The Commons On Marice.

correction orders and document the actions taken to comply in the facility's records. The Department reserves the right to return to the facility at any time should the Department receive a complaint or deem it necessar yto ensure the health, safety, and welfare of residents in your care. STATE CORRECTIO ONRDERS The enclosed State Form documents the state correction orders. MDH documents state licensing correction orders using federal software. Tag numbers are assigned to Minnesota state statutes for Assisted Living Facilities .The assigned tag number appears in the far left column entitled "ID Prefix Tag". The state statute number and the corresponding text of the state statute out of compliance are listed in the "Summary Statemen tof Deficiencies "column. This column also includes the findings that are in violation of the state statute after the statement, "This MN Requiremen tis not met as evidenced by . . ." IMPOSITION OF FINES In accordance with Minn. Stat. § 144G3. 1, Subd .4, fines and enforcement actions may be imposed based on the level and scope of the violations and may be imposed immediately with no opportunity to correct the violation first as follows: Leve l1: no fines or enforcement; Leve l2: a fine of $500 per violation, in addition to any enforcement mechanism authorized in § 144G2. 0; Leve l3: a fine of $1,000 per incident, in addition to any enforcement mechanism authorized in § 144G2. 0; An equal opportunity employer . Letter ID: IS7N REVISE 0D9/13/2021 The Commons on Marice October 29, 2025 Page 2 Leve l4: a fine of $3,000 per incident, in addition to any enforcement mechanism authorized in § 144G2. 0; Leve l5: a fine of $5,000 per violation, in addition to any enforcement mechanism authorized in § 144G2. 0. Therefore ,in accordance with Minn. Stat. §§ 144G0. 1 to 144G9. 999, the following fines are assessed pursuant to this survey: St - 0 - 0775 - 144g.45 Subd. 2. (a) - Fire Protection And Physica lEnvironment - $500.00 Therefore ,in accordance with Minn. Stat. §§ 144G0. 1 to 144G9. 999, the total amount you are assesse dis $500.00. You will be invoiced approximately 30 days after receipt of this notice, subject to . appeal DOCUMENTATIO ONF ACTION TO COMPLY In accordance with Minn. Stat. § 144G3. 0, Subd .5(c), the licensee must docum ent actions taken to comply with the correction orders within the time period outlined on the state form; however, plans of correction are not required to be submitted for approval. The correction order documentation should include the following: x Identify how the area(s) of noncompliance was corrected related to the resident(s)/ employees( ) identified in the correction order. x Identify how the area(s) of noncompliance was corrected for all of the provider’s resident(s)/ employees that may be affected by the noncompliance. x Identify what changes to your systems and practices were made to ensure compliance with the specific statute(s). CORRECTIO ONRDER RECONSIDERATI OPRNOCESS In accordance with Minn. Stat. § 144G3. 2, Subd .2, you may challenge the correction order(s) issued, including the level and scope ,and any fine assesse dthrough the correction order reconsideration process .The request for reconsideration must be in writing and received by MDH within 15 calendar days of the correction order receipt date. To submit a reconsideration request, please visit: https:/ / forms.web.health.state.mn.us/form/ HRDAppealsForm REQUESTIN AG HEARING Alternatively ,in accordance with Minn. Stat. § 144G3. 1, Subd .5(d), an assisted living provider that has been assesse da fine under this subdivision has a right to a reconsideration or a hearing under this section and chapter 14. Pursuan tto Minn. Stat. § 144G2. 0, Subd .14 and Subd .18, a request for a hearing must be in writing and received by the Department of Health within 15 business days of the correction order receipt date. The request must contain a brief and plain statement describing each matter or issue contested and any new information you believe constitutes a defense or mitigating factor. The Commons on Marice October 29, 2025 Page 3 To submit a hearing request, please visit: https:/ / forms.web.health.state.mn.us/form/ HRDAppealsForm To appea lfines via reconside ration, please follow the pr ocedur e outlined above. Plea se note that you may request a reconsideration or a hearing, but not both. If you wish to contest tags without fines in a reconsideration and tags with the fines at a hearing, please submit two separate appeals forms at the website listed above. The MDH Health Regulation Division (HRD )values your feedback about your experience during the survey and/or investigation process .Please fill out this anonymous provider feedback questionnaire at your convenience at this link: https:/ / forms.office.com/g/ Bm5uQEpHV.a Your input is important to us and will enable MDH to improve its processe sand communication with providers . If you have any questions regarding the questionnaire ,please contact Susan Winkelmann at susanw. inkelmann@state.mn.us or call 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 organizations’ Governing Body. If you have any questions ,please contact me. Sincerely, Jod iJohnson ,Supervisor State Evaluation Team Email: Jodi.Johnson@state.mn.us Telephone :507-344-2730 Fax :1-866-890-9290 CLN PRINTED: 10/29/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 30751 09/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1380 MARICE DRIVE THE COMMONS ON MARICE EAGAN, MN 55121 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE PREFIX PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 000 Initial Comments 0 000 *****ATTENTION***** Minnesota Department of Health is documenting the State Correction Orders ASSISTED LIVING PROVIDER LICENSING using federal software. Tag numbers have CORRECTION ORDER(S) been assigned to Minnesota State Statutes for Assisted Living Facilities. The In accordance with Minnesota Statutes, section assigned tag number appears in the 144G.08 to 144G.95, these correction orders are far-left column entitled "ID Prefix Tag." issued pursuant to a survey. The state Statute number and the corresponding text of the state Statute out Determination of whether violations are corrected of compliance is listed in the "Summary requires compliance with all requirements Statement of Deficiencies" column. This provided at the Statute number indicated below. column also includes the findings which When Minnesota Statute contains several items, are in violation of the state requirement failure to comply with any of the items will be after the statement, "This Minnesota considered lack of compliance. requirement is not met as evidenced by." Following the evaluators ' findings is the INITIAL COMMENTS: Time Period for Correction. SL30751016-0 PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On September 22, 2025, through September 24, STATES,"PROVIDER'S PLAN OF 2025, the Minnesota Department of Health CORRECTION." THIS APPLIES TO conducted a full survey at the above provider and FEDERAL DEFICIENCIES ONLY. THIS the following correction orders are issued. At the WILL APPEAR ON EACH PAGE. time of the survey, there were 125 residents; 92 receiving services under the Assisted Living THERE IS NO REQUIREMENT TO Facility with Dementia Care license. SUBMIT A PLAN OF CORRECTION FOR VIOLATIONS OF MINNESOTA STATE STATUTES. THE LETTER IN THE LEFT COLUMN IS USED FOR TRACKING PURPOSES AND REFLECTS THE SCOPE AND LEVEL ISSUED PURSUANT TO 144G.31 SUBDIVISION 1-3. 0 480 144G.41 Subdivision 1 Subd. 1a (a-b) Minimum 0 480 SS=F requirements; required food services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 YKH411 If continuation sheet 1 of 33 PRINTED: 10/29/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B.

Finding: 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 alleged perpetrators (AP)-1 and AP-2, who are administrative staff at the facility, abused the resident when they secluded her from visiting family member (FM)-1. Investigative Findings and Conclusion: The Minnesota Department of Health determined was not substantiated. AP-2 completed a trespass order on FM-1 for the safety of staff and residents. FM-1 was verbally and physically aggressive towards facility staff on multiple occasions. FM-1 was able to see the resident by arrangement of off-site visits. The investigation did not reveal evidence of negative effects to the resident related to the change in visit frequency of FM-1. Additionally, during the investigation, AP-1 was accused of preventing the resident from moving to another facility by telling the prospective facility lies, resulting in the facility not accepting the resident for placement. Evidence showed AP-1 participated in providing the other facility records to evaluate placement. The investigator conducted interviews with facility staff members, including administrative staff, unlicensed staff, and nursing staff. The investigator contacted a licensed social worker, family members, and the resident’s legal guardian. The investigation included review of the resident records, facility incident reports, personnel files, staff schedules, and related facility policy and procedures. Also, the investigator observed staff and resident interactions and resident cares while on site. The resident resided in an assisted living memory care unit. The resident’s diagnoses included dementia with behavioral disturbance and anxiety. The resident’s service plan included assistance with eating, dressing, bathing, medication administration and transfers. The resident’s assessment indicated the resident was dependent on the use of a wheelchair and was alert but confused. A facility provided document indicated a no trespassing order was issued to FM-1 seven months prior to the investigation. The order indicated the FM-1 could not enter the land of the facility for one year from the issued date. A family provided email correspondence indicated AP-1 contacted FM-1 one month prior to the trespass order requesting a sit-down meeting to discuss concerns the facility had regarding the actions of FM-1 that made staff feel uncomfortable. The email also stated the facility would like to assist with finding alternate placement to a different facility for the resident. The email indicated the facility had trespassed FM-1 from the facility. A nurse’s note indicated FM-1 entered the facility with a friend and was heading towards the elevator when she was intercepted by AP-2. AP-2 reminded FM-1 of the guidelines in place for visitation, and FM-1 became upset and waived papers in AP-2’s face. FM-1’s friend attempted to calm her down. The note indicated FM-1 stated she was not going to follow the guidelines. A nurse’s note indicated the resident’s legal guardian instructed AP-1 to remove a camera from the resident’s room that FM-1 had placed. Medical provider notes did not indicate any concern or change in the resident during the provider’s monthly visits after the trespass order was in place. During an interview, AP-1 stated FM-1 had been the resident’s guardian prior to the resident’s spouse pursing a third-party guardian due to family disagreements. AP-1 stated FM-1 was angry and unpredictable. AP-2 initiated a trespass order on FM-1 due to an incident when FM-1 aggressively lunged at AP-2. AP-1 stated the facility did not want to have to do a trespass order on FM-1 but had the duty to protect everyone. AP-1 stated there was further issues with FM-1 once the trespass order was in place. AP-1 stated FM-1 did not follow the order and continued to enter the building. AP-1 stated the resident continued to have visits with her family including FM-1 via home visits that were set up by family. AP-1 stated she noted a very positive change in the resident since the trespass order had been in place. The resident improved her self-feeding skills, goes to all activities, and was more vocal than before. AP-1 stated the staff did not note any negative changes in the resident since the trespass order was placed on FM-1. AP-1 stated she became aware of the resident referral to another facility when RN-2 presented to her office after she had completed an assessment on the resident. AP-1 stated RN-2 requested the resident’s medication list, face sheet and last six months of progress notes, which she provided to her. AP-1 stated she and RN-2 discussed the resident’s level of care and service plan. AP-1 stated as RN-2 looked through the resident’s progress notes, she stated she had concerns about FM-1. AP-2 stated she told RN-2 things have been better with the legal guardian in place. During an interview, AP-2 stated there had been several conversations with FM-1 regarding FM-1’s interference of the care of the resident and other facility residents. AP-2 stated FM-1 force fed the resident and gave other residents regular water who required thickened liquids. AP-2 stated he had to call the police on FM-1 when she came after him. AP-2 stated FM-1 did not think the trespass order had any value as she continued to try to enter the facility. AP-2 stated staff were directed by him to call the police if FM-1 entered the building, and there was an incident when staff began to call 911 on FM-1. FM-1 grabbed the phone from the staff member and hung up the call. AP-2 stated the resident, and her family could have visits off the property of the facility, and the facility staff prepared the resident to be ready for the visits. AP-2 stated there was a positive change noted with the resident after the trespass order was in place. AP-2 stated the resident was now on the verge of graduating from hospice services, was gaining weight, and gaining self-feeding independence. AP-2 stated having to complete a trespass order was not what they wanted to do, but felt it was necessary to protect all the resident’s and staff. During an interview, a nurse stated she met with the resident to complete an assessment for potential placement at the facility she worked for. The nurse stated she received the resident’s medication list from AP-1, and AP-1 let her know special arrangements were made for the resident to see FM-1 as she was not allowed on campus. The nurse stated the resident’s spouse let her know he used a camera in the resident’s room due to staff not having the resident up and ready when he wanted her ready. The nurse stated FM-1 wanted to be apart of the assessment, but the spouse hung his phone up on FM-1 to cut her out. The nurse stated it was unclear to her who the resident’s guardian was. The nurse stated the resident’s spouse told her about the restraint on FM-1. The nurse stated her managers made the final decision on new patient admissions, and they decided not to take the resident due to family drama that would not make the resident a fit at their facility. The nurse stated if the family drama concern was not there, the nurse‘s facility would have accepted the resident for placement. During an interview, the legal guardian stated he became the resident’s guardian when the resident’s spouse petitioned for one, two months after FM-1 was trespassed from the facility. The legal guardian stated he makes all final decisions regarding the resident. The legal guardian stated there had been a lot of lying and slandering towards him and the staff at the facility by FM-1. The legal guardian stated FM-1 violated the trespass order several times. The legal guardian stated FM-1 violated the facility’s policies several times despite many warnings and many chances to rectify. The legal guardian stated the trespass order could have been avoided. The legal guardian stated he instructed the facility to remove the second camera placed in the resident’s room by FM-1 due to FM-1 not following the proper procedure for placing the camera.

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 alleged perpetrator (AP) abused the resident when the AP refused to assist the resident out of bed. The resident was unable to get out of bed without help from staff and was unreasonably confined to bed. Investigative Findings and Conclusion: The Minnesota Department of Health determined abuse was not substantiated. Although the AP did not assist the resident out of bed when asked, the AP’s actions did not rise to the level of abuse. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator also interviewed a family member. The investigation included review of the resident records, death record, facility incident reports, personnel files, staff schedules, and related facility policy and procedures. Also, the investigator observed resident interactions with staff. The resident resided in an assisted living facility. The resident’s diagnoses included spinal stenosis, autonomic neuropathy, and spondylolysis. The resident’s services included assistance with activities of daily living, such as transfers, toileting, grooming, bathing, meals, and medication management. The resident’s assessment indicated she required the assistance of two staff members using a mechanical lift for transfers. The resident’s progress notes indicated she had requested assistance getting out of bed early in the morning. The AP told the resident it was early, and she told the resident she should stay in bed and keep her feet elevated. The resident became upset, started throwing blankets, and called a family member and told them the AP was holding her down against her will. The AP replaced the blankets and offered to assist the resident reposition in bed. The resident calmed and the AP left the room. When interviewed a supervisor said staff informed her of the progress note the AP wrote regarding the resident’s request to get out of bed. The supervisor said the resident was sleeping when day staff arrived, and they assisted the resident to get out of bed when she was ready. The supervisor stated when she spoke to the resident regarding the incident the resident stated her night was fine and she had no concerns regarding staff treatment. The supervisor said the resident was encouraged to elevate her legs as much as possible, however, the resident was not bedbound, and staff should assist the resident out of bed whenever she requests. When interviewed, the AP stated the resident asked to get out of bed early in the morning and the AP told the resident she needed to wait for another staff to assist with transferring the resident in the mechanical lift. The resident became agitated, so the AP stated when another staff was available about an hour later, they assisted the resident out of bed. When interviewed, the resident’s family stated they had no concerns with staff not assisting the resident with cares. In conclusion, the Minnesota Department of Health determined abuse 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. Abuse: Minnesota Statutes section 626.5572, subdivision 2. "Abuse" means: (a) An act against a vulnerable adult that constitutes a violation of, an attempt to violate, or aiding and abetting a violation of: (1) assault in the first through fifth degrees as defined in sections 609.221 to 609.224; (2) the use of drugs to injure or facilitate crime as defined in section 609.235; (3) the solicitation, inducement, and promotion of prostitution as defined in section 609.322; and (4) criminal sexual conduct in the first through fifth degrees as defined in sections 609.342 to 609.3451. A violation includes any action that meets the elements of the crime, regardless of whether there is a criminal proceeding or conviction. (b) Conduct which is not an accident or therapeutic conduct as defined in this section, which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to, the following: (1) hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult; (2) use of repeated or malicious oral, written, or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening. Vulnerable Adult interviewed: No, deceased. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Yes. Action taken by facility: The facility completed an investigation and provided re-training for staff. The AP is no longer employed at 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: 08/15/2024 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ C B. WING _____________________________ 30751 07/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1380 MARICE DRIVE THE COMMONS ON MARICE EAGAN, MN 55121 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 25, 2024, the Minnesota Department of Minnesota Department of Health is Health initiated an investigation of complaint documenting the State Correction Orders #HL307512293C/#HL307512840M. No correction using federal software. Tag numbers have orders are issued. been 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 is listed in the "Summary Statement of Deficiencies" column. This column also includes the findings which are in violation of the state requirement after the statement, "This Minnesota requirement is not met as evidenced by." Following the evaluators' findings is the Time Period for Correction. 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. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 PL2K11 If continuation sheet 1 of 1