Oakwood Senior Living.

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 Statement of 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 A Janesville Senio rLiving LLC October 15, 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 - 0775 - 144g.45 Subd. 2. (a) - Fire Protection And Physica lEnvironment - $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), 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: x Identify how the area(s) of noncompliance was corrected related to the resident(s)/ employee(s) 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 A Janesville Senio rLiving LLC October 15, 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 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. 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, Jod iJohnson ,Supervisor State Evaluation Team Email: Jodi.Johnson@state.mn.us Telephone :507-344-2730 Fax :1-866-890-9290 HHH PRINTED: 10/ 15/ 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 _____________________________ 32938 09/ 11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 543 OAKWOOD DRIVE A JANESVILLE SENIOR LIVING LLC JANESVILLE, MN 56048 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 Facilities. The issued pursuant to a survey. assigned tag number appears in the far-left column entitled "ID Prefix Tag. " The Determination of whether violations are corrected state Statute number and the requires compliance with all requirements corresponding text of the state Statute out provided at the Statute number indicated below. of compliance is listed in the "Summary When Minnesota Statute contains several items, Statement of Deficiencies" column. This failure to comply with any of the items will be column also includes the findings which considered lack of compliance. are in violation of the state requirement after the statement, "This Minnesota INITIAL COMMENTS: requirement is not met as evidenced by." Following the evaluators ' findings is the SL32938016- 0 Time Period for Correction. On September 8, 2025, through September 11, PLEASE DISREGARD THE HEADING OF 2025, the Minnesota Department of Health THE FOURTH COLUMN WHICH conducted a change of ownership (CHOW) STATES, "PROVIDER' S PLAN OF survey at the above provider. At the time of the CORRECTION. " THIS APPLIES TO survey, there were 21 residents; 21 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. 0 420 144G. 40 Subdivision 1 Responsibility for housing 0 420 SS= F and services LABORATORY DIRECTOR' S OR PROVIDER/ SUPPLIER REPRESENTATIVE' S SIGNATURE TITLE (X6) DATE STATE FORM 6899 RG9H11 If continuation sheet 1 of 59 PRINTED: 10/ 15/ 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.

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 a resident when they failed to administer pain medications correctly. As a result, the resident required Narcan (medication used to reverse the effects of overdose) and hospitalization. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. The staff members administered narcotic medication accurately according to the physician’s order for administration. The facility responded timely when the resident fell and appropriately coordinated her medical care. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted case workers, a medical provider, and law enforcement. The investigation included review of the resident record(s), hospital records, facility internal investigation, facility incident reports, personnel files, staff schedules, law enforcement report, and related facility policy and procedures. Also, the investigator toured the facility and observed medication administration, narcotic medication counts, meals, documentation systems, and staff interactions with other residents. The resident resided in an assisted living memory care unit. The resident’s diagnoses included dementia, bipolar disorder (mood disorder), and anxiety. The resident’s service plan included assistance with medication administration. The resident’s nursing assessment indicated the resident communicated verbally but was forgetful and had poor decision-making ability. The nursing assessment indicated the resident had verbal outbursts and repetitive thoughts/statements and required psychotropic medications (medications used to treat mental health conditions). The nursing assessment indicated the resident was unable to administer her own medications due to memory loss. Resident records indicated she went to the hospital for knee surgery and returned to the facility with a physician’s order for her to take oxycodone (opioid pain medication). The physician’s order for medication administration indicated the resident should take one or two tablets every four hours as needed for pain. Progress notes indicated two days after she returned to the facility, a staff member found the resident lying on the floor in her bathroom. The progress notes indicated the resident walked without assistance which occurred multiple times after her arrival back to the facility. At the time of the fall, the residents knee bandage was bloody. The resident told staff she felt a “ripping” sensation and she could not bend her knee. The staff sent the resident to the hospital. Hospital records indicated the resident required medical treatment for pneumonia and too much oxycodone. The records indicated physicians gave her two antibiotic medications to treat pneumonia and decreased the dose and frequency for oxycodone to one tablet every six hours as needed for pain. The resident returned to the facility two days later. The narcotic book indicated staff members verified the narcotic medication tablets during each removal of the medication and two staff members signed (initial) their name inside the book when they removed a tablet to verify the accuracy of the medication. The facilities narcotic book indicated a staff member removed two oxycodone tablets approximately two hours after they gave the resident two tablets. This would indicate the staff member inaccurately gave the resident two tablets of oxycodone approximately two hours before she was supposed to receive it. The facilities medication administration record (MAR) is an electronic recordkeeping system which electronically records when staff document medication administration. The MAR indicated staff members accurately administered the medication, within appropriate time intervals according to the physician’s order for administration. During an interview, a nurse said he was not aware of the concern the resident had a possible narcotic medication overdose until a law enforcement officer arrived at the facility. The nurse said the law enforcement officer arrived at the facility and together they reviewed the MAR and narcotic book. The nurse said there was a time discrepancy one day in the narcotic book, so he spoke to the staff involved. The nurse said the staff member inadvertently wrote the date into the narcotic book instead of the time. The nurse said the staff member gave the oxycodone tablets appropriately as electronically documented in the MAR. The nurse said at the time the resident fell; he was on the phone talking with the staff member who was in the room with the resident. The nurse said he heard the resident talking and answering his questions appropriately. The nurse said he told the staff member to send the resident into the hospital because she had recent knee surgery, and they were concerned the resident injured her knee. Law enforcement records indicated an officer spoke to the staff member who wrote in the narcotic book. Law enforcement records indicated the staff member said they made a documentation error in the narcotic book but gave the medication accurately. 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: Yes. Action taken by facility: The facility appropriately coordinated medical care for the resident. 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: 08/25/2025 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 _____________________________ 32938 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 543 OAKWOOD DRIVE A JANESVILLE SENIOR LIVING LLC JANESVILLE, MN 56048 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. HL329385408C/HL329383002M PLEASE DISREGARD THE HEADING OF HL329384207C/HL329382362M THE FOURTH COLUMN WHICH STATES,"PROVIDER'S PLAN OF On August 7, 2025, the Minnesota Department of CORRECTION." THIS APPLIES TO Health conducted a complaint investigation at the FEDERAL DEFICIENCIES ONLY. THIS above provider, and the following correction WILL APPEAR ON EACH PAGE. orders are issued. At the time of the complaint investigation, there were thirty-three residents THERE IS NO REQUIREMENT TO receiving services under the provider's Assisted SUBMIT A PLAN OF CORRECTION FOR Living with Dementia Care license. VIOLATIONS OF MINNESOTA STATE STATUTES. The following correction order is issued for HL329385408C/HL329383002M, tag THE LETTER IN THE LEFT COLUMN IS identification 630. USED FOR TRACKING PURPOSES AND REFLECTS THE SCOPE AND LEVEL No correction order is issued for ISSUED PURSUANT TO 144G.31 HL329384207C/HL329382362M. SUBDIVISION 1-3. 0 630 144G.42 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 when prescribed monthly injection was not administered within the required time. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. While it was true the medication injection was not administered on the correct day and the resident experienced anxiety and a change in mental health, the resident did receive the medication later but a week late. The medical records indicated this was an isolated error and the resident did not require immediate medical attention nor hospitalization. However, during the course of the investigation, it was found the resident’s electronic medical administration record (EMAR) indicated the injection was given on the correct day additional documentation in progress notes indicated it was administered seven days after the scheduled date. The facility failed to follow-up on the medication error and a compliance correction order was issued. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted a medical provider and guardian. The investigation included review of the resident record(s), EMARs, pharmacy records, provider notes, and facility policy and procedures. Also, the investigator observed staff interaction with the resident. The resident resided in an assisted living facility. The resident’s diagnoses included schizoaffective disorder and other mental health conditions. The resident’s service plan included nursing to administer a monthly injection and medication administration. The resident’s assessment indicated the resident was unable to administer his own medications and prescribed medications were stored in a locked medication cart. Prescribed medications and directions for administration were listed on the EMAR. A concern arose one month when the resident did not receive his scheduled medication injection as ordered causing a change in mental health which could have been avoided if medication injection would have been administered as ordered. The resident’s EMARs indicated the resident had orders to receive an injection every 28 days. The order was listed in the EMAR with the trained medication aid to inform the nurse on the day the injection was to be administered. The EMAR was reviewed with the resident receiving his injections on the 28th day except for the month in question when a recently hired nurse initialed electronically, she had administered the injection on the 28th day [every four weeks]. The medical record indicated the resident was aware of his medication order schedule and documented the times on a personal calendar when each injection was due and whether he received it or not. On this occasion, the resident did not receive his injection as scheduled and was not until the 35th day when he received the injection. Email communication with the facility indicated even though the nurse had initialed off on the 28th day she had administered the medication, it was not actually administered until day 35 according to a progress note. During an interview, an unlicensed caregiver stated unlicensed staff are not permitted to give the injection and that the nurse must administer it. The caregiver stated the order was listed on the EMAR and when the order comes up every 28 days unlicensed staff inform the nurse the injection is due on that date. Caregiver stated a licensed nurse would give the injection and then sign off on the EMAR once administered. During an interview, the resident stated the provider ordered the injections for every 28 days and does have a personal calendar to keep track of the date due. The resident stated on the month in question he asked the nurse for his injection on day 28. The resident stated the nurse stated it was to early and the injection was not due yet and so the injection was not administered until the next week and had the nurse initial his calendar. The resident stated he been on the medication for several years and can tell one or two days before the injection he needs it. The resident stated receiving the injection seven days late caused him a set back to his mental health which was very troubling and took him several days to get back to baseline. He stated he described his symptoms to his therapist. During an interview, a nurse [a different nurse involved in the incident] stated she was aware the resident kept a personal calendar with dates of injection and a licensed nurse had to give the injection. The nurse stated changes to the EMAR can only be done by nursing and it was unclear the previous nurse, who had not been here long, did not administer the medication on day 28. The nurse stated she was unable to find a completed medication error form to explain what had taken place, however she did find information in electronic notes the injection was given on the day 35. During an interview, a therapist stated the resident had a scheduled appointment a day before he received the late injection with resident not thinking a clear and having some hallucinations. The therapist advised resident to use coping skills and as needed oral medication. The resident was able to return to baseline within days after the injection was given. The attempts to interview the specific nurse involved in the medication error were unsuccessful. The nurse was no longer employed at the facility. 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. (d) For purposes of this section, a vulnerable adult is not neglected for the sole reason that: (4) an individual makes an error in the provision of therapeutic conduct to a vulnerable adult which does not result in injury or harm which reasonably requires medical or mental health care Vulnerable Adult interviewed: Yes Family/Responsible Party interviewed: Yes Alleged Perpetrator interviewed: NA Action taken by facility: The medication was given albeit a week late. The error remained isolated. Action taken by the Minnesota Department of Health: Correction order issued to the facility related to documentation of administration of medication. The facility was found to be in noncompliance. To view a copy of the Statement of Deficiencies and/or correction orders, please visit: https://www.health.state.mn.us/facilities/regulation/directory/provcompselect.html If you are viewing this report on the MDH website, please see the attached Statement of Deficiencies. You may also call 651-201-4200 to receive a copy via mail or email cc: The Office of Ombudsman for Long Term Care The Office of Ombudsman for Mental Health and Developmental Disabilities PRINTED: 04/21/2025 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 _____________________________ 32938 03/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 543 OAKWOOD DRIVE A JANESVILLE SENIOR LIVING LLC JANESVILLE, MN 56048 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 HOME CARE PROVIDER/ASSISTED LIVING using federal software. Tag numbers have PROVIDER CORRECTION 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 LICENSING COMPLIANCE REPORT Report #: HL329386764C Date Concluded: April 19, 2024 Bridgewater at Janesville LLC 543 Oakwood Dr Janesville, MN 56048 Waseca County Facility Type: Assisted Living Facility with Evaluator’s Name: Julie Serbus, RN Dementia Care (ALFDC) Special Investigator The Minnesota Department of Health conducted a complaint investigation to determine compliance with state laws and rules governing the provision of care under Minnesota Statutes, Chapter 144G. The purpose of this complaint investigation was to review if facility policies and practices comply with applicable laws and rules. No maltreatment under Minnesota Statutes, Chapter 626 was alleged. To view a copy of the correction orders, if any, please visit: https://www.health.state.mn.us/facilities/regulation/directory/provcompselect.html Or call 651-201-4201 to be provided a copy via mail or email. If you are viewing this report on the MDH website, please see the attached state form. PRINTED: 04/22/2024 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 _____________________________ 32938 04/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 543 OAKWOOD DRIVE BRIDGEWATER AT JANESVILLE LLC JANESVILLE, MN 56048 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 April 8, 2024, the Minnesota Department of Health initiated an investigation of complaint #HL329386764C. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 U5ZG11 If continuation sheet 1 of 1