Boden Sr Living - Coon Rapids

Survey completed January 13, 2022: 17 correction orders

• Tag 110: 144G.10 Subdivision 1a Assisted living director license required Level 2, widespread scope, scope/level letter F · correction period: Two (2) days
  Details

  Summary: MDH found the licensee failed to ensure the licensed assisted living director (LALD)-D was listed as the Director of Record for the licensee.

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the licensed assisted living director (LALD)-D was listed as the Director of Record for the licensee. This had the potential to affect all the licensee's residents, staff, and visitors. [...]”

  Rule cited: “Each assisted living facility must employ an assisted living director licensed or permitted by the Board of Executives for Long Term Services and Supports.”

• Tag 480: 144G.41 Subd 1 (13) (i) (B) Minimum requirements Level 2, widespread scope, scope/level letter F · correction period: Twenty-one (21) days
  Details

  MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure food was prepared and served according to the Minnesota Food Code. 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 [...]”

  Rule cited: “(13) offer to provide or make available at least the following services to residents: (i) at least three nutritious meals daily with snacks available seven days per week, according to the recommended dietary allowances in the United States Department of [...]”

• Tag 580: 144G.42 Subd. 2 Quality management Level 2, widespread scope, scope/level letter F · correction period: Twenty-One (21) days
  Details

  Summary: MDH found the licensee failed to implement and maintain a quality management program appropriate to the size of the facility and relevant to the type of services provided.

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to implement and maintain a quality management program appropriate to the size of the facility and relevant to the type of services provided. This had the potential to affect all residents, staff, and visitors. [...]”

  Rule cited: “The facility shall engage in quality management appropriate to the size of the facility and relevant to the type of services provided. [...]”

• Tag 630: 144G.42 Subd. 6 Compliance with requirements for reporting ma Level 2, widespread scope, scope/level letter F · correction period: Seven (7) days
  Details

  Summary: MDH found the licensee failed to ensure an individual abuse prevention plan (IAPP) was developed to include the required content for three of three residents (R1, R2, and R3) with records reviewed.

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure an individual abuse prevention plan (IAPP) was developed to include the required content for three of three residents (R1, R2, and R3) with records reviewed. [...]”

  Rule cited: “(b) The facility must develop and implement an individual abuse prevention plan for each vulnerable adult. [...]”

• Tag 650: 144G.42 Subd. 8 Employee records Level 1, isolated scope, scope/level letter A · correction period: Twenty-one (21) days
  Details

  Summary: MDH found the licensee failed to ensure annual performance reviews were completed for one of two employees (registered nurse (RN)-A) with employee records reviewed.

  MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure annual performance reviews were completed for one of two employees (registered nurse (RN)-A) with employee records reviewed. [...]”

  Rule cited: “(a) The facility must maintain current records of each paid employee, each regularly scheduled volunteer providing services, and each individual contractor providing services. [...]”

From MDH’s letter: no immediate fines.

Allegation, as written: “The alleged perpetrator (AP) abused the resident when he was helping her to bed in a manner that pinched her arm leaving a bruise. In addition, the AP shut all the lights off in the room when the resident requested the bathroom light be left on.”

“The Minnesota Department of Health determined abuse was inconclusive.”

Summary: MDH looked into an allegation and found: abuse inconclusive.

MDH’s conclusion, as written: “The Minnesota Department of Health determined abuse was inconclusive. The AP denied being rough with the resident or pinching the resident. The AP also denied ignoring the request to leave the resident's bathroom light on.”

Action taken by facility: “The facility suspended the AP and investigated. The facility no longer employed the AP. The facility provided reeducation to all staff on abuse prevention and customer service.”

Action taken by MDH: “No further action taken at this time.”

Survey completed November 19, 2025: no correction orders issued.

Allegation, as written: “The facility neglected the resident when he fell and was hospitalized with a fractured hip. The resident fell a second time and was hospitalized with a UTI.”

“The Minnesota Department of Health determined neglect was inconclusive.”

Summary: MDH looked into an allegation and found: neglect inconclusive.

MDH’s conclusion, as written: “The Minnesota Department of Health determined neglect was inconclusive. The resident had a history of unwitnessed falls attributed to impulsiveness and not using his call pendant. Staff contacted the nurse when the resident fell and provided care. The nurse assessed and monitored the resident and sent him to the hospital as needed. The facility lacked a process for documenting resident safety checks and lacked documentation of provided services. The nurse stated she verbalized an increase in safety checks to unlicensed personnel (ULP) and when interview, ULP stated they received verbal direction to increase the frequency of safety checks. The facility failed to complete readmission assessments from both hospitalizations, however the facility added additional services to the resident's service plan in between the two hospitalizations.”

Action taken by facility: “Nurses assessed the resident, contacted his primary care provider and sent him to the hospital when appropriate. The resident's services plans were updated with additional services after the hospitalizations. Staff documented his falls in progress notes and incident reports.”

Action taken by MDH: “The facility was found to be in noncompliance.”

Survey completed September 11, 2024: 3 correction orders

• Tag 1620: 144G.70 Subd. 2 (c-e) Initial reviews, assessments, and monitoring Level 2, widespread scope, scope/level letter F
  Details

  Summary: MDH found the licensee failed to conduct resident readmission assessments for one of one (R1) residents reviewed.

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to conduct resident readmission assessments for one of one (R1) residents reviewed. R1 had two hospitalizations within three months and two different registered nurses (RN)s failed to conduct readmission assessment to address a change in condition. In addition, the licensee updated R1's service plan with new services, but lacked an assessment to indicate R1's functional status that determined the need for that services. [...]”

  Rule cited: “(c) Resident reassessment and monitoring must be conducted no more than 14 calendar days after initiation of services. [...]”

• Tag 1640: 144G.70 Subd. 4 (a-e) Service plan, implementation and revisions to Level 2, widespread scope, scope/level letter F
  Details

  Summary: MDH found the licensee failed to have a system of documenting services of safety checks and failed to update the service plan with safety checks when they were changed in frequency, for one of one resident (R1) reviewed.

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to have a system of documenting services of safety checks and failed to update the service plan with safety checks when they were changed in frequency, for one of one resident (R1) reviewed. In addition, other services added to R1's service agreement failed to have documentation the services were provided. [...]”

  Rule cited: “(a) No later than 14 calendar days after the date that services are first provided, an assisted living facility shall finalize a current written service plan. [...]”

• Tag 1650: 144G.70 Subd. 4 (f) Service plan, implementation and revisions to Level 2, isolated scope, scope/level letter D
  Details

  Summary: MDH found the licensee failed to ensure the service plan included all required components for one of one (R1) resident reviewed.

  MDH’s finding, as written: “Based on record review and interview, the licensee failed to ensure the service plan included all required components for one of one (R1) resident reviewed. 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 was issued at an isolated scope (when one or a limited number of residents are affected or one [...]”

  Rule cited: “(f) The service plan must include: (1) a description of the services to be provided, the fees for services, and the frequency of each service, according to the resident's current assessment and resident preferences; (2) the identification of staff or [...]”

Survey completed March 30, 2026: no correction orders issued.

Allegation, as written: “The facility neglected the resident. The resident had chronic leg wounds that were wrapped and required wound care and management. She developed lower limb ischemia (no circulation) with gangrene and was hospitalized. The resident died from sepsis.”

“The Minnesota Department of Health determined neglect was not substantiated.”

Summary: MDH looked into an allegation and found: neglect not substantiated.

MDH’s conclusion, as written: “The Minnesota Department of Health determined neglect was not substantiated. The resident was her own decision maker. She had weekly out-patient complex wound care visits and treatments for chronic leg ulcers and osteomyelitis. The facility did not manage her wounds; therefore the nurse did not assess the resident's legs because they were wrapped with compression dressings and in soft casts. The resident did not often share information from the clinic visits with the facility nurse. When the resident experienced a change in condition a few days after a wound clinic visit, the nurse called 911 and sent the resident to the hospital. The resident was admitted and died from critical limb ischemia and gangrene.”

Action taken by facility: “The facility nurse assessed the resident and sent her to the hospital.”

Action taken by MDH: “The facility was found to be in noncompliance.”

Survey completed June 17, 2025: 2 correction orders

• Tag 730: 144G.43 Subd. 3 Contents of resident record Level 2, isolated scope, scope/level letter D
  Details

  Summary: MDH found the licensee failed to ensure the contents of a resident record included contact information for medical providers and documentation of significant changes in the resident's status and actions taken for one of two residents (R2) reviewed.

  MDH’s finding, as written: “Based on record review and interviews, the licensee failed to ensure the contents of a resident record included contact information for medical providers and documentation of significant changes in the resident's status and actions taken for one of two residents (R2) reviewed. R2's record lacked documentation that nursing staff attempted to contact the wound care provider for regular updates on R2's leg wounds and complex wound dressings. R2 was hospitalized with sepsis and died. [...]”

  Rule cited: “Contents of a resident record include the following for each resident: (1) identifying information, including the resident's name, date of birth, address, and telephone number; (2) the name, address, and telephone number of the resident's emergency contact, [...]”

• Tag 2360: 144G.91 Subd. 8 Freedom from maltreatment
  Details

  Summary: MDH found the facility failed to ensure one of one resident reviewed (R1) was free from maltreatment.

  MDH’s finding, as written: “The facility failed to ensure one of one resident reviewed (R1) was free from maltreatment. Findings include: The Minnesota Department of Health (MDH) issued a determination maltreatment occurred, and an individual person was responsible for the maltreatment, in connection with incidents which occurred at the facility. Please refer to the public maltreatment report for details.”

  Rule cited: “Residents have the right to be free from physical, sexual, and emotional abuse; neglect; financial exploitation; and all forms of maltreatment covered under the Vulnerable Adults Act.”