New Perspective Prior Lake.

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; 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. An equal opportunity employer . Letter ID: IS7N REVISE 0D9/13/2021 New Perspectiv ePrior Lake October 27, 2025 Page 2 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), 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: 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 matter or issue contested and any new information you believe constitutes a defense or mitigating factor. To submit a hearing request, please visit: https:/ / forms.web.health.state.mn.us/form/ HRDAppealsForm To appe al fines via reconsideration ,please fol low the proce dure outlined above. Pleas e 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. New Perspectiv ePrior Lake October 27, 2025 Page 3 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 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, Jodi Johnson ,Supervisor State Evaluation Team Email: Jodi.Johnson@state.mn.us Telephone :507-344-2730 Fax :1-866-890-9290 KKM PRINTED: 10/27/2025 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 _____________________________ 22094 09/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4685 PARK NICOLLET AVENUE NEW PERSPECTIVE PRIOR LAKE PRIOR LAKE, MN 55372 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 LICENSING using federal software. Tag numbers have CORRECTION ORDER(S) been assigned to Minnesota State Statutes for Assisted Living Facilities. The In accordance with Minnesota Statutes, section assigned tag number appears in the 144G.08 to 144G.95, these correction orders are far-left column entitled "ID Prefix Tag." issued pursuant to a survey. The state Statute number and the corresponding text of the state Statute out Determination of whether violations are corrected of compliance is listed in the "Summary requires compliance with all requirements Statement of Deficiencies" column. This provided at the Statute number indicated below. column also includes the findings which When Minnesota Statute contains several items, are in violation of the state requirement failure to comply with any of the items will be after the statement, "This Minnesota considered lack of compliance. requirement is not met as evidenced by." Following the evaluators ' findings is the INITIAL COMMENTS: Time Period for Correction. SL22094026-0 PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On September 22, 2025, through September 25, STATES,"PROVIDER'S PLAN OF 2025, the Minnesota Department of Health CORRECTION." THIS APPLIES TO conducted a full survey at the above provider and FEDERAL DEFICIENCIES ONLY. THIS the following correction orders are issued. At the WILL APPEAR ON EACH PAGE. time of the survey, there were 119 residents; 110 receiving services under the Assisted Living THERE IS NO REQUIREMENT TO Facility with 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 JHEE11 If continuation sheet 1 of 32 PRINTED: 10/27/2025 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: Inconclusive 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 pushed the resident while trying to take the resident to her room for cares. Investigative Findings and Conclusion: The Minnesota Department of Health determined abuse was inconclusive. While the AP, who was an unlicensed caregiver, was witnessed interacting with the resident in a discourteous manner, there was insufficient evidence to demonstrate abuse occurred. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed caregivers. The investigator contacted the resident’s family member. The investigation included review of the resident records, incident report, service plan, assessments, related facility policy and procedures, hospital records, and the AP’s file. During an onsite visit, the investigator observed the resident along with staff interactions with the resident. The resident resided in an assisted living memory care unit. The resident’s diagnosis included dementia. The resident’s service plan included assistance with bathing, dressing when needed, medication administration, assistance with toileting, and reminders to go to meals. The resident at times refused cares and caregivers were directed to reattempt or reapproach to complete the services. The individual abuse prevention plan (IAPP) indicated the resident is unable to make her needs known, could not report abuse, and was susceptible to abuse by others. The resident’s assessment indicated the resident was alert and orientated to self with severe short-term memory and uncooperative with cares. One day the AP was directed by another unlicensed caregiver to toilet the resident as she appeared to be incontinent. The AP followed the direction and was witnessed to have pushed and pulled the resident forcefully when directing the resident to her room for cares. The resident was observed to be visibly shaken and crying so someone else took over her cares. Review of the resident’s progress notes indicated resident is at baseline and did not require a change in her care plan. The resident did not receive any injuries related to the incident. During an interview, unlicensed caregiver #1 stated she was busy at the medication cart and noticed the resident needed incontinence cares because she smelled of urine and the resident had refused to be changed overnight. Caregiver #1 asked AP to take the resident to the bathroom. Caregiver #1 stated she was aware the resident did not particularly care for the AP, but still requested AP to assist the resident. The AP approached the resident, but she refused saying “no, no, no” and the AP began to “push” her down the hallway. During an interview, unlicensed caregiver #2 stated she was near the medication cart, and she heard the AP trying to get the resident to her room, but the resident refused. Caregiver #2 stated both the AP and the resident were becoming upset, so she approached them to intervene. At first the AP wanted to keep trying and pulled the resident by her arm to coax her down the hallway. Caregiver #2 stated the resident looked scared. Caregiver #2 took over the cares and the AP did not provide cares. During an interview, AP stated unlicensed caregiver #1 was working on the medication cart and asked AP to assist resident to her room for toileting because she was incontinent. The AP stated she was aware the resident’s skin was at risk due to frequent incontinence and refusal of cares. AP stated the resident did say no and so she tried to encourage her to come down the hallway verbally. The AP stated she took her by the hand and tried to guide down the hallway, but the resident became upset. Caregiver #2 approached the resident and took over the cares. During an interview, a manager stated caregivers do have a challenging time completing the resident’s activities of daily living and caregivers are trained to either reapproach or ask another staff to attempt to assist the resident. The manager stated unlicensed caregiver #2 did report the concerns along with taking over care of the resident. The manager stated they did not have camera footage of the incident in question. The manager stated formal retraining had not been provided after this incident or prior incidents involving the AP. During an interview, a family member stated when they would visit the resident, she was frequently incontinent. The family member stated they were aware the resident often refused cares, only accepts help when she is ready, and has been this way all her life. In conclusion, the Minnesota Department of Health determined abuse was inconclusive. Inconclusive: Minnesota Statutes, section 626.5572, Subdivision 11. "Inconclusive" means there is less than a preponderance of evidence to show that maltreatment did or 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. Vulnerable Adult interviewed: NA due to cognitive status Family/Responsible Party interviewed: Yes Alleged Perpetrator interviewed: Yes the Action taken by facility: AP no longer is employed at the facility. Action taken by the Minnesota Department of Health: No further action required. cc: The Office of Ombudsman for Long Term Care The Office of Ombudsman for Mental Health and Developmental Disabilities PRINTED: 04/15/2024 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 _____________________________ 22094 03/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4685 PARK NICOLLET AVENUE NEW PERSPECTIVE - PRIOR LAKE PRIOR LAKE, MN 55372 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 March 18, 2024, the Minnesota Department of Minnesota Department of Health is Health initiated an investigation of complaint documenting the State Correction Orders #HL220946772C/#HL220949245M. No correction using federal software. Tag numbers have orders are issued. been assigned to Minnesota State Statutes for Assisted Living License ******ATTENTION****** Providers. The assigned tag number appears in the far left column entitled "ID HOME CARE PROVIDER/ASSISTED LIVING Prefix Tag." The state Statute number and PROVIDER CORRECTION ORDER the corresponding text of the state Statute out of compliance is listed in the In accordance with Minnesota Statutes, section "Summary Statement of Deficiencies" 144A.43 to 144A.482/144G.08 to 144G.95, these column. This column also includes the correction orders are issued pursuant to a findings which are in violation of the state complaint investigation. requirement after the statement, "This Minnesota requirement is not met as Determination of whether a violation is corrected evidenced by." Following the surveyors' requires compliance with all requirements findings is the Time Period for Correction. provided at the statute number indicated below. When a Minnesota Statute contains several PLEASE DISREGARD THE HEADING OF items, failure to comply with any of the items will THE FOURTH COLUMN WHICH be considered lack of compliance. STATES,"PROVIDER'S PLAN OF CORRECTION." THIS APPLIES TO INITIAL COMMENTS: FEDERAL DEFICIENCIES ONLY. THIS WILL APPEAR ON EACH PAGE.

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 . . ." 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; h owever, no immediate fines are assessed for this survey of your facility. 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). An equal opportunity employer. Letter ID: IS7N REVISED 09/13/2021 New Perspective - Prior Lake July 28, 2023 Page 2 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). 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 state form with your organization’s Governing Body. If you have any questions, please contact me. Sincerely, Jess Schoenecker, Supervisor State Evaluation Team Email: jess.schoenecker@state.mn.us Telephone: 651-201-3789 Fax: 6 51-281-9796 JMD PRINTED: 07/28/2023 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 _____________________________ 22094 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4685 PARK NICOLLET AVENUE NEW PERSPECTIVE - PRIOR LAKE PRIOR LAKE, MN 55372 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. SL22094015-0 PLEASE DISREGARD THE HEADING OF On July 10, 2023, through July 13, 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 94 active residents; 74 WILL APPEAR ON EACH PAGE. 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. 0 510 144G.41 Subd. 3 Infection control program 0 510 SS=D (a) All assisted living facilities must establish and maintain an infection control program that LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 F57F11 If continuation sheet 1 of 21 PRINTED: 07/28/2023 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 _____________________________ 22094 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4685 PARK NICOLLET AVENUE NEW PERSPECTIVE - PRIOR LAKE PRIOR LAKE, MN 55372 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) 0 510 Continued From page 1 0 510 complies with accepted health care, medical, and nursing standards for infection control. (b)The facility's infection control program must be consistent with current guidelines from the national Centers for Disease Control and Prevention (CDC) for infection prevention and control in long-term care facilities and, as applicable, for infection prevention and control in assisted living facilities. (c) The facility must maintain written evidence of compliance with this subdivision. This MN Requirement is not met as evidenced by: Based on observation, interview, and record review, the licensee failed to establish and maintain an infection control (IC) program that complies with accepted health care, medical and nursing standards for infection control. The deficient practice had the potential to affect residents, employees, and visitors. 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 an isolated scope (when one or a limited number of residents are affected or one or a limited number of staff are involved or the situation has occurred only occasionally). The findings include: R3 was admitted on June 10, 2022, with diagnosis which included diabetes mellitus Type 2, cirrhosis of liver, and hypertension. R3 resided in a two-bedroom apartment which was shared with another resident not related to R3. R3 and the other resident each had their own private STATE FORM 6899 F57F11 If continuation sheet 2 of 21 PRINTED: 07/28/2023 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 _____________________________ 22094 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4685 PARK NICOLLET AVENUE NEW PERSPECTIVE - PRIOR LAKE PRIOR LAKE, MN 55372 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) 0 510 Continued From page 2 0 510 bedroom and shared a common kitchen, laundry room, and living space.