Iris Park Commons.

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; Leve l4: a fine of $3,000 per incident, in addition to any enforcement mechanism authorized in An equal opportunity employer . Letter ID: IS7N REVISE 0D9/13/2021 Iris Park Commons October 29, 2025 Page 2 § 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 - 0510 - 144g.41 Subd. 3 - Infection Control Program - $500.00 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 $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. Iris Park Commons 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, Renee L. Anderson ,Supervisor State Evaluation Team Email: ReneeL. .Anderson@state.mn.us Telephone :651-201-5871 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 _____________________________ 23247 10/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1850 UNIVERSITY AVENUE WEST IRIS PARK COMMONS SAINT PAUL, MN 55104 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 far 144G.08 to 144G.95, these correction orders are 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. SL23247016-0 PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On September 29, 2025, through October 1, 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 60 residents; 60 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 8RKN11 If continuation sheet 1 of 12 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 facility neglected the resident when the facility failed provide appropriate care and services to prevent falls and subsequent injury. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. During the last week at the facility, the resident had a decline in health with increased weakness and unsteadiness. Following every fall, the facility nurse assessed, and implemented interventions to prevent future falls. Despite the interventions, the resident continued to fall and required hospitalization for a brain bleed. The investigator conducted interviews with facility nursing staff, unlicensed staff, and the resident’s family member. The investigator also interviewed the resident’s medical provider. The investigation included review of the resident’s medical records, hospital records, and facility policies and procedures. An equal opportunity employer. The resident resided in an assisted living memory care unit. The resident’s diagnoses included dementia, high blood pressure, coronary artery disease (this causes coronary arteries to narrow, limiting blood flow to the heart), and high cholesterol. The resident’s service plan included assistance with dressing, toileting, and medication management. The resident’s assessment indicated the resident was a high fall risk and walked independently with no devices. The resident’s assessment indicated the resident had severe cognitive impairment. The resident’s medical record indicated the week prior to the hospitalization, the resident had increased weakness and difficulty walking. The facility implemented interventions that included the resident wore proper footwear, a toileting schedule, and placing the resident in common areas while awake for staff supervision. In addition, the facility provided the resident an in-house wheelchair for mobility when the resident had difficulty walking due to increased safety concerns with falls. During that time, facility staff requested a physical and occupational therapy referral from the resident’s provider for an assessment. At the end of the week, facility staff assessed the resident for a change in condition including increased weakness and confusion. The resident’s provider requested an evaluation of the resident at the hospital. The resident returned to the facility that same evening. One hour after returning, the resident had an unwitnessed fall in the dining room. The resident sustained a bump to his forehead and a skin tear to his wrist. The family chose to keep the resident at the facility because the resident had just been evaluated at the hospital. Three days later, the resident had another unwitnessed fall with a cut to the resident’s head at the eyebrow. The facility arranged for the resident to be evaluated at a hospital and the resident was diagnosed with a brain bleed. The resident remained at the hospital to arrange for a higher level of care. Eight days later, the resident passed away at the hospital with comfort care. The resident’s hospital record indicated the resident sustained a brain bleed following a fall at the facility. The resident was severely agitated and confused. The resident received a platelet transfusion (cell fragments in the blood that forms clots and stop or prevent bleeding) because of the resident’s low platelet count in the blood, the brain bleed, and the resident’s use of Plavix (antiplatelet drug to prevent blood clots) and Aspirin. A provider prescribed Plavix and Aspirin to the resident because of the resident’s coronary artery disease. The resident received comfort cares and passed away eight days after admission to the hospital. Review of the hospital records indicated during the first hospital visit the resident’s platelet count was within normal range. Three days later, the resident’s platelet count was low. During an interview, the primary medical provider stated the resident had increased weakness and was sent to the hospital for an evaluation. The resident received the medications Plavix and Aspirin due to a stent (a tubular support placed temporarily inside a blood vessel, canal, or duct to aid healing or relieve an obstruction) placement. Plavix and Aspirin are medications used to decrease the chances of a heart attack or stroke. A cardiologist managed the resident’s Plavix and Aspirin. During an interview, leadership stated the resident was able to walk independently until the final week at the facility. The resident’s health declined, and the resident had a difficult time walking. The resident was provided an in-house wheelchair, staff were to continue to attempt to have the resident walk, but if it was too unsafe for the resident or staff, the resident was to use the wheelchair. In addition, the resident’s primary medical provider requested a physical and occupational therapy referral. Prior to the therapy assessment the resident was admitted to the hospital with a brain bleed and did not return to the facility. The resident was also to be in the common areas when awake. Leadership stated the resident received medications as prescribed by a physician order and medications can only be discontinued with a physician order. Review of the resident’s certificate of death indicated the primary cause of death was complications of a closed head injury from a fall to the floor. Other significant conditions contributing to the cause of death include lung disease, diabetes, coronary artery disease, hypertension, and past prostate cancer. During an interview, the family member stated the resident walked independently, but in the last week of being at the facility started to decline. The resident walked but became more unsteady. In the last week the facility staff arranged for the resident to use a wheelchair. During the investigation an additional concern investigated included staff failed to place the resident’s back brace on according to provider orders. During an interview, an unlicensed staff member stated the resident wore the back brace when not in bed or as the resident allowed. 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: The facility implemented interventions such as, making sure the resident had proper footwear on, a toileting schedule, had the resident in common areas while awake, provided a wheelchair for mobility and was seen at the emergency room on different occasions. 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: 08/11/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ C B. WING _____________________________ 23247 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1850 UNIVERSITY AVENUE WEST IRIS PARK COMMONS SAINT PAUL, MN 55104 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 27, 2023, the Minnesota Department of Health initiated an investigation of complaint HL232476825M/HL232472836C. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 1RG811 If continuation sheet 1 of 1

correction orders issued pursuant to the June 1, 2023 survey. In accordance with Minn. Stat. § 144G.31 Subd. 4 (a), state correction orders issued pursuant to the last survey, completed on June 1, 2023, found not corrected at the time of the September 27, 2023, follow-up survey and/or subject to penalty assessment are as follows: 0480 - Minimum Requirements - 144g.41 Subd 1 (13) (i) (b) - $500.00 The details of the violations noted at the time of this follow-up survey completed on September 27, 2023 (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. Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, t he total amount you are assessed is $500.00. You will be invoiced approximately 30 days after receipt of this notice, subject to appeal. 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. IMPOSITION OF FINES: Level 1: no fines or enforcement. Level 2: a fine of $500 per violation, in addition to any enforcement mechanism authorized in §144G.20 for widespread violations; Level 3: a fine of $3,000 per violation per incident, in addition to any enforcement mechanism authorized in §144G.20. An equal opportunity employer. Letter ID: 8GKP Revised 04/14/2023 Iris Park Commons October 17, 2023 Page 2 Level 4: a fine of $5,000 per incident, in addition to any enforcement mechanism authorized in §144 G.20. 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 REQUESTING A 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 MDH 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. Requests for hearing may be emailed to: Health.HRD.Appeals@state.mn.us. To appeal fines via reconsideration, please follow the procedure outlined above. P lease note that you may request a reconsideration o r a hearing, but not both. We urge you to review these orders carefully. If you have questions, please contact Jonathan Hill at Iris Park Commons October 17, 2023 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, Jonathan Hill, Supervisor State Evaluation Team Email: jonathan.hill@state.mn.us Telephone: 651-201-3993 Fax: 1 -866-890-9290 JMD PRINTED: 10/17/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ R B. WING _____________________________ 23247 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1850 UNIVERSITY AVENUE WEST IRIS PARK COMMONS SAINT PAUL, MN 55104 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 been assigned to Minnesota State Statutes for Assisted Living License In accordance with Minnesota Statutes, section Providers. The assigned tag number 144G.08 to 144G.95, this correction order(s) has appears in the far left column entitled "ID been issued pursuant to a survey. Prefix Tag." The state Statute number and the corresponding text of the state Statute Determination of whether a violation has been out of compliance is listed in the corrected requires compliance with all "Summary Statement of Deficiencies" requirements provided at the Statute number column. This column also includes the indicated below. When Minnesota Statute findings which are in violation of the state contains several items, failure to comply with any requirement after the statement, "This of the items will be considered lack of Minnesota requirement is not met as compliance. evidenced by." Following the surveyors' findings is the Time Period for Correction. INITIAL COMMENTS: SL23247015-1 PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On September 26-27, 2023, the Minnesota STATES,"PROVIDER'S PLAN OF Department of Health conducted a revisit at the CORRECTION." THIS APPLIES TO above provider to follow-up on orders issued FEDERAL DEFICIENCIES ONLY. THIS pursuant to a survey completed June 1, 2023. At WILL APPEAR ON EACH PAGE. the time of the survey, there were 58 active residents receiving services under the Assisted THERE IS NO REQUIREMENT TO Living with Dementia Care license. As a result of SUBMIT A PLAN OF CORRECTION FOR the revisit, the following orders were reissued. 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 KDFJ12 If continuation sheet 1 of 13 PRINTED: 10/17/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ R B. WING _____________________________ 23247 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1850 UNIVERSITY AVENUE WEST IRIS PARK COMMONS SAINT PAUL, MN 55104 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 had the potential to affect all residents of the assisted living facility. 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 September 27, 2023, for the specific Minnesota Food Code deficiencies. {0 680} 144G.42 Subd.