Diamond Willow Assisted Living

Last evaluation

December 10, 2025

Evaluations on record

2

Investigations substantiated

3 kept 7 years

Inconclusive

0 kept 4 years

Unsubstantiated

0 kept 3 years

Most recent evaluation (December 10, 2025, state report KR0311)

MDH: “On December 8, 2025, through December 10, 2025, the Minnesota Department of Health conducted a full survey at the above provider and the following correction orders are issued.”

Survey completed December 10, 2025: 13 correction orders

• Tag 480: 144G.41 Subdivision 1 Subd. 1a (a-b) Minimum requirements; required food services Level 2, widespread scope, scope/level letter F · correction period: Please refer to the FBEIR for any compliance dates
  Details

  Summary: MDH found the licensee failed to ensure food was prepared and served according to the Minnesota Food Code.

  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, but was not likely to cause serious injury, impairment, or death), and is issued at a widespread scope (when problems are pervasive or represent a systemic failure that has [...]”

  Rule cited: “(a) Except as provided in paragraph (b), food must be prepared and served according to the Minnesota Food Code, Minnesota Rules, chapter 4626. [...]”

• Tag 485: 144G.41 Subdivision 1.a (a) Minimum requirements; required food services Level 1, widespread scope, scope/level letter C · correction period: Twenty-one (21) days
  Details

  Summary: MDH found the licensee failed to ensure the assisted living contract did not require any resident to include and pay for meals as a part of their assisted living contract.

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the assisted living contract did not require any resident to include and pay for meals as a part of their assisted living contract. This had the potential to affect all residents. [...]”

  Rule cited: “(a) All assisted living facilities must offer to provide or make available 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 Agriculture (USDA) [...]”

• Tag 510: 144G.41 Subd. 3 Infection control program Level 2, pattern scope, scope/level letter E · correction period: Seven (7) days
  Details

  Summary: MDH found the licensee failed to ensure services were provided according to accepted health care, medical, or nursing standards in regard to infection control during medication administration

  MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure services were provided according to accepted health care, medical, or nursing standards in regard to infection control during medication administration for two of five employees (unlicensed personnel (ULP)-F, ULP-E). [...]”

  Rule cited: “(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. [...]”

• Tag 660: 144G.42 Subd. 9 Tuberculosis prevention and control Level 2, isolated scope, scope/level letter D · correction period: Twenty-one (21) days
  Details

  Summary: MDH found the licensee failed to establish and maintain a tuberculosis (TB) prevention program based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC) and Minnesota Department of Health (MDH), including completion of a two-step TST (tuberculin skin test) or other evidence of TB screening such as a blood test for one of two employees (clinical nurse supervisor (CNS) -B).

  MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to establish and maintain a tuberculosis (TB) prevention program based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC) and Minnesota Department of Health (MDH), including completion of a two-step TST (tuberculin skin test) or other evidence of TB screening such as a blood test for one of two employees (clinical nurse supervisor (CNS) -B). [...]”

  Rule cited: “(a) The facility must establish and maintain a comprehensive tuberculosis infection control program according to the most current tuberculosis infection control guidelines issued by the United States Centers for Disease Control and Prevention (CDC), Division [...]”

• Tag 680: 144G.42 Subd. 10 Disaster planning and emergency preparedness Level 1, widespread scope, scope/level letter C · correction period: Twenty-one (21) days
  Details

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the missing resident policy was reviewed quarterly. This had the potential to affect all residents. This practice resulted in a level one violation (a violation that will cause only minimal impact on the resident and does not affect health or safety) and 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 [...]”

  Rule cited: “(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 [...]”

From MDH’s letter: the letter says the facility is in substantial compliance; no immediate fines.

Food and beverage inspection (included in this report): Food and beverage inspection report included

Substantiated investigations (state reports)

• January 14, 2025 · report HL253806722M · MDH finding: Substantiated, facility responsibility
  Details

  Allegation, as written: “The alleged perpetrator (AP), facility staff, neglected the resident when the AP did not follow the resident's plan of care, falsely documented services were completed, and the resident fell from a mechanical lift.”

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

  “The facility was responsible for the maltreatment.”

  Summary: MDH looked into an allegation and found: neglect substantiated (facility responsibility).

  MDH’s conclusion, as written: “The Minnesota Department of Health determined neglect was substantiated. The facility was responsible for the maltreatment. Facility licensed staff failed to accurately assess and care plan in order to provide the resident with appropriate transfer assistance following the resident's change in condition. As a result, the resident fell from a standing lift.”

  Action taken by facility: “The facility collaborated with an outside agency to provide services for the resident.”

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

  Survey completed December 17, 2024: 6 correction orders

  • Tag 1620: 144G.70 Subd. 2 (c-e) Initial reviews, assessments, and monitoring Level 2, isolated scope, scope/level letter D · correction period: Twenty-One (21) days
    Details

    Summary: MDH found the licensee failed to complete an accurate comprehensive reassessment by a registered nurse (RN) for one of one resident (R1) with a change of condition, including addition of interventions as needed with a change of conditions.

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to complete an accurate comprehensive reassessment by a registered nurse (RN) for one of one resident (R1) with a change of condition, including addition of interventions as needed with a change of conditions. [...]”

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

  • Tag 1650: 144G.70 Subd. 4 (f) Service plan, implementation and revisions to Level 2, isolated scope, scope/level letter D · correction period: Twenty-One (21) days
    Details

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

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the service plan included all required content for one of one resident (R1) with records 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 [...]”

    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 [...]”

  • Tag 1940: 144G.72 Subd. 3 Individualized treatment or therapy managemen Level 2, isolated scope, scope/level letter D · correction period: Seven (7) days
    Details

    Summary: MDH found the licensee failed to develop an individualized treatment management plan to include all required content for one of one resident (R1) who received supplemental oxygen treatments.

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop an individualized treatment management plan to include all required content for one of one resident (R1) who received supplemental oxygen treatments. [...]”

    Rule cited: “For each resident receiving management of ordered or prescribed treatments or therapy services, the assisted living facility must prepare and include in the service plan a written statement of the treatment or therapy services that will be provided to the [...]”

  • Tag 1950: 144G.72 Subd. 4 Administration of treatments and therapy Level 3, isolated scope, scope/level letter G · correction period: Seven (7) days
    Details

    Summary: MDH found the licensee failed to ensure specific written instructions for each resident were documented in one of one resident's record (R1) who received treatments.

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure specific written instructions for each resident were documented in one of one resident's record (R1) who received treatments. This failure had the potential to affect R1's health and safety. [...]”

    Rule cited: “Ordered or prescribed treatments or therapies must be administered by a nurse, physician, or other licensed health professional authorized to perform the treatment or therapy, or may be delegated or assigned to unlicensed personnel by the licensed health [...]”

  • Tag 1960: 144G.72 Subd. 5 Documentation of administration of treatments Level 2, isolated scope, scope/level letter D · correction period: Seven (7) days
    Details

    Summary: MDH found the licensee failed to ensure treatments or therapies were monitored and/or followed up on for effectiveness for one of one resident (R1) with supplemental oxygen, pressure sore reducing boots and wound care managed by the provider.

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure treatments or therapies were monitored and/or followed up on for effectiveness for one of one resident (R1) with supplemental oxygen, pressure sore reducing boots and wound care managed by the provider. [...]”

    Rule cited: “Each treatment or therapy administered by an assisted living facility must be in the resident record. [...]”

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

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

    MDH’s finding, as written: “The facility failed to ensure one of one residents reviewed (R1) was free from maltreatment. Findings include: The Minnesota Department of Health (MDH) issued a determination maltreatment occurred, and the facility 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.”

• August 2, 2024 · report HL253803962M · MDH finding: Substantiated, facility responsibility
  Details

  Allegation, as written: “The resident was abused when facility staff restrained the resident using chemical restraints, bed railings, and other objects. Then, staff forced dentures into the resident's mouth causing the resident to cry and be visibly shaken. In addition, the resident was neglected when staff failed to provide the resident assistance with cares and the resident was observed wearing food encrusted clothing and smelling of urine with a saturated brief.”

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

  Summary: MDH looked into an allegation and found: neglect substantiated (facility responsibility).

  MDH’s conclusion, as written: “The Minnesota Department of Health determined neglect was substantiated. The facility was responsible for the neglect. The facility failed to ensure toileting and incontinence care was consistently provided. The resident was observed multiple times over several months in soiled clothing with a saturated incontinence brief. The allegation of abuse was not substantiated. The residents medications, side rails, and body pillow was reviewed and no restraints were identified.”

  Action taken by facility: “No action was taken.”

  Action taken by MDH: “The responsible party will be notified of their right to appeal the maltreatment finding. The facility was found to be in noncompliance.”

  Survey completed June 24, 2024: 4 correction orders

  • Tag 620: 144G.42 Subd. 6 (a) / 626.557, Subd. 3 Compliance with requirements for reporting ma Level 2, isolated scope, scope/level letter D · correction period: Seven (7) days
    Details

    MDH’s finding, as written: “Based on interview and record review the licensee failed to report an allegation of abuse to the Minnesota Adult Abuse Reporting Center (MAARC) for one of one resident's (R1) when it was reported an unlicensed staff (ULP)-C was observed forcefully putting in R1's dentures which caused the resident to cry and appear visibly shaken. [...]”

    Rule cited: “(a) The assisted living facility must comply with the requirements for the reporting of maltreatment of vulnerable adults in section 626.557. [...]”

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

    MDH’s finding, as written: “Based on interview and record review the licensee failed to develop and implement an individualized abuse prevention plan (IAPP) to include and assessment of the residents susceptibility to abuse, and statements of specific measures to be taken to minimize the risk of abuse for one of one resident's (R1) reviewed. R1's IAPP failed to identify individual vulnerabilities with interventions to reduce the risk of abuse and failed to update the IAPP after an incident occurred to prevent recurrence. [...]”

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

  • Tag 730: 144G.43 Subd. 3 Contents of resident record Level 2, isolated scope, scope/level letter D · correction period: Seven (7) days
    Details

    Summary: MDH found the licensee failed to ensure the resident record had the required contents including documentation services provided as identified in the resident's assessment of needs, frequency of services to be provided on the resident's service plan, incident's involving the resident and actions taken in response to the needs of the resident, and failed to document complaints and resolution of concerns reported for one of one residents (R1) with records reviewed.

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the resident record had the required contents including documentation services provided as identified in the resident's assessment of needs, frequency of services to be provided on the resident's service plan, incident's involving the resident and actions taken in response to the needs of the resident, and failed to document complaints and resolution of concerns reported for one of one residents (R1) with records reviewed. [...]”

    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 residents reviewed (R1) was free from maltreatment.

    MDH’s finding, as written: “The facility failed to ensure one of one residents reviewed (R1) was free from maltreatment. Findings include: The Minnesota Department of Health (MDH) issued a determination maltreatment occurred, and the facility 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.”

• June 17, 2024 · report HL253802460M · MDH finding: Substantiated, facility responsibility
  Details

  Allegation, as written: “The facility neglected the resident when the resident sustained multiple falls and staff failed to assess and develop new interventions to prevent further falls. In addition the facility failed to ensure medication was administered as prescribed and the resident was not administered scheduled morphine and lorazepam.”

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

  “The facility was responsible for the maltreatment.”

  Summary: MDH looked into an allegation and found: neglect substantiated (facility responsibility).

  MDH’s conclusion, as written: “The Minnesota Department of Health determined neglect was substantiated. The facility was responsible for the maltreatment. The resident sustained multiple falls and the facility failed to investigate the cause, reassess the resident and failed to create and implement new fall interventions following each fall. The resident fell nine times in the month that he died; seven of the falls occurred in the days leading up to his death. In addition, the facility failed to ensure a system was in place to ensure medications were transcribed and administered in accordance with physician's orders and the resident did not receive scheduled pain and anxiety medications.”

  Action taken by facility: “No action taken.”

  Action taken by MDH: “The responsible party will be notified of their right to appeal the maltreatment finding. The facility was found to be in noncompliance.”

  Survey completed April 9, 2024: 16 correction orders

  • Tag 250: 144G.20 Subdivision 1 Conditions Level 2, widespread scope, scope/level letter F · correction period: Twenty-one (21) days
    Details

    Summary: MDH found the licensee failed to ensure the management officials who were in charge of the day-to-day operations and responsible for the resident's assisted living services, understood all of the assisted living facility regulations.

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the management officials who were in charge of the day-to-day operations and responsible for the resident's assisted living services, understood all of the assisted living facility regulations. This had the potential to affect all residents. [...]”

    Rule cited: “(a) The commissioner may refuse to grant a provisional license, refuse to grant a license as a result of a change in ownership, refuse to renew a license, suspend or revoke a license, or impose a conditional license if the owner, controlling individual, or [...]”

  • Tag 450: 144G.41 Subdivision 1 Minimum requirements Level 2, widespread scope, scope/level letter F · correction period: Twenty-one (21) days
    Details

    Summary: MDH found the licensee failed to follow up on concerns brought forward related to resident care and the service delivery process and failed to provide services in a person-centered manner for

    MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to follow up on concerns brought forward related to resident care and the service delivery process and failed to provide services in a person-centered manner for two of three residents reviewed (R2, R6). [...]”

    Rule cited: “All assisted living facilities shall: (1) distribute to residents the assisted living bill of rights; (2) provide services in a manner that complies with the Nurse Practice Act in sections 148.171 to 148.285; (3) utilize a person-centered planning and service [...]”

  • Tag 490: 144G.41 Subd 1 (13) (ii)-(vii) Minimum requirements Level 2, widespread scope, scope/level letter F · correction period: Twenty-one (21) days
    Details

    Summary: MDH found the licensee failed to have daily programs of social and recreational activities based on individual and group interests, physical, mental, and psychosocial needs.

    MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to have daily programs of social and recreational activities based on individual and group interests, physical, mental, and psychosocial needs. This had the potential to affect all residents. [...]”

    Rule cited: “(iv) upon the request of the resident, provide direct or reasonable assistance with arranging for transportation to medical and social services appointments, shopping, and other recreation, and provide the name of or other identifying information about the [...]”

  • Tag 510: 144G.41 Subd. 3 Infection control program Level 2, widespread scope, scope/level letter F · correction period: Seven (7) days
    Details

    Summary: MDH found the licensee failed to establish and maintain an effective infection control program to comply with accepted health care, medical, and nursing standards for infection control and current recommendations for hand hygiene.

    MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to establish and maintain an effective infection control program to comply with accepted health care, medical, and nursing standards for infection control and current recommendations for hand hygiene. This had the potential to affect all the licensee's residents, staff, and visitors. [...]”

    Rule cited: “(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. [...]”

  • Tag 800: 144G.45 Subd. 2 (a) (4) Fire protection and physical environment Level 2, widespread scope, scope/level letter F · correction period: Seven (7) days
    Details

    Summary: MDH found the licensee failed to provide the physical environment in a continuous state of good repair and operation with regard to the health, safety, and well-being of the residents.

    MDH’s finding, as written: “Based on observation and interview, the licensee failed to provide the physical environment in a continuous state of good repair and operation with regard to the health, safety, and well-being of the residents. This had the potential to directly affect all residents, staff, and visitors. [...]”

    Rule cited: “(4) keep the physical environment, including walls, floors, ceiling, all furnishings, grounds, systems, and equipment in a continuous state of good repair and operation with regard to the health, safety, comfort, and well-being of the residents in accordance [...]”

  Show all 16

  • Tag 1460: 144G.63 Subdivision 1 Orientation of staff and supervisors Level 2, widespread scope, scope/level letter F · correction period: Twenty-One (21) days
    Details

    Summary: MDH found the licensee failed to ensure orientation to assisted living licensing requirements and regulations was completed for one of one employees (licensed practical nurse (LPN)-D).

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure orientation to assisted living licensing requirements and regulations was completed for one of one employees (licensed practical nurse (LPN)-D). This has the potential to affect all residents. [...]”

    Rule cited: “All staff providing and supervising direct services must complete an orientation to assisted living facility licensing requirements and regulations before providing assisted living services to residents. [...]”

  • Tag 1690: 144G.71 Subdivision 1 Medication management services Level 2, widespread scope, scope/level letter F · correction period: Seven (7) days
    Details

    Summary: MDH found the licensee failed to implement and maintain current medication management policies and procedures that were developed under the supervision and direction of a registered nurse (RN) consistent with current practice standards and guidelines.

    MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to implement and maintain current medication management policies and procedures that were developed under the supervision and direction of a registered nurse (RN) consistent with current practice standards and guidelines. The licensee failed to follow their policy related to medication errors and failed to take action after identifying an issue with the process to receive orders. [...]”

    Rule cited: “(a) This section applies only to assisted living facilities that provide medication management services. [...]”

  • Tag 1940: 144G.72 Subd. 3 Individualized treatment or therapy managemen Level 2, isolated scope, scope/level letter D · correction period: Seven (7) days
    Details

    Summary: MDH found the licensee failed to develop and implement a treatment or therapy management plan to include all required content for one of one resident (R3) who had treatments managed by the facility.

    MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to develop and implement a treatment or therapy management plan to include all required content for one of one resident (R3) who had treatments managed by the facility. [...]”

    Rule cited: “For each resident receiving management of ordered or prescribed treatments or therapy services, the assisted living facility must prepare and include in the service plan a written statement of the treatment or therapy services that will be provided to the [...]”

  • Tag 1950: 144G.72 Subd. 4 Administration of treatments and therapy Level 2, isolated scope, scope/level letter D · correction period: Seven (7) days
    Details

    Summary: MDH found the licensee failed to ensure the registered nurse (RN) specified, in writing, specific treatment instructions for each resident, and documented those instructions in the resident record one of one residents (R3).

    MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) specified, in writing, specific treatment instructions for each resident, and documented those instructions in the resident record one of one residents (R3). In addition, the licensee failed to ensure the RN instructed unlicensed personnel in the proper methods with respect to each resident and that unlicensed personnel demonstrated the ability to competently follow the procedures. [...]”

    Rule cited: “Ordered or prescribed treatments or therapies must be administered by a nurse, physician, or other licensed health professional authorized to perform the treatment or therapy, or may be delegated or assigned to unlicensed personnel by the licensed health [...]”

  • Tag 2310: 144G.91 Subd. 4 (a) Appropriate care and services Level 3, isolated scope, scope/level letter G · correction period: IMMEDIATE
    Details

    Summary: MDH found the licensee failed to provide care and services according to acceptable health care standards, and medical or nursing standards for one of one residents (R2) who utilized consumer bed rails.

    MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to provide care and services according to acceptable health care standards, and medical or nursing standards for one of one residents (R2) who utilized consumer bed rails. This resulted in an immediate correction order issued on April 2, 2024, at 2:00 p.m. [...]”

    Rule cited: “(a) Residents have the right to care and assisted living services that are appropriate based on the resident's needs and according to an up-to-date service plan subject to accepted health care standards.”

  • Tag 2320: 144G.91 Subd. 4 (b) Appropriate care and services Level 3, pattern scope, scope/level letter H · correction period: Seven (7) days
    Details

    Summary: MDH found the licensee failed to provide care and services according to acceptable health care, medical, or nursing standards related to falls and medication errors.

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide care and services according to acceptable health care, medical, or nursing standards related to falls and medication errors. The licensee failed to have a fall management system that ensured staff provided the resident with supervision and implemented interventions after falls for one of one resident (R1) reviewed. [...]”

    Rule cited: “(b) Residents have the right to receive health care and other assisted living services with continuity from people who are properly trained and competent to perform their duties and in sufficient numbers to adequately provide the services agreed to in the [...]”

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

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

    MDH’s finding, as written: “The facility failed to ensure one of one residents reviewed (R1) was free from maltreatment. Findings include: The Minnesota Department of Health (MDH) issued a determination maltreatment occurred, and the facility 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.”

  • Tag 2410: 144G.91 Subd. 13 Personal and treatment privacy Level 2, pattern scope, scope/level letter E
    Details

    MDH’s finding, as written: “Based on observation, interview, and document review, the licensee failed to ensure the resident's right to privacy was respected during toileting and other activities of personal hygiene for two of two residents (R2, R3) reviewed. [...]”

    Rule cited: “(a) Residents have the right to consideration of their privacy, individuality, and cultural identity as related to their social, religious, and psychological well-being. [...]”

  • Tag 2430: 144G.91 Subd. 15 Confidentiality of records Level 2, widespread scope, scope/level letter F · correction period: Twenty-one (21) days
    Details

    MDH’s finding, as written: “Based on observation and interview the licensee failed to ensure resident's personal health and medical information was kept private. This had the potential to affect all residents residing in the facility. [...]”

    Rule cited: “(a) Residents have the right to have personal, financial, health, and medical information kept private, to approve or refuse release of information to any outside party, and to be advised of the assisted living facility's policies and procedures regarding [...]”

  • Tag 2480: 144G.91 Subd. 20 Grievances and inquiries Level 2, isolated scope, scope/level letter D · correction period: Seven (7)
    Details

    Summary: MDH found the licensee failed to respond to grievances of one of resident (R5) reviewed for grievances.

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to respond to grievances of one of resident (R5) reviewed for grievances. 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 an isolated scope (when one or a limited number of residents are affected or one or a limited number of staff are involved or the situation has occurred only occasionally). [...]”

    Rule cited: “Residents have the right to make and receive a timely response to a complaint or inquiry, without limitation. [...]”

  • Tag 3100: 144.6502, Subd. 9 Obstruction of Electronic Monitoring Devices Level 2, isolated scope, scope/level letter D
    Details

    Summary: MDH found the licensee knowingly hampered with an electronic monitoring device placed in the resident's room after facility staff requested the camera be removed.

    MDH’s finding, as written: “Based on interview and record review, the licensee knowingly hampered with an electronic monitoring device placed in the resident's room after facility staff requested the camera be removed. [...]”

    Rule cited: “(a) A person must not knowingly hamper, obstruct, tamper with, or destroy an electronic monitoring device placed in a resident's room or private living unit without the permission of the resident or resident representative. [...]”

Summaries are ours and are marked “Summary”; quoted text is MDH’s own, shortened where marked [...]. Read the full reports at the links above or search every report on MDH’s site.

MDH keeps investigation results for seven years when allegations are substantiated, four years when inconclusive, and three years when unsubstantiated, so the counts cover different periods. This community is licensed for 30 residents; larger communities are evaluated and reported on more often, so read counts with size in mind. Source: Minnesota Department of Health, Health Regulation Division, data as of September 28, 2026. Always visit in person and ask the community about anything listed here.