Suite Living Senior Care of Va.

STATE LICENSING COMPLIANCE REPORT Report #: HL332607689C Date Concluded: October 3, 2025 Name, Address, and County of Facility Investigated: Suite Living Senior Care of VA 580 Liberty Way Vadnais Heights, MN 55127 Hennepin County Facility Type: Assisted Living Facility with Evaluator’s Name: Willette Shafer, RN Dementia Care (ALFDC) Special Investigator The Minnesota Department of Health conducted a complaint investigation to determine compliance with state laws and rules governing the provision of care under Minnesota Statutes, Chapter 144G. The purpose of this complaint investigation was to review if facility policies and practices comply with applicable laws and rules. No maltreatment under Minnesota Statutes, Chapter 626 was alleged. To view a copy of the correction orders, if any, please visit: https://www.health.state.mn.us/facilities/regulation/directory/provcompselect.html, or call MDH website, please see the attached state form. PRINTED: 10/08/2025 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 _____________________________ 33260 09/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 580 LIBERTY WAY SUITE LIVING SENIOR CARE OF VADNAIS VADNAIS HEIGHTS, MN 55127 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 complaint #HL332607689C. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 WTK811 If continuation sheet 1 of 1

correction orders issued pursuant to the last survey, completed on September 12, 2025, found not corrected at the time of the December 17, 2025, follow-up survey and/ or subject to penalty assessment are as follows: 2310-Appropriate Care And Services-144g.91 Subd. 4 (a) - $1,000.00 The details of the violations noted at the time of this follow-up survey completed on December 17, 2025 (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 $1,000.00. You will be invoiced approximately 30 days after receipt of this notice, subject to appeal. Also, at the time of this follow-up survey completed on December 17, 2025, we identified the following violation(s): 1890-Prescription Drugs-144g.71 Subd. 20 The details of the violation(s) noted at the time of this follow-up survey are delineated on the attached State Form. Only the ID Prefix Tag in the left hand column without brackets will identify these state correction orders. It is not necessary to develop a plan of correction. 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 An equal opportunity employer. Letter ID: 8GKP Revised 04/14/2023 Suite Living Senior Care of Vadnais Heights January 15, 2026 Page 2 required to be submitted for approval. 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 Jess Schoenecker at 651-201-3789. Suite Living Senior Care of Vadnais Heights January 15, 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, Jess Schoenecker, Supervisor State Evaluation Team Email: Jess.Schoenecker@state. mn.us Telephone: 651-201-3789 Fax: 1-866-890-9290 CLN PRINTED: 01/ 15/ 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 _____________________________ 33260 12/ 17/ 2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 580 LIBERTY WAY SUITE LIVING SENIOR CARE OF VA VADNAIS HEIGHTS, MN 55127 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 License INITIAL COMMENTS Providers. The assigned tag number SL33260016- 1 appears in the far-left column entitled "ID Prefix Tag." The state Statute number and From December 16, 2025, through December 17, the corresponding text of the state Statute 2025, the Minnesota Department of Health out of compliance is listed in the conducted a follow-up survey at the above "Summary Statement of Deficiencies" provider to follow-up on orders issued pursuant to column. This column also includes the a survey completed on September 12, 2025. At findings which are in violation of the state the time of the survey, there were 27 residents; requirement after the statement, "This 27 receiving services under the Assisted Living Minnesota requirement is not met as with Dementia Care license. As a result of the evidenced by." Following the evaluators' follow-up survey, the following orders were issued findings is the Time Period for Correction. and reissued. 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. {0 510} 144G. 41 Subd. 3 Infection control program {0 510} SS= E (a) All assisted living facilities must establish and LABORATORY DIRECTOR' S OR PROVIDER/ SUPPLIER REPRESENTATIVE' S SIGNATURE TITLE (X6) DATE STATE FORM 6899 R2ZR12 If continuation sheet 1 of 14 PRINTED: 01/ 15/ 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 _____________________________ 33260 12/ 17/ 2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 580 LIBERTY WAY SUITE LIVING SENIOR CARE OF VA VADNAIS HEIGHTS, MN 55127 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} maintain an infection control program that 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: Not reviewed during this survey. {0 650} 144G. 42 Subd. 8 (a) Staff records {0 650} SS= D (a) The facility must maintain current records of each paid staff member, each regularly scheduled volunteer providing services, and each individual contractor providing services.