompliance was corrected for all of the provider’s residents/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 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 Department of Health 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 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: H ealth.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 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. If you have any questions, please contact me. Sincerely, Jessica Sellner, Supervisor State Rapid Response Team Email: jessica.sellner@state.mn.us Telephone: 320-223-7370 Fax: 1-800-337-9238 HHH PRINTED: 09/28/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 38860 09/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3501 DOUGLAS DRIVE SUITE LIVING SENIOR CARE OF CRYSTAL LLC MINNEAPOLIS, MN 55442 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 LICENSING CORRECTION ORDER In accordance with Minnesota Statutes, section 144G.08 to 144G.95, these correction orders are issued pursuant to a survey. Determination of whether violations are corrected requires compliance with all requirements provided at the Statute number indicated below. When Minnesota Statute contains several items, failure to comply with any of the items will be considered lack of compliance. INITIAL COMMENTS: SL#38860015 On August 28, 2023-September 6, 2023, the survey at the above provider, and the following correction order is issued. At the time of the survey and investigation, there were 26 residents receiving services under the provider's Provisional Assisted Living Facility license. 0 680 144G.42 Subd. 10 Disaster planning and 0 680 SS=F emergency preparedness (a) The facility must meet the following requirements: (1) have a written emergency disaster plan that contains a plan for evacuation, addresses elements of sheltering in place, identifies temporary relocation sites, and details staff assignments in the event of a disaster or an emergency; LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 GXB611 If continuation sheet 1 of 4 PRINTED: 09/28/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 38860 09/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3501 DOUGLAS DRIVE SUITE LIVING SENIOR CARE OF CRYSTAL LLC MINNEAPOLIS, MN 55442 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) 0 680 Continued From page 1 0 680 (2) post an emergency disaster plan prominently; (3) provide building emergency exit diagrams to all residents; (4) post emergency exit diagrams on each floor; and (5) have a written policy and procedure regarding missing residents. (b) The facility must provide emergency and disaster training to all staff during the initial staff orientation and annually thereafter and must make emergency and disaster training annually available to all residents. Staff who have not received emergency and disaster training are allowed to work only when trained staff are also working on site. (c) The facility must meet any additional requirements adopted in rule. This MN Requirement is not met as evidenced by: Based on the interview and record review, the licensee failed to provide the minimum frequency of load test and inspection requirements for the permanent emergency power generator as part of the emergency plan to ensure the proper performance of the generator. This had the potential to affect all residents, staff, and visitors of the licensee. 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 was issued at a widespread scope (when problems are pervasive or represent a systemic failure that has affected or has potential to affect a large portion or all of the residents). The findings include: STATE FORM 6899 GXB611 If continuation sheet 2 of 4 PRINTED: 09/28/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 38860 09/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3501 DOUGLAS DRIVE SUITE LIVING SENIOR CARE OF CRYSTAL LLC MINNEAPOLIS, MN 55442 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) 0 680 Continued From page 2 0 680 On September 1, 2023, at approximately 4:15 p.m., survey staff requested records relating to the emergency generator load tests, inspections, and maintenance for review from the regional director of operations (RDO)-D for compliance with the requirements for the emergency power generator as outlined under NFPA 110, (referenced under the Code of Federal Regulations, title 42, section 483.73) as part of the facility's shelter-in-place emergency plan required under Minnesota Rules, Part 4659.0100, to ensure proper performance of the generator. At approximately 4:30 p.m., record review and interview with the RDO-D indicated that only one test log record for 8/24/2023, was available after the RDO-D attempted to locate the electronic records.