River Pointe of Moorhead.

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 CORRECTIO NORDERS The enclosed State Form documents the state correction orders. MDH documents state licensing correction orders using federal software. Tag numbers are assigned to Minnesota state statutes for Assisted Living Facilities. The assigned tag number appears in the far left column entitled "ID Prefix Tag." The state statute number and the corresponding text of the state statute out of compliance are listed in the "Summary Statement of Deficiencies" column. This column also includes the findings that are in violation of the state statute after the statement, "This MN Requirement is not met as evidenced by . . ." In accordance with Minn. Stat. § 144G.31 Subd. 4, MDH may assess fines based on the level and scope of the violati ons ; however, no immediate fines are assessed for this survey of your facility. DOCUMENTATIO ONF ACTION TO COMPLY In accorda nce with Mi nn. Stat. § 144G.30, Sub d. 5(c), th e lic ens ee mus t docum ent ac tions taken to comply with the correction orders within the time period outlined on the state form; however, plans of correction are not required to be submitted for approval. The correction order documentation should include the following: An equal opportunity employer. Letter ID: IS7N REVISE D09/13/2021 River Pointe Of Moorhead April 30, 2026 Page 2 Identify how the area( s) of noncompliance was corrected related to the · resident( s)/ employee( s) identified in the correction order. Identify how the area( s) of noncompliance was corrected for all of the provider’s · resident( s)/ employees that may be affected by the noncompliance. Identify what changes to your systems and practices were made to ensure compliance with · the specific statute( s). 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 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 KKM PRINTED: 04/ 30/ 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 _____________________________ 30646 04/ 22/ 2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2401 11TH STREET SOUTH RIVER POINTE OF MOORHEAD MOORHEAD, MN 56560 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. SL3064616- 0 PLEASE DISREGARD THE HEADING OF On April 20, 2026, through April 22, 2026, the THE FOURTH COLUMN WHICH survey at the above provider, and the following CORRECTION. " THIS APPLIES TO correction orders are issued. At the time of the FEDERAL DEFICIENCIES ONLY. THIS survey, there were eighty residents, with WILL APPEAR ON EACH PAGE. sixty-eight residents that were receiving services under the provider' s Assisted Living with THERE IS NO REQUIREMENT TO Dementia Care license. 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. 0 480 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 GRC711 If continuation sheet 1 of 4 PRINTED: 04/ 30/ 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 _____________________________ 30646 04/ 22/ 2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2401 11TH STREET SOUTH RIVER POINTE OF MOORHEAD MOORHEAD, MN 56560 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) 0 480 Continued From page 1 0 480 (a) Except as provided in paragraph (b), food must be prepared and served according to the Minnesota Food Code, Minnesota Rules, chapter 4626. (b) For an assisted living facility with a licensed capacity of ten or fewer residents: (1) notwithstanding Minnesota Rules, part 4626. 0033, item A, the facility may share a certified food protection manager (CFPM) with one other facility located within a 60- mile radius and under common management provided the CFPM is present at each facility frequently enough to effectively administer, manage, and supervise each facility's food service operation; (2) notwithstanding Minnesota Rules, part 4626. 0545, item A, kick plates that are not removable or cannot be rotated open are allowed unless the facility has been issued repeated correction orders for violations of Minnesota Rules, part 4626. 1565 or 4626. 1570; (3) notwithstanding Minnesota Rules, part 4626. 0685, item A, the facility is not required to provide integral drainboards, utensil racks, or tables large enough to accommodate soiled and clean items that may accumulate during hours of operation provided soiled items do not contaminate clean items, surfaces, or food, and clean equipment and dishes are air dried in a manner that prevents contamination before storage; (4) notwithstanding Minnesota Rules, part 4626. 1070, item A, the facility is not required to install a dedicated handwashing sink in its existing kitchen provided it designates one well of a two-compartment sink for use only as a handwashing sink; (5) notwithstanding Minnesota Rules, parts 4626. 1325, 4626. 1335, and 4626. 1360, item A, existing floor, wall, and ceiling finishes are STATE FORM 6899 GRC711 If continuation sheet 2 of 4 PRINTED: 04/ 30/ 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 resident choked on food and passed away at the hospital. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. Although the resident choked resulting in death, the resident’s plan of care was followed at the time of the incident. When the resident was found slumped over in her chair after choking, facility staff provided immediate assistance and contacted emergency medical services. The resident died at the hospital. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted the primary care provider (PCP) and the speech language pathologist (SLP). The investigation included review of the resident record, hospital records, facility internal investigation, facility incident reports, staff schedules, law enforcement reports, and related facility policy and procedures. Also, the investigator observed meal service at the facility. The resident resided in an assisted living facility. The resident’s diagnoses included myotonic muscular dystrophy (a genetic disorder of progressive muscle weakness) and dysphagia (difficulty swallowing). The resident’s service plan included assistance including dressing, grooming, toileting, and medication administration. The resident’s assessment indicated the resident could eat independently and did not need assistance. The resident did not have any dietary restrictions and had a normal diet with thin liquids. The resident’s assessment indicated the resident was cognitively intact and able to make her needs known. The facility's internal investigation indicated another resident sitting at the table with the resident stated the resident was eating her hamburger and kind of "ahemmed" and put her hand up like she does sometimes when she has a hard time swallowing. They asked the resident if she was ok and she shook her head yes, they asked again if she needed help, and she shook her head yes. Another resident pressed the resident’s call pendant and went to find a staff member. Emergency medical services (EMS) reports indicated the resident was found unresponsive, and EMS provided chest compressions and removed a large amount of debris. When the resident arrived at the hospital lifesaving efforts were stopped and the resident passed away. Facility staff told EMS the resident had a history of choking, but the incidents had not been as bad as this one. Review of medical records indicated the resident had a history of choking. The resident was seen by her medical provider and speech therapist regarding concerns. Recommendations were provided to the resident to prevent choking. The resident acknowledged the recommendations and remained independent with eating. The resident was ordered a normal diet when the incident occurred. During an interview, a facility staff stated he was aware the resident had a history of choking but was not aware of any restrictions she had. The day of the incident a facility staff responded to the dining room after the emergency pull cord was activated and when he arrived there was a dietary staff member there already. A facility staff stated the resident kept bobbing forward so he tried to help hold her in her wheelchair until the nurse arrived. During an interview, a resident who witnessed the incident stated the resident had some issues with choking due to her diagnosis. The resident stated there had been a few times in the past when the resident would start choking on food and the resident had been told to raise her hands above her head so it would clear the food. During an interview, a facility nurse stated the resident didn't have any dietary restrictions. The resident wanted to make her own food decision so she'd order off the menu things she wanted to eat and would take smaller bites, cut them up, or take longer to chew things, and if she knew there were things she couldn't eat, she'd not eat those things. The nurse stated the resident had prior choking incidents in the dining room where she'd cough on different textures of food, but she'd be able to clear it on her own by putting her hands up in the air. The nurse stated the resident knew the risks and wanted to keep eating what she wanted to eat and make those choices independently. The resident’s primary care provider stated the resident was well informed of her diagnosis and her disease process could lead to choking. 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, deceased. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Not Applicable. Action taken by facility: The facility investigated the incident and reported it to MAARC. 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: 11/07/2025 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 _____________________________ 30646 09/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2401 11TH STREET SOUTH RIVER POINTE OF MOORHEAD MOORHEAD, MN 56560 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 September 11, 2025, the Minnesota Minnesota Department of Health is Department of Health initiated an investigation of documenting the State Correction Orders complaint #HL306465503M/ #HL306462777C. using federal software. Tag numbers have No correction orders are issued. been 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 is listed in the "Summary Statement of Deficiencies" column. This column also includes the findings which are in violation of the state requirement after the statement, "This Minnesota 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. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 FRQJ11 If continuation sheet 1 of 1

Finding Not Sbstantiated Nature of Investigation The Minnesota Department of Health investigated an allegation of maltreatment, in accordance with the Minnesota Reporting of Maltreatment of Vlnerable Adlts Act, Minn. Stat. 626.557, and to evalate compliance with applicable licensing standards for the provider type. Initial Investigation Allegation(s) The alleged perpetrator (AP), a facility nlicensed personnel (ULP), neglected the resident when he failed to administer schedled inslin as prescribed. As a reslt, the resident was hospitalized with high blood sgar. Investigative Findings and Conclusion The Minnesota Department of Health determined neglect was not sbstantiated. Althogh the resident was hospitalized after the AP failed to administer inslin, the error was an isolated incident. The resident was treated for high blood sgar and retrned to their baseline health condition. The investigator condcted interviews with facility staff members, inclding administrative staff, nrsing staff, and nlicensed staff. The investigation inclded review of the resident records, hospital records, facility internal investigation docmentation, facility incident reports, personnel files, staff schedles, and related facility policies and procedres. Also, the investigator observed medication administration at the facility. The resident resided in an assisted living facility. The resident’s diagnoses inclded diabetes and chronic kidney disease. The resident’s service plan inclded assistance with blood sgar management and medication administration. The resident’s assessment indicated the resident was diabetic bt did not follow a diabetic diet. The resident liked to keep ice cream in his apartment and tried to replace meals with ice cream, casing high blood sgar levels. The resident reqired assistance with inslin administration and blood sgar checks. The resident’s medication administration record (MAR) from the day of the incident, indicated the 8:00 a.m. blood sgar check was not completed de to resident refsal. The MAR indicated the resident also refsed his Hmalog (a fast-acting inslin) and Lants (a long-acting inslin) administration. The facility’s internal investigation indicated the AP did not administer the resident’s 8:00 a.m. medications, inclding inslin, or check the resident’s blood sgar, and failed to notify the RN. The medication error was not identified ntil the resident’s blood sgar was checked later that morning, and the monitor read that it was too high to be measred. The AP called the RN at 12:05 p.m. to report the high reading and was instrcted by the RN to check it again and call back. The AP called back at 12:12 p.m. and stated the reading was still high. The RN directed the AP to se a different blood sgar machine and call back with the reslt. The resident’s blood sgar reading remained high. The resident reported feeling sick, was lightly sweating, and was sent to the emergency room. After emergency room staff called the facility to verify medication administration, it was discovered that the resident’s 8:00 a.m. medications, inslin, and blood sgar check were marked as refsed. The internal investigation indicated administrative staff interviewed the AP who reported that he didn’t get to his 7:00 a.m. shift ntil 7:45 a.m. and was already behind and so he did not pass the morning medications. The resident’s medical record indicated that the day of the incident, the resident had a large bowl of ice cream for breakfast. Administrative staff members stated that after the error occrred, they reviewed what systems cold have led to the staff member feeling too rshed to complete medication administration. This inclded review of camera footage to see what the AP was doing dring the shift, analyzed service schedles, and interview with other staff who worked that day. The internal investigation indicated the AP was asked by several coworkers to help with nonrgent tasks. The AP wasn’t comfortable saying no and overetended himself trying to help everyone before completing his time sensitive tasks. Dring an interview, the AP stated the morning of the medication error, he was rnning behind on his assigned tasks. The AP stated one resident had increased aniety and took p a lot of his time. He was not able to calm the resident down and he was also asked to help with other tasks throghot the facility. The AP stated he was familiar with diabetes bt didn’t realize the resident was a type-one diabetic and thoght he wold be ok to administer the inslin a little later than schedled while he worked to catch p on his tasks. The AP stated the resident ate a large bowl of ice cream for breakfast, bt he wasn’t aware of that ntil after he obtained the high blood sgar level reading. In conclsion, the Minnesota Department of Health determined neglect was not sbstantiated. Not Substantiated” means An investigatory conclsion indicating the preponderance of evidence shows that an act meeting the definition of maltreatment did not occr. Neglect Minnesota Statutes, section 626.5572, subdivision 17 Neglect” means neglect by a caregiver or self-neglect. (a) "Caregiver neglect" means the failre or omission by a caregiver to spply a vlnerable adlt with care or services, inclding bt not limited to, food, clothing, shelter, health care, or spervision which is: (1) reasonable and necessary to obtain or maintain the vlnerable adlt's physical or mental health or safety, considering the physical and mental capacity or dysfnction of the vlnerable adlt; and (2) which is not the reslt of an accident or therapetic condct. Vulnerable Adult interviewed: Yes FamilyResponsible Party interviewed: Yes Alleged Perpetrator interviewed: Yes Action taken by facility The facility reported the incident, sspended the AP, and completed an internal investigation. The AP was retrained on medication administration and time management. Action taken by the Minnesota Department of Health No frther action taken at this time. cc: The Office of Ombdsman for Long Term Care The Office of Ombdsman for Mental Health and Developmental Disabilities PRINTED: 07/26/2024 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 _____________________________ 30646 07/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2401 11TH STREET SOUTH RIVER POINTE OF MOORHEAD MOORHEAD, MN 56560 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 July 1, 2024, the Minnesota Department of Minnesota Department of Health is Health initiated an investigation of complaint documenting the State Correction Orders #HL306464281M/ #HL306465087C. No using federal software. Tag numbers have correction orders are issued. been 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 is listed in the "Summary Statement of Deficiencies" column. This column also includes the findings which are in violation of the state requirement after the statement, "This Minnesota 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. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 1OY411 If continuation sheet 1 of 1

CORRECTION ORDERS The enclosed State Form documents the state correction orders. The 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 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. In accordance with Minn. Stat. § 144G.31, Subd. 4 (a)(5), the MDH may impose fine amounts of either $1,000 or $5,000 to licensees who are found to be responsible for maltreatment. The MDH may impose a fine of $1,000 for each substantiated maltreatment violation that consists of abuse, neglect, or financial exploitation according to Minn. Stat. § 626.5572, Subds. 2, 9, 17. The MDH An equal opportunity employer. Letter ID: IS7N REVISED 09/13/2021 River Pointe Of Moorhead June 26, 2023 Page 2 also may impose a fine of $5,000 for each substantiated maltreatment violation consisting of sexual assault, death, or abuse resulting in serious injury. In accordance with Minn. Stat. § 144G.31, Subd. 4 (b), when a fine is assessed against a facility for substantiated maltreatment, the commissioner shall not also impose an immediate fine under this chapter for the same circumstance. Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, the following fines are assessed pursuant to this survey: St ‐ 0 ‐ 1620 ‐ 144g.70 Subd. 2 (c‐E) ‐ Initial Reviews, Assessments, And Monitoring ‐ $3,000.00 Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.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. DOCUMENTATION OF ACTION TO COMPLY In accordance with Minn. Stat. § 144G.30, Subd. 5(c), the licensee must document actions taken to comply with the correction orders within the time period outlined on the state form; however, plans of correction are not required to be submitted for approval. The correction order documentation should include the following:  Identify how the area(s) of noncompliance was corrected related to the resident(s)/employee(s) identified in the correction order.  Identify how the area(s) of noncompliance was corrected for all of the provider’s resident(s)/employees that may be affected by the noncompliance.  Identify what changes to your systems and practices were made to ensure compliance with the specific statute(s). CORRECTION ORDER RECONSIDERATION PROCESS In accordance with Minn. Stat. § 144G.32, Subd. 2, you may challenge the correction order(s) issued, including the level and scope, and any fine assessed through the correction order reconsideration process. The request for reconsideration must be in writing and received by 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. 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). River Pointe Of Moorhead June 26, 2023 Page 3 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. Please note that you may request a reconsideration or 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 state form with your organization’s Governing Body. If you have any questions, please contact me. Sincerely, Jessica Chenze, Supervisor State Evaluation Team Email: jessica.chenze@state.mn.us Telephone: 218‐332‐5175 Fax: 651‐281‐9796 JMD PRINTED: 06/26/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ 30646 B. WING _____________________________ 05/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2401 11TH STREET SOUTH RIVER POINTE OF MOORHEAD MOORHEAD, MN 56560 (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 ******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. SL30646015 PLEASE DISREGARD THE HEADING OF On May 22, 2023, through May 24, 2023, the THE FOURTH COLUMN WHICH survey at the above provider, and the following CORRECTION." THIS APPLIES TO correction orders are issued. At the time of the FEDERAL DEFICIENCIES ONLY. THIS survey, there were 78 active residents, all of WILL APPEAR ON EACH PAGE. whom were receiving services under the Assisted Living with 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 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 2BHI11 If continuation sheet 1 of 39 PRINTED: 06/26/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ 30646 B.