Rivers of Life.

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 . . ." 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. Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, the following fines are assessed An equal opportunity employer. Letter ID: IS7N REVISE D09/13/2021 Rivers Of Life LLC February 4, 2026 Page 2 pursuant to this survey: 0775 - 144g.45 Subd. 2. (a) - Fire Protection And Physical Environment - $500.00 1290 - 144g.60 Subdivision 1 - Background Studies Required - $1,000.00 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 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). 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 Rivers Of Life LLC February 4, 2026 Page 3 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. 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, Jodi Johnson, Supervisor State Evaluation Team Email: jodi.johnson@ state. mn.us Tel ephon e: 507-344- 2730 Fax: 1-866- 890- 9290 JMD PRINTED: 02/ 04/ 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 _____________________________ 35978 01/ 14/ 2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6700 EGAN DRIVE RIVERS OF LIFE LLC SAVAGE, MN 55378 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 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 survey. 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. SL35978016- 0 PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On January 12, 2026, through January 14, 2026, STATES, "PROVIDER' S PLAN OF the Minnesota Department of Health conducted a CORRECTION. " THIS APPLIES TO full survey at the above provider and the following FEDERAL DEFICIENCIES ONLY. THIS correction orders are issued. At the time of the WILL APPEAR ON EACH PAGE. survey, there were 33 residents; 33 receiving services under the Assisted Living Facility with THERE IS NO REQUIREMENT TO Dementia Care license. SUBMIT A PLAN OF CORRECTION FOR VIOLATIONS OF MINNESOTA STATE STATUTES. 1290: An immediate correction order was issued on January 13, 2026, at a level 3/Widespread (I). THE LETTER IN THE LEFT COLUMN IS The licensee took immediate action; however, the USED FOR TRACKING PURPOSES AND scope and level remain at I. 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 KX6H11 If continuation sheet 1 of 17 PRINTED: 02/ 04/ 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 woke up with swelling, bruising, and dried blood on forehead. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. The cause of the resident’s injuries remained unknown and there was no unwitnessed falls. The facility took appropriate steps to update the medical provider and seek care when the injuries were identified. The investigator conducted interviews with facility staff members, including nursing staff, and unlicensed staff. The investigation included review of the resident’s records, internal investigation documentation, incident reports, staff schedules, policies, and procedures. The resident lived in an assisted living secured memory care building. The resident’s diagnoses included dementia without behavioral disturbance. The service plan indicated that the resident required assistance with some activities of daily living and medication administration. It also included safety checks every two hours during the night. The resident’s assessment indicated he was independent with transfers and mobility. A concern arose when the resident was found with swelling, bruising, and dried blood on his forehead however the resident was unable to tell the caregiver what had happened. A notification was sent to the provider regarding the abrasion, and the medical provider ordered the facility to monitor for any neurological changes and to update as needed. The following day, the progress notes indicated the resident came to the dining room with the same bump on the forehead and a new bump on the back of the head although the cause was unknown. The note also indicated the caregiver observed the resident behaving differently than usual as he was unable to engage in conversation as he normally would, although he was alert, sitting in a chair, and showed no signs of pain or discomfort. The facility obtained vital signs and, while those were normal limits, emergency services were called, and the resident was transferred to the hospital for further evaluation. During an interview, a manager, who was also a nurse, stated the resident walked miles every day, was very active, and, if he did fall, could get up himself and continue walking. He walked without using any assistive device. The manager said there was no documentation of a fall, so she did not know when or how he sustained the wound on his forehead. Caregivers had conducted safety checks every two hours at night, starting at midnight, and confirmed he was in bed both nights. During an interview, an unlicensed caregiver stated the resident was very mobile, walking everywhere but returning for mealtimes. The caregivers stated she was the one who found him with swelling, bruising, and dried blood on his forehead so she took images and provided them to the nurse. The resident continued his day as usual, eating breakfast and lunch. She said it was difficult to determine what had happened since he often walked independently and could get up by himself and she had not witnessed a fall. During an interview, a family member stated they were happy with the care provided by the facility and confirmed the facility called to notify them about the incident. Unfortunately, the family member said the resident passed away a week after being admitted to the hospital. 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. The resident was deceased. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Not Applicable. the Action taken by facility: No action required. 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: 11/17/2025 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 _____________________________ 35978 09/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6700 EGAN DRIVE RIVERS OF LIFE LLC SAVAGE, MN 55378 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 Department of Health initiated an investigation of complaints #HL359785242M/HL359781882C. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 JGLB11 If continuation sheet 1 of 1

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 fell resulting in injuries. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. Although the resident did have an unwitnessed fall resulting in a fracture, the facility had followed the resident’s care plan for safety checks and toileting. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted a family member. The investigation included review of plan of care, assessments, progress notes, and Individual Abuse Prevention Plan. Also, the investigator completed an onsite visit to observe staff to resident interactions. The resident resided in an assisted living memory care unit. The resident’s diagnoses included memory loss and blindness. The resident’s service plan included assistance with escort to all destinations, bathing, medication administration, dressing, grooming, and toileting. The resident also needed to be cued at meals where food was located on her plate along with verbal cues regarding her surroundings. The resident’s assessment indicated the resident required hands on guidance from staff. On the day the resident fell, staff had earlier been assisting resident in her room. Resident had been diagnosed with COVID and required to remain in room. Caregivers had been in and out of the resident’s room at mealtimes, medication administration times, toileting, and safety checks. At the time of the fall itself, a caregiver had been walking down the hallway to the resident’s room and heard a loud noise followed by the resident yelling. The unlicensed caregiver found the resident on the floor. The facility contacted the resident’s medical provider who ordered a portable X-ray to check for fractures. The X-ray indicated there was a humerus (upper arm) fracture. The resident’s family opted to have the resident sent to the hospital. During an interview, the unlicensed caregiver stated when any resident falls, the staff members are trained to request another staff member to come assist, take a set of vitals, call the nurse (or if in the building ask the nurse to come to the area), and do not move the resident until cleared through nursing. During an interview, the nurse stated the resident had been diagnosed with COVID and had become more restless making the resident’s actions more impulsive. During an interview, a family member stated the resident had fell at the family’s home two months prior. The family member stated the resident’s short-term memory had been declining but the resident wanted to be independent and complete tasks without requesting assistance from staff. The family member stated the resident knew the path in her room which was kept clear, and resident would use furniture to feel her way around her room. The family member stated the resident had been experiencing transient ischemic attacks (similar to a stroke) affecting her activities of daily living and ambulation. 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 Page 3 of 3 (2) which is not the result of an accident or therapeutic conduct. Vulnerable Adult interviewed: No Family/Responsible Party interviewed: Yes Alleged Perpetrator interviewed: NA Action taken by facility: No action required. 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: 08/16/2024 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 _____________________________ 35978 07/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6700 EGAN DRIVE RIVERS OF LIFE LLC SAVAGE, MN 55378 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 11, 2024, the Minnesota Department of Health initiated an investigation of complaint #HL359781415C/#HL359782345M. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 RZNE11 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 . . ." 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 Rivers Of Life LLC August 30, 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: 08/30/2023 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 _____________________________ 35978 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6700 EGAN DRIVE RIVERS OF LIFE LLC SAVAGE, MN 55378 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 with Dementia In accordance with Minnesota Statutes, section Care License Provider. The assigned tag 144G.08 to 144G.95, these correction orders are number appears in the far left column issued pursuant to a survey. entitled "ID Prefix Tag." The state Statute number and the corresponding text of the Determination of whether violations are corrected state Statute out of compliance is listed in requires compliance with all requirements the "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. SL35978015 PLEASE DISREGARD THE HEADING OF On July 24, 2023, through July 27, 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 28 active residents, all of WILL APPEAR ON EACH PAGE. whom received 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 9YBC11 If continuation sheet 1 of 32 PRINTED: 08/30/2023 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 _____________________________ 35978 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6700 EGAN DRIVE RIVERS OF LIFE LLC SAVAGE, MN 55378 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 following services to residents: (B) food must be prepared and served according to the Minnesota Food Code, Minnesota Rules, chapter 4626; and This MN Requirement is not met as evidenced by: Based on observation, interview and record review, the licensee failed to ensure food was prepared and served according to the Minnesota Food Code. 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) and was issued at a widespread scope (when problems are pervasive or represent a systemic failure that has affected or has the potential to affect a large portion or all the residents). The findings include: Please refer to the included document titled, Food and Beverage Establishment Inspection Report dated July 24, 2023, for the specific Minnesota Food Code deficiencies. TIME PERIOD FOR CORRECTION: Twenty-one (21) days 0 550 144G.41 Subd. 7 Resident grievances; reporting 0 550 SS=F maltreatment All facilities must post in a conspicuous place information about the facilities' grievance procedure, and the name, telephone number, and email contact information for the individuals who are responsible for handling resident grievances. STATE FORM 6899 9YBC11 If continuation sheet 2 of 32 PRINTED: 08/30/2023 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 _____________________________ 35978 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6700 EGAN DRIVE RIVERS OF LIFE LLC SAVAGE, MN 55378 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) 0 550 Continued From page 2 0 550 The notice must also have the contact information for the Office of Ombudsman for Long-Term Care and the Office of Ombudsman for Mental Health and Developmental Disabilities and must have information for reporting suspected maltreatment to the Minnesota Adult Abuse Reporting Center. The notice must also state that if an individual has a complaint about the facility or person providing services, the individual may contact the Office of Health Facility Complaints at the Minnesota Department of Health. This MN Requirement is not met as evidenced by: Based on observation, interview, and record review, the licensee failed to post the required information related to the grievance procedure.