New Perspective Golden Valley.

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 alleged perpetrator (AP) abused the resident when the AP tied the resident’s wheelchair to another dining chair restraining the resident from moving about the unit. Investigative Findings and Conclusion: The Minnesota Department of Health determined abuse was not substantiated. Although the incident occurred, the incident did not meet the definition of abuse. No physical restraint was utilized on the resident, there was no evidence of harm to the resident and the resident was not aware the incident occurred. The investigator conducted interviews with facility staff members, including administrative staff, and nursing staff. The investigator also contacted the hospice agency. The investigation included review of the resident record, death record, staff records, facility policy and procedures. The investigator also toured the facility, observed staff members interacting with residents and completing scheduled care activities. The resident resided in an assisted living memory care unit. The resident’s diagnoses included dementia, and anxiety. The resident’s service plan included assistance with medication management, activities of daily living and ambulation. The resident’s assessment indicated the resident was independent in repositioning while in a chair, although had a history of falls. Staff were directed to provide standby assistance while the resident was out of her apartment. During a scheduled visit to the facility, an outside agency staff member observed the resident asleep, seated in the main living area in her Broda chair (a type of wheelchair). The resident was seated in a reclined position as a dining room chair was positioned in front of the resident’s Broda chair to elevate her legs and feet. Upon closer inspection, the agency staff member noticed the dining room chair was tied to the resident’s chair, preventing them from moving apart. The outside agency staff member was concerned that the chairs were being used as a restraint and asked a facility staff member to assist with untying the dining room chair and reported the findings to the nurse. The facility nurse assessed the resident and found no evidence of injury. The resident was asleep at the time the agency staff member arrived and was not aware of the incident. The facility completed an investigation into the incident. The staff member/alleged perpetrator (AP) who worked the night shift stated the resident had been restless that night and acknowledged she tied the chairs together to try to keep the resident from falling. There were no witnesses to the incident, and no photos were taken of the way the chairs were positioned or tied. The resident was assessed and had no evidence of harm or recollection of the incident. The AP was terminated following the investigation and all staff were reeducated. During an interview, the AP stated she was familiar with the resident’s baseline behaviors. The AP stated the resident was restless and had come out into the common area. The AP stated that around 5:00 a.m. she positioned a dining room chair in front of the resident who was seated in her wheelchair. The AP positioned the resident’s legs out in front of her, so her feet were resting on the padded seat of the dining hall chair. She then took plastic garbage bags from the kitchen and used them to bind the two chairs together. The AP then gave the resident a snack and the resident fell asleep. The AP could not recall how long the resident was in this position prior to falling asleep. The AP stated she tied the chairs together for safety and better monitoring of the resident’s behavior and was not aware that this was a restraint. During an interview, the outside agency staff member stated that upon entering the facility at approximately 7:00 a.m. she observed the resident asleep in her Broda chair in the common area of the memory care unit. The resident’s legs were extended out in front of her and resting on a dinning room chair that was tied with plastic garbage bags to the front of the Broda chair. The caregiver untied the restraints and wheeled the resident into her room to complete her assigned cares. She stated that the resident showed no signs of distress. After she finished with her assigned cares, she reported the incident to the facility nurse. She stated that multiple staff and administrators questioned her over the incident. During an interview, the nurse stated that the resident’s behavior of independently getting out of her wheelchair and lowering herself onto the floor was well known by the resident’s care team as well as the facility staff and documented in the resident’s plan of care. During a recent care conference, the family, as well as the resident’s primary care provider had agreed to alternate safety measures including monitoring, redirection techniques, and allowing the resident to continue to get out of her chair independently if done safely. The nurse stated that she was first made aware of the incident when the hospice caregiver came to her office later that morning. The nurse then notified the facility administrators, and an internal investigation was completed. During an interview, an administrator stated that during a follow up phone conversation with the AP, she admitted to securing the chairs together to keep the resident from crawling out of the chair and onto the floor. Upon review of the incident, multiple staff members including the AP were suspended and their employment was terminated for failing to follow facility policies during that shift. 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. Abuse: Minnesota Statutes section 626.5572, subdivision 2. "Abuse" means: (a) An act against a vulnerable adult that constitutes a violation of, an attempt to violate, or aiding and abetting a violation of: (1) assault in the first through fifth degrees as defined in sections 609.221 to 609.224; (2) the use of drugs to injure or facilitate crime as defined in section 609.235; (3) the solicitation, inducement, and promotion of prostitution as defined in section 609.322; and (4) criminal sexual conduct in the first through fifth degrees as defined in sections 609.342 to 609.3451. A violation includes any action that meets the elements of the crime, regardless of whether there is a criminal proceeding or conviction. (b) Conduct which is not an accident or therapeutic conduct as defined in this section, which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to, the following: (1) hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult; (2) use of repeated or malicious oral, written, or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening; or (3) use of any aversive or deprivation procedure, unreasonable confinement, or involuntary seclusion, including the forced separation of the vulnerable adult from other persons against the will of the vulnerable adult or the legal representative of the vulnerable adult unless authorized under applicable licensing requirements or Minnesota Rules, chapter 9544. (c) Any sexual contact or penetration as defined in section 609.341, between a facility staff person or a person providing services in the facility and a resident, patient, or client of that facility. (d) The act of forcing, compelling, coercing, or enticing a vulnerable adult against the vulnerable adult's will to perform services for the advantage of another. Vulnerable Adult interviewed: No. Deceased Family/Responsible Party interviewed: N/A Alleged Perpetrator interviewed: Yes the Action taken by facility: The AP and other staff members were suspended and terminated. The facility provided refresher training to all staff regarding resident rights. Action taken by the Minnesota Department of Health: No further action taken at this time. cc: The Office of Ombudsman for Long Term Care The Office of Ombudsman for Mental Health and Developmental Disabilities PRINTED: 04/ 22/ 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: ______________________ C B.

correction orders issued pursuant to the June 25, 2025 survey. In accordance with Minn. Stat. § 144G3. 1 Subd .4 (a), state correction orders issued pursuant to the last survey ,completed on June 25, 2025, found not corrected at the time of the Septembe r18, 2025, follow-up survey and/or subject to penalty assessmen at re as follows: 1290-Background Studies Required-144g.60 Subdivision 1 - $1,000.00 The details of the violations noted at the time of this follow-up survey completed on Septembe r18, 2025 (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. Therefore ,in accordance with Minn. Stat. §§ 144G0. 1 to 144G9. 999, the total amount you are assesse dis $1,000.00. You will be invoiced approximately 30 days after receipt of this notice, subject to appeal. DOCUMENTATIO ONF ACTION TO COMPLY In acc ordanc e with Minn. Stat. § 144 G.30 , Subd .5(c), the licensee must do cume nt ac tio ns ta ken to comply with the correction orders outlined on the state form; however, plans of correction are not required to be submitted for approval. 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 § 144G.20; Leve l3: a fine of $1,000 per incident, in addition to any enforcement mechanism authorized in § 144G2. 0; Leve l4: a fine of $3,000 per incident, in addition to any enforcement mechanism authorized in § 144G.20; Leve l5: a fine of $5,000 per violation, in addition to any enforcement mechanism authorized in An equal opportunity employer . Letter ID: 8GKP Revised 04/14/2023 Sunrise of Golden Valley October 24, 2025 Page 2 § 144G2. 0. CORRECTIO ONRDER RECONSIDERATI OPNROCESS 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 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 reconsideration ,please follow the procedure outlined above. Please 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. We urge you to review these orders carefully. If you have questions ,please contact Jess Schoenecke ar t 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 organizations’ Governing Body. Sincerely, Jess Schoenecke rS, upervisor State Evaluation Team Email: JessS. choenecker@state.mn.us Telephone :651-201-3789 Fax :1-866-890-9290 HHH PRINTED: 10/24/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ R B. WING _____________________________ 23982 09/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4950 OLSON MEMORIAL HIGHWAY SUNRISE OF GOLDEN VALLEY GOLDEN VALLEY, MN 55422 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 Correction Orders ASSISTED LIVING PROVIDER FOLLOW UP using federal software. Tag numbers have SURVEY WITH RE-ISSUE OF ORDERS been assigned to Minnesota State Statutes for Assisted Living Facilities. The INITIAL COMMENTS assigned tag number appears in the SL23982016-1 far-left column entitled "ID Prefix Tag." The state Statute number and the On September 15, 2025, through September 18, corresponding text of the state Statute out 2025, the Minnesota Department of Health of compliance is listed in the "Summary conducted a follow-up survey at the above Statement of Deficiencies" column. This provider to follow-up on orders issued pursuant column also includes the findings which to a survey completed on June 26, 2025. As a are in violation of the state requirement result of the follow-up survey, the following order after the statement, "This Minnesota was reissued. requirement is not met as evidenced by." Following the evaluators' findings is the Time Period for Correction. PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH STATES,"PROVIDER'S PLAN OF CORRECTION." THIS APPLIES TO FEDERAL DEFICIENCIES ONLY. THIS 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 LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 NMB812 If continuation sheet 1 of 24 PRINTED: 10/24/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ R B. WING _____________________________ 23982 09/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4950 OLSON MEMORIAL HIGHWAY SUNRISE OF GOLDEN VALLEY GOLDEN VALLEY, MN 55422 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) {0 470} Continued From page 1 {0 470} (11) develop and implement a staffing plan for 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: Not evaluated during this survey. {0 480} 144G.41 Subdivision 1 Subd. 1a (a-b) Minimum {0 480} SS=F requirements; required food services (a) Except as provided in paragraph (b), food must be prepared and served according to the STATE FORM 6899 NMB812 If continuation sheet 2 of 24 PRINTED: 10/24/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ R B.

PRINTED: 01/03/2024 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 23982 B. WING _____________________________ 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4950 OLSON MEMORIAL HIGHWAY SUNRISE OF GOLDEN VALLEY GOLDEN VALLEY, MN 55422 (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 November 30, 2023, the Minnesota Department of Health initiated an investigation of complaints #HL239827484M/HL239824054C. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 OJ6Q11 If continuation sheet 1 of 1

correction orders issued pursuant to the August 2, 2023 survey. In accordance with Minn. Stat. § 144G.31 Subd. 4 (a), state correction orders issued pursuant to the last survey, completed on August 2, 2023, found not corrected at the time of the October 18, 2023, follow-up survey and/ or subject to penalty assessment are as follows: 2310-Appropriate Care And Services-144g.91 Subd. 4 (a) - $3,000.00 The details of the violations noted at the time of this follow-up survey completed on October 18, 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. The re fore , in accorda nc e wi th Mi nn. Sta t. §§ 144G. 01 to 144 G .9999, the total amount you are assessed is $3,000.00. You will be invoiced approximately 30 days after receipt of this notice, subject to appeal . DOCUMENTATIO ONF ACTION TO COMPLY In accorda nc e wi th Mi nn. Sta t. § 144G.30, Subd. 5(c), the licens ee mus t doc ument acti ons ta ken 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. 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. An equal opportunity employer. Le tter ID: 8GKP Revised 04/14/2023 Sunrise Of Golden Valley November 3, 2023 Pa ge 2 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 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 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. Pl ea se ema il rec ons idera ti on reques ts to: Health. HRDA. ppeals@state. mn. us. Pl ea se atta c h thi s 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 HRD 3A, 3rd Floor 625 Robert Street North St. Paul, MN 55155 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 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 hea ri ng ma y be ema iled to: Health. HRDA. ppeals@state. mn. us. To appe al fi ne s vi a rec ons ider a ti on, pl ease fol low the proc edure outl ined above . Pl ease note tha t you ma y re ques t a rec ons idera ti on or a hea ri ng , but not both. We urge you to review these orders carefully. If you have questions, please contact Casey DeVries at Sunrise Of Golden Valley November 3, 2023 Pa ge 3 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, Casey DeVries, Supervisor State Evaluation Team Email: casey. devries@state. mn.us Telephone: 651-201-5917 Fax: 1-866-890-9290 PMB PRINTED: 11/03/ 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 _____________________________ 23982 10/ 18/ 2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4950 OLSON MEMORIAL HIGHWAY SUNRISE OF GOLDEN VALLEY GOLDEN VALLEY, MN 55422 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 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 this correction order( s) has appears in the far-left column entitled "ID been issued pursuant to a survey. Prefix Tag." The state Statute number and the corresponding text of the state Statute Determination of whether a violation has been out of compliance is listed in the corrected requires compliance with all "Summary Statement of Deficiencies" requirements provided at the Statute number column. This column also includes the indicated below. When Minnesota Statute findings which are in violation of the state contains several items, failure to comply with any requirement after the statement, "This of the items will be considered lack of Minnesota requirement is not met as compliance. evidenced by." Following the surveyors' findings is the Time Period for Correction. INITIAL COMMENTS: SL23982015- 1 PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On October 17, 2023, through October 18, 2023, STATES, "PROVIDER' S PLAN OF the Minnesota Department of Health conducted a CORRECTION. " THIS APPLIES TO revisit at the above provider to follow-up on FEDERAL DEFICIENCIES ONLY. THIS orders issued pursuant to a survey completed on WILL APPEAR ON EACH PAGE. August 2, 2023. At the time of the survey, there were 44 residents, all of whom received services THERE IS NO REQUIREMENT TO under the Assisted Living with Dementia Care SUBMIT A PLAN OF CORRECTION FOR license. As a result of the revisit, the following VIOLATIONS OF MINNESOTA STATE orders were reissued. 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. {0 250} 144G. 20 Subdivision 1 Conditions {0 250} SS= F (a) The commissioner may refuse to grant a provisional license, refuse to grant a license as a LABORATORY DIRECTOR' S OR PROVIDER/ SUPPLIER REPRESENTATIVE' S SIGNATURE TITLE (X6) DATE STATE FORM 6899 CCTY12 If continuation sheet 1 of 30 PRINTED: 11/03/ 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.