Amira Choice Minnetonka.

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; 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 An equal opportunity employer . Letter ID: IS7N REVISE 0D9/13/2021 Amira Choice Minnetonka Novembe r17, 2025 Page 2 pursuant to this survey: St - 0 - 1950 - 144g.72 Subd. 4 - Administration Of Treatments And Therapy - $1,000.00 Therefore ,in accordance with Minn. Stat. §§ 144G0. 1 to 144G9. 999, the total amount you are assesse dis $1,000.00. 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. 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 Amira Choice Minnetonka Novembe r17, 2025 Page 3 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, Casey DeVries ,Supervisor State Evaluation Team Email: CaseyD. eVries@state.mn.us Telephone :651-201-5917 Fax :1-866-890-9290 CLN 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: ______________________ B. WING _____________________________ 33358 11/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2004 PLYMOUTH ROAD AMIRA CHOICE MINNETONKA MINNETONKA, MN 55305 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. SL33358016-0 PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On November 3, 2025, through November 5, 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 109 residents; 57 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 An immediate correction order was identified on STATUTES. November 4, 2025, issued for SL33358016-0, tag identification 1950. THE LETTER IN THE LEFT COLUMN IS USED FOR TRACKING PURPOSES AND During the survey, the licensee took action to REFLECTS THE SCOPE AND LEVEL mitigate the immediate risk. However, ISSUED PURSUANT TO 144G.31 noncompliance remained, and the scope and SUBDIVISION 1-3. level remain unchanged. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 07GR11 If continuation sheet 1 of 19 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: ______________________ B. WING _____________________________ 33358 11/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2004 PLYMOUTH ROAD AMIRA CHOICE MINNETONKA MINNETONKA, MN 55305 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) 0 510 Continued From page 1 0 510 0 510 144G.41 Subd. 3 Infection control program 0 510 SS=E (a) All assisted living facilities must establish and maintain an infection control program that complies with accepted health care, medical, and nursing standards for infection control.

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 alleged perpetrator (AP), facility staff, neglected the resident when the AP failed to provide services to the resident per the resident’s plan of care. The resident fell and laid on the floor with a broken hip yelling for help for 48 minutes before staff found her. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was substantiated. The AP was responsible for the maltreatment. The AP failed to assist the resident with dressing in appropriate sleep wear, perform safety checks, provide toileting assistance, and administer medication for sleeplessness. The AP failed to provide cares for approximately 9 hours prior to the resident falling. After the resident fell, she laid on the floor yelling for help for approximately 48 minutes until staff entered the apartment. The resident was sent to the hospital, diagnosed with a right hip fracture, underwent surgery for comfort, and died five days later. The resident’s death record indicated the resident died of complications of a right leg fracture due to a fall five days previously. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigation included review of medical records, death record, hospital records, facility internal investigation, facility incident reports, personnel files, staff schedules, and related facility policy and procedures. Also, the investigator observed staff members providing care to residents. The resident resided in an assisted living memory care unit. The resident’s diagnoses included dementia, painful joint disease (osteoarthritis), and difficulty sleeping (insomnia). The resident’s service plan included evening assistance dressing and getting ready for bed and directed staff to ensure the resident wore a night shirt. The service plan directed staff to complete safety checks to monitor for wandering twice during the night shift with notation staff administer trazadone, (medication used for sleep) if the resident was not sleeping by 11:00 P.M. The resident’s service plan included toileting and continence care twice each night shift, indicating again the resident should wear a night shirt. The resident’s assessment indicated the resident had cognitive deficits, delayed response, needed additional time for communication, had chronic knee pain, required verbal cueing, and needed assistance of one staff member for dressing and toileting and incontinence care. During the night of the incident, the AP documented completing evening dressing assistance and two-night shift safety checks. Service checkoff documentation indicated the AP did not complete toileting twice during the night due and wrote, “other” and resident “performed self care.” Medication administration record the night of the incident indicated as needed trazadone for sleeplessness after 11:00 P.M. was not administered. Review of video footage from the night of the incident the AP was observed opening the resident’s closet full of clothing and then he went to a dresser and pulled out a long robe. The AP did not greet the resident or explain what he was about to do, rather the AP verbalized abrupt commands to the resident. The AP dressed the resident in a long open robe leaving her breasts exposed. The AP stated, “okay, go to bed”, picked up items from the floor, turned off the main light, and left the resident’s apartment while the resident continued to try to get comfortable and get her legs into bed. Video footage indicated the resident was up and walking in her apartment throughout the night until she lost her balance while attempting to dress herself. The resident laid on the floor yelling for help for approximately 48 minutes until staff entered the apartment. Video footage indicated staff did not enter the resident’s apartment after the AP assisted with bedtime cares until over nine hours later when staff found the resident on the floor. Video footage indicated the resident expressed to emergency response team members she was in severe pain and emergency response staff removed the resident from her apartment via gurney. Review of hospital records indicated the resident presented with a right hip fracture, underwent surgery for comfort, and died five days later. During interview, an unlicensed staff member working the night of the incident stated she and a second staff member heard a repeating cry. The first and second staff member found the resident on the floor of her apartment. During interview, a second unlicensed staff member working the night of the incident stated staff were directed to check on residents, especially during the night, to make sure residents are not soiled and to assist with toileting. During interview, the AP stated he cared for the resident the evening and night shift of the incident. The AP stated he put the resident in a robe because he could not find other bed clothing for the resident. The AP stated during a night shift (which is eight hours long) he checked on residents every two hours and looked in on residents from apartment doorways. The AP stated he did not wake residents if they were sleeping in bed. The AP stated during the night he checked on the resident two times and the resident was in bed the last time he checked. During interview, a leadership member indicated she reviewed hallway surveillance footage from the night of the incident and no staff were observed going into the resident’s room, indicating safety checks and toileting were not completed. The leadership member stated the AP was assigned to the resident during the night of the incident and erroneously documented completing services. The leadership member stated the AP previously had issues conducting cares, including not performing services as indicated. During interview, a second leadership member indicated she reviewed apartment video footage from the time in question. The second leadership member stated she had concerns regarding the care the resident received during the night of the incident, including the AP dressing the resident in a robe because the resident was likely uncomfortable. The AP failed to conduct safety checks and the resident laid on the floor for a significant amount of time after the fall. The second leadership member stated staff are to check on residents at night to make sure residents are safe and that residents are toileted as needed. Review of the AP’s employee file indicated the AP completed training regarding dementia, resident bill of rights, customer service, fall prevention, bathing and dressing, toileting, medication management, and vulnerable adults. In conclusion, the Minnesota Department of Health determined neglect was substantiated. Substantiated: Minnesota Statutes, section 626.5572, Subdivision 19. “Substantiated” means a preponderance of evidence shows that an act that meets the definition of maltreatment occurred. 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, deceased. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Yes. Action taken by facility: The facility conducted an internal review of the incident and re-educated staff members regarding resident safety checks. The AP is no longer employed by the facility. Action taken by the Minnesota Department of Health: The facility was found to be in noncompliance. To view a copy of the Statement of Deficiencies and/or correction orders, please visit: https://www.health.state.mn.us/facilities/regulation/directory/provcompselect.html If you are viewing this report on the MDH website, please see the attached Statement of Deficiencies. You may also call 651-201-4200 to receive a copy via mail or email The responsible party will be notified of their right to appeal the maltreatment finding. If the maltreatment is substantiated against an identified employee, this report will be submitted to the nurse aide registry for possible inclusion of the finding on the abuse registry and/or to the Minnesota Department of Human Services for possible disqualification in accordance with the provisions of the background study requirements under Minnesota 245C.

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, both unlicensed caregivers, neglected the resident by marking services as completed when they were not performed. The resident was not checked on from 7:30 pm to 12:30 am. She was found on the floor with a deep cut above her left eye. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. The facility scheduled a safety check at 7:30 PM with the next one scheduled at 1:00 AM. It may have been true no one checked on the resident after 7:30 PM until after midnight but the facility did not have any safety checks scheduled at that time during that shift. The investigator conducted interviews with facility staff members, including administrative staff, and unlicensed staff. The investigation included review of the resident’s records, internal investigation documentation, incident reports, personnel files, staff schedules, policies, and procedures. The resident resided in an assisted living memory care unit. The resident’s assessment indicated the resident needed assist of one person for mobility and alert to self only. The resident’s service plan included safety checks. An incident report indicated the resident was found on the floor shortly after midnight when AP #2 entered the room to perform a safety check. AP #2 contacted the on-call nurse, and the resident was sent to the hospital to treatment of a deep cut above her left eye. Later a concern arose that the resident’s safety checks were not performed the evening leading up to the resident’s fall. A video recording was reported to the facility which showed no one entered the resident’s room from 7:30 PM on the 14th day of that month until 1230 AM on the 15th (evening into night shift). During this time, AP#1 worked the evening shift while AP #2 worked the night shift and they had documented completion of all the scheduled safety checks from 7:30 PM to 12:30 AM. The service checkoff list for the 14th indicated the facility scheduled safety checks at 7:00 PM and at 7:30 PM on the evening shift. The same document indicated the next safety check the facility scheduled was at 1:00 AM on the night shift. A review of this document identified no scheduled safety checks between 7:30 PM and 1:00 AM for AP #1 nor AP #2 to perform. The same document indicated the facility did add more safety checks like one at 11 PM but that did not go into effect until the 15th (about 24 hours after the resident’s fall). During an interview, a manager stated she received a report from triage about the fall overnight. The manager stated the resident returned to the facility the same day with an order for wound care. The manager said that staff members were expected to perform safety checks on all residents in the memory care unit every two hours. However, according to the video footage provided by the family in the resident’s room, staff members did not check on the resident from 7:30 pm to 12:30 am, when the resident was found on the floor. During an interview, AP #1 stated she had already left for the day when the resident was found on the floor. She was not sure, but she said the last time she checked on the resident was around 8 pm. AP #1 stated she recalled the resident safety checks were about every three hours. During an interview, AP #2 stated she found the resident on the floor during her rounds. She stated she recalled the resident’s safety checks were about every two hours. During the investigation, despite multiple attempts, the investigator was unable to obtain a copy of the video footage, so it was not viewed. 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: No, attempted but did not reach. Alleged Perpetrator interviewed: Yes. Action taken by facility: The resident was sent to the hospital for further evaluation. The resident’s service plan was updated with additional safety checks. 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: 07/29/2024 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 _____________________________ 33358 06/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2004 PLYMOUTH ROAD AMIRA CHOICE MINNETONKA MINNETONKA, MN 55305 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 June 24, 2024, the Minnesota Department of Health initiated an investigation of complaints #HL333582160M/HL333581180C, and #HL333584081M/HL333584687C . No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 ZYBW11 If continuation sheet 1 of 1