The Gardens at Winsted Al.

correction orders and document the actions taken to comply in the facility's records. The Department reserves the right to return to the facility at any time should the Department receive a complaint or deem it necessary to ensure the health, safety, and welfare of residents in your care. STATE CORRECTIO NORDERS The enclosed State Form documents the state correction orders. MDH documents state licensing correction orders using federal software. Tag numbers are assigned to Minnesota state statutes for Assisted Living Facilities. The assigned tag number appears in the far left column entitled "ID Prefix Tag." The state statute number and the corresponding text of the state statute out of compliance are listed in the "Summary Statement of Deficiencies" column. This column also includes the findings that are in violation of the state statute after the statement, "This MN Requirement is not met as evidenced by . . ." 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; An equal opportunity employer. Letter ID: IS7N REVISE D09/13/2021 The Gardens At Winsted AL January 21, 2026 Page 2 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 pursuant to this survey: 0510 - 144g.41 Subd. 3 - Infection Control Program - $500.00 0775 - 144g.45 Subd. 2. (a) - Fire Protection And Physical Environment - $500.00 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 $1,000.00. 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 The Gardens At Winsted AL January 21, 2026 Page 3 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. The MDH Health Regulation Division (HRD )values your feedback about your experience during the survey and/ or investigation process. Please fill out this anonymous provider feedback questionnaire at your conv enien ce at thi s link: https: / / forms. office.com/ g/ Bm5uQEpHVa. Your inpu t is import ant to us and will enable MDH to improve its processes and communication with providers. If you have any questions regarding the questionnaire, please contact Susan Winkelmann at susan. winkelmann@state. mn.us or call 651-201-5952. You are encouraged to retain this document for your records. It is your responsibility to share the information contained in the letter and state form with your organization’s Governing Body. If you have any questions, please contact me. Sincerely, Kelly Thorson, Supervisor State Evaluation Team Email: kelly.thorson@ state. mn.us Tel ephon e: 320-223- 7336 Fax: 1-866- 890- 9290 JMD PRINTED: 01/ 21/ 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 _____________________________ 28112 12/ 17/ 2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 300 FAIRLAWN AVENUE WEST THE GARDENS AT WINSTED AL WINSTED, MN 55395 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 ASSISTED LIVING PROVIDER LICENSING Minnesota Department of Health is CORRECTION ORDER( S) documenting the State Correction Orders using federal software. Tag numbers have In accordance with Minnesota Statutes, section been assigned to Minnesota State 144G. 08 to 144G. 95, these correction orders are Statutes for Assisted Living License issued pursuant to a survey. Providers. The assigned tag number appears in the far-left column entitled "ID Determination of whether violations are corrected Prefix Tag." The state Statute number and requires compliance with all requirements the corresponding text of the state Statute provided at the Statute number indicated below. out of compliance is listed in the When Minnesota Statute contains several items, "Summary Statement of Deficiencies" failure to comply with any of the items will be column. This column also includes the considered lack of compliance. findings which are in violation of the state requirement after the statement, "This INITIAL COMMENTS: Minnesota requirement is not met as evidenced by." Following the surveyors' SL28112016- 0 findings is the Time Period for Correction. On December 15, 2025, through December 17, PLEASE DISREGARD THE HEADING OF 2025, the Minnesota Department of Health THE FOURTH COLUMN WHICH conducted a full survey at the above provider. At STATES, "PROVIDER' S PLAN OF the time of the survey, there were seventeen (17) CORRECTION. " THIS APPLIES TO residents; 17 receiving services under the FEDERAL DEFICIENCIES ONLY. THIS Assisted Living Facility with Dementia Care WILL APPEAR ON EACH PAGE. 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 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 1X5L11 If continuation sheet 1 of 23 PRINTED: 01/ 21/ 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 resident #1 and resident #2 when staff failed to provide sufficient supervision. As a result, there was unwanted resident-to-resident sexual contact. In addition, because of the incident, the facility failed to allow resident #1 to continue to attend facility activities. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. Resident #1 was found in resident #2’s room with resident #2’s hand inside the front of resident #1’s pants. At the time of the incident, staff were providing cares and services according to both residents’ plan of care. Resident #2 had no known history of sexually inappropriate behaviors. In addition, following the incident resident #1 continued to attend scheduled activities with other residents with continuous staff supervision. During an onsite observation, resident #1 was observed seated directly next to unlicensed staff playing bingo. The investigator conducted interviews with facility staff members, including nursing staff, and unlicensed staff. The investigation included review of both residents’ records, facility internal investigation, facility incident report, law enforcement report, and related facility policy and procedures. Also, the investigator observed the facility, observed resident #1 and resident #2, and staff interactions with residents. Resident #1 resided in an assisted living memory care unit. Resident #1’s diagnoses included dementia. Resident #1’2 service plan included assistance with reassurance checks at scheduled times during the day which included 6:00 a.m., 9:00 a.m., 12:00 p.m. and 2:00 p.m. and cues of redirection as needed. Resident #1’s assessment indicated the resident walked independently, was oriented to person, forgetful, confused, and wandered. Resident #1 had complete hearing loss on the right side, moderate hearing loss on the left, and had visual loss. Resident #1’s vulnerability assessment indicated goals for a support system included meeting new people and to take part in social activities to enhance quality of life. Resident #1 did not exhibit inappropriate sexual behaviors. Resident #2 resided in an assisted living memory care unit. Resident #2’s diagnoses included dementia. Resident #2’s service plan included assistance with reassurance checks at scheduled times during the day which included 6:00 a.m., 8:00 a.m., 10:00 a.m. 12:00 p.m. and 2:00 p.m., cues of redirection as needed. Resident #2’s assessment indicated the resident walked independently, was oriented to person, forgetful, confused, wandered, and had impaired decision making. Resident #2’s vulnerability assessment indicated goals for a support system included meeting new people and to take part in social activities to enhance quality of life. Resident #2 did not exhibit inappropriate sexual behaviors. During observation, resident #1 and resident #2’s room placement was located on opposite sides of the facility. Resident #2’s shared room consisted of hung linen curtain entrances to the left and ride side of the room. The facility internal investigation indicated one day at around 1:15 p.m., both residents were attending activities. About fifteen minutes later, during the activity an unlicensed entered resident #2’s room to assist his roommate. The unlicensed staff heard a female voice say “No”. At that time, the unlicensed staff observed resident #2’s hand inside resident #2’s pants. Resident #2’s hand was between resident #1’s thighs near resident #1’ peri-area. The unlicensed staff separated both residents to their room on opposite sides of the building. Every 15-minute checks were implements for both residents. Both residents had skin checks with no noted redness, abrasions, or bruising on their body. The facility reassurance checks audits indicated after the incident facility staff monitored resident #1 and resident #2 every 15 minutes, then adjusted to every 30 minutes, and after that every one hour. The internal investigation timeline indicated both residents returned to staff reassurance check monitoring according to their service agreement. During an interview, unlicensed personnel stated resident #1 and resident #2 both walked independently. Both residents were watching a singing group perform on resident #2’s side of the facility. The unlicensed personnel stated she was present, had cleaned up the area after lunch, and was providing cares to other residents going in and out of rooms. The unlicensed personnel stated she entered resident #2’s shared room to assist resident #2’s roommate. Unlicensed personnel stated In the room she heard voices coming from resident #2’s side of the room. The unlicensed personnel stated she heard a female say “no” “stop.” The unlicensed personnel entered resident #2’s side of the room and observed resident #2’s hand down the inside front of resident #1’s pants. The unlicensed personnel immediately intervened, was able to redirect resident #2 away from resident #1, and separated the two residents. The unlicensed personnel stated she walked resident #1 back to her room on the other side of the facility. Unlicensed staff stated she checked resident #1’s skin and said resident #1 did not have any visible injury, scratches, or marks. The unlicensed personnel stated she did not see resident #1 and resident #2 leave the singing group activity and walk back to resident #2’s room. During an interview, a nurse stated after the incident, resident #1 and resident #2’s skin was checked by unlicensed staff and was also assessed by licensed nurses. Nothing abnormal was observed. Both resident #1 and resident #2 had a BIMS (Brief Interview for Mental Status) conducted, which indicated both residents were severely cognitively impaired. The nurse stated the behavior was out of character for resident #2, and they had not witnessed that type of behavior from resident #2 before. The nurse stated since the incident, resident #1 was not prevented from attending facility activities. During an interview, another nurse stated after the incident resident #2 was assessed by facility licensed nurses and evaluated by his provider. There had been no prior incidents involving resident #2’s inappropriate sexual behaviors, and there had been no further incidents of this nature. Both resident #1 and resident #2 did not recall the incident when licensed nurses assessed and spoke to them. The nurse stated the facility acted and implemented interventions to have staff always present to supervise resident #1 when resident #1 was on resident #2’s side of the facility for activities. 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. Attempted. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Not Applicable. Action taken by facility: The facility staff immediately separated both residents, skin checks and vulnerability assessments were conducted, Resident #1 and Resident #2 providers were updated, facility educated staff to ensure continuous supervision when residents are together for activities from either side of the facility. 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: 08/07/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ C B. WING _____________________________ 28112 07/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 300 FAIRLAWN AVENUE WEST THE GARDENS AT WINSTED AL WINSTED, MN 55395 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 21, 2025, the Minnesota Department of Health initiated an investigation of complaint #HL281126548C/#HL281123442M. No correction orders are issued.

correction orders and document the actions taken to comply in the facility's records. The Department reserves the right to return to the facility at any time should the Department receive a complaint or deem it necessary to ensure the health, safety, and welfare of residents in your care. STATE 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 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 The Gardens at Winsted Assisted Living LLC October 23, 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, Kelly Thorson, Supervisor State Evaluation Team Email: kelly.thorson@state.mn.us Telephone: 320-223-7336 Fax: 1-866-890-9290 HHH PRINTED: 10/23/2023 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 _____________________________ 28112 09/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 300 FAIRLAWN AVENUE WEST THE GARDENS AT WINSTED AL WINSTED, MN 55395 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 INITIAL COMMENTS: ******ATTENTION****** SL28118015 ASSISTED LIVING PROVIDER On September 25, 2023, through September 27, LICENSING CORRECTION ORDER(S) 2023, the Minnesota Department of Health conducted a survey at the above provider, and In accordance with Minnesota Statutes, the following correction orders are issued. At the section 144G.08 to 144G.95, these time of the survey, there were 16 active residents correction orders are issued pursuant to a receiving services under the Assisted Living with survey. Dementia Care license. Determination of whether violations are corrected requires compliance with all requirements provided at the Statute number indicated below. When Minnesota Statute contains several items, failure to comply with any of the items will be considered lack of compliance. 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 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 according to the Minnesota Food Code. This had the potential to affect all residents. 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 LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 YQK011 If continuation sheet 1 of 20 PRINTED: 10/23/2023 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 _____________________________ 28112 09/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 300 FAIRLAWN AVENUE WEST THE GARDENS AT WINSTED AL WINSTED, MN 55395 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 was issued at a widespread scope (when problems are pervasive or represent a systemic failure that has affected or has potential to affect a large portion or all of the residents). The findings include: Please refer to the additional documentation included in the Food and Beverage Establishment Inspection Reports, dated September 26, 2023. TIME PERIOD FOR CORRECTION: Twenty-one (21) days 0 680 144G.42 Subd. 10 Disaster planning and 0 680 SS=F emergency preparedness (a) The facility must meet the following requirements: (1) have a written emergency disaster plan that contains a plan for evacuation, addresses elements of sheltering in place, identifies temporary relocation sites, and details staff assignments in the event of a disaster or an emergency; (2) post an emergency disaster plan prominently; (3) provide building emergency exit diagrams to all residents; (4) post emergency exit diagrams on each floor; and (5) have a written policy and procedure regarding missing residents. (b) The facility must provide emergency and disaster training to all staff during the initial staff orientation and annually thereafter and must make emergency and disaster training annually available to all residents. Staff who have not received emergency and disaster training are allowed to work only when trained staff are also STATE FORM 6899 YQK011 If continuation sheet 2 of 20 PRINTED: 10/23/2023 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 _____________________________ 28112 09/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 300 FAIRLAWN AVENUE WEST THE GARDENS AT WINSTED AL WINSTED, MN 55395 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) 0 680 Continued From page 2 0 680 working on site. (c) The facility must meet any additional requirements adopted in rule. This MN Requirement is not met as evidenced by: Based on observation, interview, and record review, the licensee failed to post a written emergency preparedness plan (EPP) with all required content. This had the potential to affect all residents, staff, and visitors of the facility.