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StarlynnCare
Minnesota · Prior Lake

Suite Living Senior Care.

Suite Living Senior Care is Grade C−, ranked in the bottom 49% of Minnesota memory care with 1 MDH citation on record; last inspected Jan 2026.

ALF · Memory Care32 licensed beds · mediumDementia-trained staff
5600 Credit River Road SE · Prior Lake, MN 55372LIC# ALRC:1984
Limited Inspection History · fewer than 4 records in 3 years
Facility · Prior Lake
A 32-bed ALF · Memory Care with one citation on file (Nov 2024).
Last inspection · Jan 2026 · citedSource · MDH
Licensed beds
32
Memory care
✓ Yes
Last inspection
Jan 2026
Last citation
Nov 2024
Operated by
Phone
§ 01 · Snapshot

A medium home, reviewed on public record.

§ 02 · Peer Comparison

Ranked against 187 Minnesota facilities.

ALF memory care · 36-month window. Higher percentile = better. Source: Minnesota Dept. of Health · Health Regulation Division.

Severity rank
20th
Weighted citations per bed.
peer median
0
100
Repeat rank
100th
Repeat deficiencies as share of total.
peer median
0
100
Frequency rank
28th
Deficiencies per inspection.
peer median
0
100

FACILITY WATCH · BETA

Suite Living Senior Care has 1 citation on record. Know the moment anything changes.

New findings, complaint investigations, or status changes — emailed to you free.

§ 03 · The Record

Citation history, plotted month by month.

1 deficiencie on record. Each bar is a month with a citation.

10weighted score · 24 mo
Last citation: NOV 2024. Compared against peer median (dashed).
peer median
NOV 2024
Jun 2024May 2026

Finding distribution

1 total · 36 months

Scope × Severity (CMS A–L)

Isolated
Pattern
Widespread
Sev 4 · IJ
J
K
L
Sev 3
G1
H
I
Sev 2
D
E
F
Sev 1
A
B
C
§ 06 · Full Inspection Record

Every MDH visit, verbatim.

3 inspections in the public record, most recent first. Click any row to expand — cited rows open automatically.

3
reports on file
1
total deficiencies
2026-01-29
Annual Compliance Visit
No findings

Plain-language summary

A follow-up survey on April 14, 2026 found that the facility had not corrected three violations from its January 29, 2026 inspection involving service plan implementation and prescription drug management; the facility was assessed $1,500 in fines for these uncorrected violations. The facility remains in substantial compliance overall and must document actions taken to correct these violations in its records, though the facility has the right to appeal or request a hearing on the fines within 15 business days.

Full inspector notes

correction orders issued pursuant to the January 29, 2026 survey. The Department of Health concludes the licensee is in substantial compliance. State law requires the facility must take action to correct the state 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. In accordance with Minn. Stat. § 144G.31 Subd. 4 (a), state correction orders issued pursuant to the last survey, completed on January 29, 2026, found not corrected at the time of the April 14, 2026, follow-up survey and/ or subject to penalty assessment are as follows: 1640-Service Plan, Implementation And Revisions To-144g.70 Subd. 4 (a-E) - $500.00 1650-Service Plan, Implementation And Revisions To-144g.70 Subd. 4 (f) - $500.00 1890-Prescription Drugs-144g.71 Subd. 20 - $500.00 The details of the violations noted at the time of this follow-up survey completed on April 14, 2026 (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 refor e, in accor danc e wit h Minn. Sta t. §§ 144G.01 to 144G.999 9, the total amount you are assessed is $1,500.00. You will be invoiced approximately 30 days after receipt of this notice, subject to appeal. DOCUMENTATIO ONF ACTION TO COMPLY In accorda nce with Min n. Stat. § 144G.30, Sub d. 5(c), th e lic ens ee mus t docum ent ac tions taken t o comply with the correction orders outlined on the state form; however, plans of correction are not required to be submitted for approval. An equal opportunity employer. Letter ID: 8GKP Revised 04/14/2023 Suite Living Senior Care of Prior Lake LLC April 29, 2026 Page 2 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; Level 3: a fine of $1,000 per incident, in addition to any enforcement mechanism authorized in § 144G.20; Level 4: a fine of $3,000 per incident, in addition to any enforcement mechanism authorized in § 144G.20; Level 5: a fine of $5,000 per violation, in addition to any enforcement mechanism authorized in § 144G.20. 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 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 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 fi nes via re cons iderat ion , pl ease follow the procedu r e outl ined abo ve. Plea se no te tha t you may re que st a rec onside rati on or a hearing, bu t not bot h. If you wish to cont est ta gs with out fine s 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 Jodi Johnson at Suite Living Senior Care of Prior Lake LLC April 29, 2026 Page 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, Jodi Johnson, Supervisor State Evaluation Team Email: Jodi.Johnson@state. mn.us Telephone: 507-344-2730 Fax: 1-866-890-9290 CLN PRINTED: 04/ 29/ 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: ______________________ R B. WING _____________________________ 39149 04/ 14/ 2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5600 CREDIT RIVER ROAD SE SUITE LIVING SENIOR CARE OF PRIOR LAKE LLC WHITE BEAR LAKE, MN 55110 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 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 SL39149016- 1 far-left column entitled "ID Prefix Tag. " The state Statute number and the On April 13, 2026, through April 14, 2026, , the corresponding text of the state Statute out follow-up survey at the above provider to Statement of Deficiencies" column. This follow-up on orders issued pursuant to a survey column also includes the findings which completed on January 29, 2026. At the time of are in violation of the state requirement the survey, there were 28 residents; 28 receiving after the statement, "This Minnesota services under the Assisted Living with Dementia requirement is not met as evidenced by." Care license. As a result of the follow-up survey, Following the evaluators' findings is the the following orders were reissued: 1640, 1650, Time Period for Correction. 1890. 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. {01640} 144G. 70 Subd. 4 (a- e) Service plan, {01640} SS= D implementation and revisions to LABORATORY DIRECTOR' S OR PROVIDER/ SUPPLIER REPRESENTATIVE' S SIGNATURE TITLE (X6) DATE STATE FORM 6899 XC2Z12 If continuation sheet 1 of 11 PRINTED: 04/ 29/ 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: ______________________ R B. WING _____________________________ 39149 04/ 14/ 2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5600 CREDIT RIVER ROAD SE SUITE LIVING SENIOR CARE OF PRIOR LAKE LLC WHITE BEAR LAKE, MN 55110 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) {01640} Continued From page 1 {01640} (a) No later than 14 calendar days after the date that services are first provided, an assisted living facility shall finalize a current written service plan. (b) The service plan and any revisions must include a signature or other authentication by the facility and by the resident documenting agreement on the services to be provided. The service plan must be revised, if needed, based on resident reassessment under subdivision 2.

2024-11-12
Complaint Investigation
1 · Substantiated Finding

Plain-language summary

MDH investigated a complaint that a registered nurse gave a resident unprescribed antipsychotic medications without the prescriber's or hospice's approval, which caused the resident to become sedated, disoriented, and fall. The investigation substantiated abuse; the nurse placed unprescribed medications in the resident's medication cup and instructed unlicensed staff to administer them, stating she did so because she did not want to deal with the resident's aggressive behavior, and she later gave additional sedating medications despite the resident already being drowsy. The nurse was found individually responsible for the maltreatment.

Substantiated FindingMinn. Stat. §MN-SUBST
Verbatim citation text · Minn. Stat. §MN-SUBST

MDH substantiated maltreatment or licensing violation finding

Full inspector notes

Finding: Substantiated, individual responsibility 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 AP abused the resident when she administered antipsychotic medications to him without a prescription and caused a chemical restraint. The resident was sedated, disoriented and fell. Investigative Findings and Conclusion: The Minnesota Department of Health determined abuse was substantiated. The AP was responsible for the maltreatment. The AP gave the resident unprescribed medications even though hospice staff declined to add Haldol (an antipsychotic) and quetiapine (an antipsychotic) to the resident’s medications. The AP, a registered nurse, intentionally placed antipsychotic medications, without a prescription, into the resident’s morning medication cup and directed the unlicensed personnel (ULP) to administer them, as well directed the ULP to administer prescribed as needed medications to induce a chemical restraint. Additionally, a few hours later, the AP administered the resident prescribed as needed medications although the resident had been sleepy and drowsy. The AP told staff members she gave the unprescribed medications to the resident because he was aggressive, and she did not want to deal with him. The resident took his morning medications, became disoriented, unsteady on his feet, displayed slurred speech, and fell. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted the resident’s family but was not able to schedule a timely interview. One family member provided a text message statement. The investigation included review of the resident records, pharmacy records, facility internal investigation, facility incident reports, video, personnel files, staff schedules, and related facility policy and procedures. Also, the investigator observed staff administering resident medications and interacting with residents in their rooms and in common areas. The resident resided in the assisted living. The resident’s diagnoses included prostate and kidney cancer, kidney disease, Alzheimer’s disease and depression. The resident’s service plan included assistance with medication management and administration. The resident was a new admission to the memory care unit. The resident’s preadmission assessment, signed and dated by the AP, indicated the resident was alert but had cognitive impairment, orientation issues and forgetfulness. He displayed verbal and physical aggression, anxiety, agitation and wandering behavior. He was enrolled in hospice. The resident’s care plan directed management of behaviors included safety checks every two hours, monitoring whereabouts when wandering, provide orientation cues and reminders, and provide clear explanation of care activities prior to contact. If the resident was resistive to cares, the care plan directed staff to stop, ensure safety and then reapproach. The care plan directed to limit staff to one person at a time, two staff at most for one staff to provide care and the second staff to provide “pleasant” distraction. Additionally, the care plan indicated hospice provided pain management and staff were to monitor for any side effects of pain medications to report to the nurse. The resident was not able to walk safely and was at risk for falls. On admission to the facility, the prescriber ordered the resident’s prescribed Haldol, 1mg tablets, be discontinued and to start morphine (opiod pain medication), lorazepam (antianxiety medication) and Levsin (medication to reduce secretions). There were no prescriber orders to for quetiapine. The AP signed the prescriber orders and faxed the orders to the pharmacy. The next day, the AP received a telephone order to increase the resident’s prescribed antipsychotic, olanzapine, dose. The resident’s progress notes indicated on the resident’s fourth day of admission, the resident had behaviors of pacing, exit seeking, raised voice and redirection was ineffective. Hospice provided orders to increase the as needed (PRN) order for the resident’s olanzapine, in addition to the scheduled doses. The AP received and transcribed the new orders. Progress notes indicated the next morning, the AP documented she received report the resident had restlessness, agitation, and wandering during the overnight shift. The overnight staff contacted hospice, who indicated they would provide a visit to the resident that day. The AP indicated in the progress note at 7:07 a.m., the resident was asleep and waiting hospice staff to discuss medication adjustments. The resident’s electronic medication administration record (eMAR) indicated medications administered to the resident at 8:00 a.m. included scheduled olanzapine, an antidepressant, PRN lorazepam and PRN morphine. The resident’s progress notes, the same day, at 12:26 p.m., indicated the resident ate breakfast and was amenable to medication administration from the ULP. The resident was drowsy and sleeping. The AP documented hospice staff completed their visit and addressed concerns. The resident required two staff to assist him into his recliner. The resident had difficulty walking and slept awkwardly in his chair. The resident’s eMAR indicated at 12:30 p.m., the AP administered PRN morphine, PRN lorazepam and PRN olanzapine and documented the PRNs were ineffective, although he was sleeping and drowsy during her documented progress notes at 7:07 a.m. and 12:26 p.m. The resident progress notes, the same day, at 2:00 p.m., indicated the AP received an order from hospice to scheduled morphine three times a day, in addition to the PRN order of morphine. The resident’s record lacked orders for Haldol and quetiapine. Approximately a week later, the resident was discharged to the hospital for falls. He died in the hospital. The resident’s death record indicated he died of acute kidney injury. The ULP 1 provided a written statement to the facility. The ULP indicated that same morning, at the start of the day shift, the AP approached her to talk about how the resident was the previous night. The AP directed the ULP to provide the resident his scheduled morning medications, which included olanzapine, but to also add PRN morphine and lorazepam because she was “not dealing with this today.” The ULP prepared the resident’s 8:00 a.m. medications and the AP came back with Haldol “pills.” The ULP administered the resident’s scheduled medication, the PRN medications and the medications provided by the AP. The ULP stated she later learned there was no prescription for Hadol. At 12:30 p.m., the AP asked for the ULP’s medication cart keys, prepared PRN morphine and lorazepam in a syringe and went to administer them to the resident. The AP returned from the resident’s room, stated it was a failed attempt to give medications and crushed unknown pills into a medication cup, “slurried” them with orange juice and administered the mixture to the resident. Approximately 30 minutes later, ULP 1 heard a loud noise and found the resident hanging off the edge of his recliner. The resident slurred his words, tried standing and fell backwards into his chair, then collapsed into his wheelchair against a wall. ULP 1 wrote she expressed her concern over the resident’s condition to the AP who told her to “let him fall” or leave him on the floor. At 2:00 p.m. shift change, ULP 1 wrote the AP reported to staff we “snowed” the resident, therefore hospice would provide a Broda chair (assisted positioning chair) and a mechanical lift because the resident was a “monkey & belongs in a zoo.” A witness, ULP 2, emailed her concerns to the facility management staff that same day, around 2:00 p.m. ULP 2 indicated the AP told her directly she added two medications to the resident’s morning medication cup before ULP 1 administered them and told ULP 1 “you didn’t see me do that.” ULP 2 indicated the AP said she placed Haldol and quetiapine. ULP 2 indicated the AP said she hoped hospice would order those medications later in the day. ULP 2 indicated the AP said she wanted the resident “snowed” so he was not a “busy bee” or aggressive. ULP 2 wrote the AP became loud and upset when hospice did not order Haldol and quetiapine and said she would have to add those medication to his eMAR even though they were not ordered for him. ULP 2 indicated the resident was unsteady on his feet, unable to walk or hold his balance after administration and was walking fine prior. After the 12:30 p.m., medication administration, the resident was falling over and ULP 2 caught him. ULP 2 reported to the AP the resident was not stable walking and the AP responded to let him fall or put him on the floor to stay there.

2024-04-19
Complaint Investigation
No findings

Plain-language summary

A complaint investigation found that a resident developed bruising on her forehead, but the Minnesota Department of Health determined there was insufficient evidence to conclude the bruising was caused by abuse; the resident had a history of falls, was on blood-thinning medication, and had experienced new onset weakness and confusion, but staff interviews and facility records did not identify how the bruising occurred. No further action was taken by the Department of Health.

Full inspector notes

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 facility abused the resident when the resident sustained unexplained bruising to her face. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect inconclusive. While the resident did develop bruising on her forehead, there was insufficient evidence to attribute the bruises to abuse. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigation included review of the hospital records, facility internal investigation, facility incident reports, staff schedules, resident progress notes, resident service plan, resident individual abuse protection plan (IAPP), and related facility policy and procedures. The investigator observed direct care staff interaction with residents. The resident resided in an assisted living memory care unit. The resident’s diagnoses included Alzheimer’s, Lewy bodies (abnormal deposits of a protein in the brain), history of falls, and depression. The resident’s service plan included hands-on staff assistance of one for set up, cueing and assistance with dressing. This same plan indicated hands-on assistance of one staff for toileting. The resident was primarily independent with transfers but required occasional assistance from a seated to standing or lying position and could reposition herself in bed. The resident required stand by assist of one staff and a two-wheeled walker when walking. The resident has a history of falls with safety checks approximately every 2 hours. The resident’s medical record indicated at times the resident transferred herself from bed to recliner to WC and back without calling for assistance. The facility incident report indicated a nurse observed the resident had bruising on her left forehead, however the cause of the bruising was unknown. The facility’s internal investigation indicated the staff members were asked for written statements. One unlicensed caregiver stated the resident was not herself the day prior and notified the on-call nurse. None of the statements or interviews indicated a fall occurred or been reported, no issues of skin concerns by unlicensed caregivers, the nurse, or therapy staff earlier that morning prior to discovering the bruising. The internal investigation did not identify any other causes of the bruising. The resident’s facility progress notes medical record indicated the resident experienced new onset weakness and confusion the day prior to the appearance of the resident’s bruises. The resident’s medication administration recorded indicated the resident was prescribed a blood thinner (a medication which can cause bruising to occur more easily). During an interview, an unlicensed caregiver, who worked the night shift, stated the resident did not have any falls or injuries overnight. The caregiver stated during rounds the resident’s eyeglasses were found on the floor with the lens broken and this was reported to the next shift. During an interview, a nurse stated she had spoken to the resident in-person that morning and did not observe any bruising at that time. During an interview, a therapy staff member stated the resident had received physical therapy that morning and during therapy no bruising was observed. 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 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: No Family/Responsible Party interviewed: No, attempted Alleged Perpetrator interviewed: NA the Action taken by facility: The facility assessed the resident and conducted an internal investigation. 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: 04/22/2024 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 _____________________________ 39149 03/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5600 CREDIT RIVER ROAD SE SUITE LIVING SENIOR CARE OF PRIOR LAKE WHITE BEAR LAKE, MN 55110 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 19, 2024, the Minnesota Department of Health initiated an investigation of complaint #HL391498064C/#HL391499867M. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 TTLC11 If continuation sheet 1 of 1

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