Diamond Willow Assisted Living

Last evaluation

September 25, 2025

Evaluations on record

2

Investigations substantiated

5 kept 7 years

Inconclusive

0 kept 4 years

Unsubstantiated

4 kept 3 years

Most recent evaluation (September 25, 2025, state report 01N711)

MDH: “On September 22, 2025, through September 25, 2025, the Minnesota Department of Health conducted a full survey at the above provider and the following correction orders are issued.”

Survey completed September 25, 2025: 18 correction orders

• Tag 480: 144G.41 Subdivision 1 Subd. 1a (a-b) Minimum requirements; required food services Level 4, widespread scope, scope/level letter L · correction period: Please refer to the FBEIR for any compliance dates · fine: $3,000.00 assessed
  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 four violation (a violation that harmed a resident ' s health or safety, not including serious injury or death, or a violation that was likely to lead to serious injury or death), and was issued at a widespread scope (when problems are pervasive or represent a systemic failure that has affected or has potential to [...]”

  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 3, widespread scope, scope/level letter I · fine: $1,000.00 assessed
  Details

  Summary: MDH found the licensee failed to provide or make available at least three nutritious meals daily with snacks available seven days per week according to the licensee's posted menu.

  MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to provide or make available at least three nutritious meals daily with snacks available seven days per week according to the licensee's posted menu. This had the potential to affect all 30 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 490: 144G.41 Subdivision 1b Minimum requirements; other required services 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 30 residents at the facility. [...]”

  Rule cited: “All assisted living facilities must offer to provide or make available the following services to residents: (1) weekly housekeeping; (2) weekly laundry service; (3) upon the request of the resident, provide direct or reasonable assistance with arranging for [...]”

• Tag 510: 144G.41 Subd. 3 Infection control program Level 2, widespread scope, scope/level letter F · correction period: Seven (7) days · fine: $500.00 assessed
  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 and treatment administration for one of five employees (unlicensed personnel (ULP)-E).

  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 and treatment administration for one of five employees (unlicensed personnel (ULP)-E). In addition, the licensee failed to ensure infection control standards were followed to disinfect shared reusable medical equipment for one of one employee (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 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 current 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. [...]”

From MDH’s letter: the letter says the facility is in substantial compliance.

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

Fines assessed by MDH

• Tag 480 (144g.41 Subdivision1 Subd.1a (a-B) - Min. Req.; Req.Food Servs.): $3,000.00
• Tag 485 (144g.41 Subdivision1.A (a) - Min. Req.; Req.Food Servs): $1,000.00
• Tag 510 (144g.41 Subd.3 - Infection Control Program): $500.00
• Tag 775 (144g.45 Subd.2. (a) - Fire Protection And PhysicalEnvironment): $500.00

Total fines assessed, as printed in the letter: $5,000.00.

Substantiated investigations (state reports)

• September 26, 2024 · report HL236094061M · MDH finding: Substantiated, facility responsibility
  Details

  Allegation, as written: “The facility neglected the resident when the facility failed to ensure the resident received necessary care and services and as a result, the resident developed pressure sores, a urinary tract infection, and weight loss.”

  “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 facility failed to ensure staff provided the resident with his care planned needs including catheter care, repositioning, and assist with eating. Due to the lack of care, the resident developed pressure sores, a urinary tract infection, and a 30-pound weight loss.”

  Action taken by facility: “The facility was in the process of hiring individuals to fill leadership roles on campus.”

  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 September 4, 2024: 10 correction orders

  • Tag 250: 144G.20 Subdivision 1 Conditions Level 2, widespread scope, scope/level letter F · correction period: Seven (7) 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 residents' assisted living services, understood all of the assisted living provider regulations; and the licensee failed to ensure policies and procedures were developed and/or implemented.

    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 residents' assisted living services, understood all of the assisted living provider regulations; and the licensee failed to ensure policies and procedures were developed and/or implemented. This had the potential to affect all thirty (30) 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 470: 144G.41 Subdivision 1 Minimum requirements Level 3, pattern scope, scope/level letter H · correction period: Seven (7) days
    Details

    Summary: MDH found the licensee failed to provide adequate staffing to meet the needs of one of one resident (R1) reviewed who was fully dependent on staff for all needs.

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide adequate staffing to meet the needs of one of one resident (R1) reviewed who was fully dependent on staff for all needs. This failure caused the resident actual harm and had the potential to affect all residents requiring staff assistance. [...]”

    Rule cited: “(11) develop and implement a staffing plan for determining its staffing level that: (i) includes an evaluation, to be conducted at least twice a year, of the appropriateness of staffing levels in the facility; (ii) ensures sufficient staffing at all times to [...]”

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

    Summary: MDH found the licensee failed to ensure licensee's staff

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure licensee's staff documented services provided according to the residents' service plans for two of two residents (R1, R2) reviewed. This failure had the potential to affect all residents that resided at the licensee. [...]”

    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 1350: 144G.60 Subd. 5 Temporary staff Level 2, widespread scope, scope/level letter F · correction period: Seven (7) days
    Details

    Summary: MDH found the licensee failed to ensure contracted staff met all requirements required for personnel employed by the facility for three of three unlicensed personnel (ULP-I, ULP-J, ULP-K) reviewed.

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure contracted staff met all requirements required for personnel employed by the facility for three of three unlicensed personnel (ULP-I, ULP-J, ULP-K) reviewed. This failure had the potential to affect all residents that resided at the licensee. [...]”

    Rule cited: “When a facility contracts with a temporary staffing agency, those individuals must meet the same requirements required by this section for personnel employed by the facility and shall be treated as if they are staff of the facility.”

  • Tag 1460: 144G.63 Subdivision 1 Orientation of staff and supervisors Level 2, widespread scope, scope/level letter F · correction period: Seven (7) days
    Details

    MDH’s finding, as written: “Based on observation, interview and record review, licensee failed to ensure employees received orientation training to the assisted living licensing requirements and regulations for three of three unlicensed personnel (ULP)-I, ULP-J, ULP-K) reviewed. This failure had the potential to affect all residents that resided at the licensee. [...]”

    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. [...]”

  Show all 10

  • Tag 1750: 144G.71 Subd. 7 Delegation of medication administration Level 3, widespread scope, scope/level letter I · correction period: Seven (7) days
    Details

    Summary: MDH found the licensee failed to ensure prior to delegating the nursing task of medication administration, unlicensed personnel (ULP) were trained in the proper methods to perform the task or procedure for each resident and were able to demonstrate the ability to competently follow the procedure for three of three unlicensed personnel (ULP)-I, ULP-J, ULP-K) reviewed.

    MDH’s finding, as written: “Based on interview, and record review, the licensee failed to ensure prior to delegating the nursing task of medication administration, unlicensed personnel (ULP) were trained in the proper methods to perform the task or procedure for each resident and were able to demonstrate the ability to competently follow the procedure for three of three unlicensed personnel (ULP)-I, ULP-J, ULP-K) reviewed. This failure had the potential to affect all the residents that resided at the facility. [...]”

    Rule cited: “When administration of medications is delegated to unlicensed personnel, the assisted living facility must ensure that the registered nurse has: (1) instructed the unlicensed personnel in the proper methods to administer the medications, and the unlicensed [...]”

  • Tag 1760: 144G.71 Subd. 8 Documentation of administration of medication Level 2, widespread scope, scope/level letter F · correction period: Seven (7) days
    Details

    Summary: MDH found the licensee failed to ensure medication administration documentation included the name and title of the person who administered the medication for two of two residents (R1, R2) with records reviewed.

    MDH’s finding, as written: “Based on interview, and record review, the licensee failed to ensure medication administration documentation included the name and title of the person who administered the medication for two of two residents (R1, R2) with records reviewed. The licensee failed to transcribe physician orders on the medication administration record (MAR) to ensure medication was administered as prescribed for one of one resident (R1) reviewed. [...]”

    Rule cited: “Each medication administered by the assisted living facility staff must be documented in the resident's record. The documentation must include the signature and title of the person who administered the medication. [...]”

  • Tag 1960: 144G.72 Subd. 5 Documentation of administration of treatments Level 3, isolated scope, scope/level letter G · correction period: Seven (7) days
    Details

    Summary: MDH found the licensee failed to ensure treatments or therapies were administered as prescribed and if not administered, the reason why they were not provided was documented for one of one resident (R1) reviewed with wounds managed by the provider.

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure treatments or therapies were administered as prescribed and if not administered, the reason why they were not provided was documented for one of one resident (R1) reviewed with wounds managed by the provider. This practice had the ability to affect all residents that resided at the licensee who required any type of treatment and therapy services. [...]”

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

  • Tag 2070: 144G.81 Subd. 4 Awake staff requirement Level 3, widespread scope, scope/level letter I · correction period: Two (2) days
    Details

    Summary: MDH found the licensee failed to ensure one or more persons were physically present and available 24 hours a day, seven days a week, who were responsible for responding to requests for assistance with health and safety needs of residents in four of four secured memory care buildings on campus.

    MDH’s finding, as written: “Based on interview, and record review, the licensee failed to ensure one or more persons were physically present and available 24 hours a day, seven days a week, who were responsible for responding to requests for assistance with health and safety needs of residents in four of four secured memory care buildings on campus. This had the potential to affect all 30 residents residing in the memory care buildings. [...]”

    Rule cited: “An assisted living facility with dementia care providing services in a secured dementia care unit must have an awake person who is physically present in the secured dementia care unit 24 hours per day, seven days per week, who is responsible for responding to [...]”

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

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

    MDH’s finding, as written: “Based on observations, interviews, and document review, the facility failed to ensure one of two residents reviewed (R1) was free from maltreatment. R1 was neglected. Findings include: On September 4, 2024, the Minnesota Department of Health (MDH) issued a determination that neglect occurred, and that the facility was responsible for the maltreatment, in connection with incidents which occurred at the facility. The MDH concluded there was a preponderance of evidence that maltreatment occurred.”

    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.”

• March 12, 2024 · report HL236099947M
  Details

  Survey completed February 7, 2024: 1 correction order

  • 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.”

• January 23, 2024 · report HL236098284M · MDH finding: Substantiated, facility and individual responsibility
  Details

  Allegation, as written: “The resident was neglected when the alleged perpetrator, (AP)1, failed to safely transfer the resident as indicated in the resident's plan of care, the resident fell, and sustained a proximal right femur (hip) fracture. In addition, AP2 neglected the resident when AP2 failed to safely transfer the resident as indicated in the resident's plan of care, the resident fell again with pain in her right hip.”

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

  “AP1 and the facility were responsible for the maltreatment.”

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

  MDH’s conclusion, as written: “The Minnesota Department of Health determined neglect was substantiated. AP1 and the facility were responsible for the maltreatment. AP1 failed to follow the residents plan of care which instructed staff to use a transfer belt and leg brace with transfers. The resident fell and sustained a right femur fracture requiring surgical repair and hospitalization. AP2 failed to follow the resident's plan of care for safe transfers. The resident fell and complained of pain. However, the facility failed to ensure AP2 had completed training and competency prior to providing care independently to the resident. An equal opportunity employer.”

  Action taken by facility: “The resident was assessed for injures after the incident's occurred, and the facility communicated with the resident's provider and family. The facility provided re-education to staff on safe transfer techniques after the incidents occurred.”

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

  Survey completed December 14, 2023: 2 correction orders

  • Tag 730: 144G.43 Subd. 3 Contents of resident record Level 2, isolated scope, scope/level letter D · correction period: Fourteen (14) days
    Details

    Summary: MDH found the licensee failed to ensure one of one resident, (R1), medical records contained the required documentation of a thorough investigation of incidents, and complaints/grievances involving the resident and actions taken in response, when suspected maltreatment of R1 a resident occurred including interviews/statements of staff and potential witnesses involved for one of one resident (R1) reviewed.

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure one of one resident, (R1), medical records contained the required documentation of a thorough investigation of incidents, and complaints/grievances involving the resident and actions taken in response, when suspected maltreatment of R1 a resident occurred including interviews/statements of staff and potential witnesses involved for one of one resident (R1) 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 resident(s) reviewed, (R1) was free from maltreatment,

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

• March 13, 2023 · report HL236093323M · MDH finding: Substantiated, facility responsibility
  Details

  Allegation, as written: “The facility neglected a resident when they did not prevent resident falls.”

  “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 had multiple falls with injury and the facility failed to investigate the cause, reassess the resident and implement new fall interventions after each fall. In addition, during the investigation, it was determined the resident eloped from the facility and the event was not documented. The facility failed to investigate the incident, assess the resident, and implement elopement interventions. After the resident's fourth documented fall, the resident died three weeks later due to falls, rib fractures and dementia. An equal opportunity employer.”

  Action taken by facility: “The facility staff sent the resident to the hospital following falls with injury and contacted law enforcement when the resident eloped. The nurse identified training needs.”

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

  Survey completed January 10, 2023: 9 correction orders

  • 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 engage in and maintain documentation of quality management activity appropriate to the size and relevant to the type of services provided by the assisted living.

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to engage in and maintain documentation of quality management activity appropriate to the size and relevant to the type of services provided by the assisted living. This had the potential to affect all 30 residents receiving assisted living services. [...]”

    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 620: 144G.42 Subd. 6 (a) Compliance with requirements for reporting ma Level 2, widespread scope, scope/level letter F
    Details

    Summary: MDH found the licensee failed to comply with requirements to immediately report suspected maltreatment to Minnesota Adult Abuse Reporting Center (MAARC) for one of one resident (R1) reviewed.

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to comply with requirements to immediately report suspected maltreatment to Minnesota Adult Abuse Reporting Center (MAARC) for one of one resident (R1) reviewed. R1 had multiple falls with injury and fractures and an elopement. [...]”

    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 3, isolated scope, scope/level letter G · correction period: Seven (7) days
    Details

    Summary: MDH found the licensee failed to update the individual abuse prevention plan (IAPP) with content related risk of elopement and interventions following an elopement for one of one resident (R1) with records reviewed.

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to update the individual abuse prevention plan (IAPP) with content related risk of elopement and interventions following an elopement for one of one resident (R1) with records reviewed. [...]”

    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 3, isolated scope, scope/level letter G
    Details

    Summary: MDH found the licensee failed to include documentation of significant changes in the resident's status, including incidents, actions taken in response, and communication pertinent to the resident's services for one of one residents (R1) reviewed.

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to include documentation of significant changes in the resident's status, including incidents, actions taken in response, and communication pertinent to the resident's services for one of one residents (R1) 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 1620: 144G.70 Subd. 2 (c-e) Initial reviews, assessments, and monitoring Level 3, isolated scope, scope/level letter G
    Details

    Summary: MDH found the licensee failed to ensure a registered nurse (RN) conducted assessments after each incident and completed a new comprehensive assessment every 90-days for one of one resident (R1) reviewed.

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure a registered nurse (RN) conducted assessments after each incident and completed a new comprehensive assessment every 90-days for one of one resident (R1) reviewed. As a result, the licensee failed to identify and implement interventions related to fall which resulted in subsequent falls for R1 with injuries. [...]”

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

  Show all 9

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

    Summary: MDH found the licensee failed to ensure new fall interventions were implemented following falls for one of one resident (R1) reviewed.

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure new fall interventions were implemented following falls for one of one resident (R1) reviewed. R1 had several falls with injuries and required hospital visits. R1's primary cause of death was falls and rib fracture. [...]”

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

    MDH’s finding, as written: “Based on interviews and document review the facility failed to ensure two of two residents (R1, R2) reviewed were free from maltreatment. R1 was neglected. R2 was abused. Findings include: The Minnesota Department of Health (MDH) issued a determination maltreatment occurred, and the facility was responsible for maltreatment of R1 and an individual staff person was responsible for the maltreatment of R2, in connection with incidents which occurred at the facility. [...]”

    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 3, isolated scope, scope/level letter G · correction period: Seven (7) Days
    Details

    Summary: MDH found the licensee failed to conduct cares discreetly with privacy and maintain confidentiality for one of one resident (R2) reviewed.

    MDH’s finding, as written: “Based on interview, and record review, the licensee failed to conduct cares discreetly with privacy and maintain confidentiality for one of one resident (R2) reviewed. This practice resulted in a level three violation (a violation that harmed a resident's health or safety, not including serious injury, impairment, or death, or a violation that has the potential to lead to serious injury, impairment, or death) and was issued at an isolated scope (when one or a limited number of residents are [...]”

    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 3000: 626.557 Subd. 3 Timing of report Level 2, widespread scope, scope/level letter F
    Details

    Summary: MDH found the licensee failed to comply with requirements to immediately report suspected maltreatment to Minnesota Adult Abuse Reporting Center (MAARC) for one of one resident (R1) reviewed.

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to comply with requirements to immediately report suspected maltreatment to Minnesota Adult Abuse Reporting Center (MAARC) for one of one resident (R1) reviewed. R1 had multiple falls with injury and fractures and an elopement. [...]”

    Rule cited: “(a) A mandated reporter who has reason to believe that a vulnerable adult is being or has been maltreated, or who has knowledge that a vulnerable adult has sustained a physical injury which is not reasonably explained shall immediately report the information [...]”

• March 13, 2023 · report HL236093644M
  Details

  Survey completed January 10, 2023: 9 correction orders

  • 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 engage in and maintain documentation of quality management activity appropriate to the size and relevant to the type of services provided by the assisted living.

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to engage in and maintain documentation of quality management activity appropriate to the size and relevant to the type of services provided by the assisted living. This had the potential to affect all 30 residents receiving assisted living services. [...]”

    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 620: 144G.42 Subd. 6 (a) Compliance with requirements for reporting ma Level 2, widespread scope, scope/level letter F
    Details

    Summary: MDH found the licensee failed to comply with requirements to immediately report suspected maltreatment to Minnesota Adult Abuse Reporting Center (MAARC) for one of one resident (R1) reviewed.

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to comply with requirements to immediately report suspected maltreatment to Minnesota Adult Abuse Reporting Center (MAARC) for one of one resident (R1) reviewed. R1 had multiple falls with injury and fractures and an elopement. [...]”

    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 3, isolated scope, scope/level letter G · correction period: Seven (7) days
    Details

    Summary: MDH found the licensee failed to update the individual abuse prevention plan (IAPP) with content related risk of elopement and interventions following an elopement for one of one resident (R1) with records reviewed.

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to update the individual abuse prevention plan (IAPP) with content related risk of elopement and interventions following an elopement for one of one resident (R1) with records reviewed. [...]”

    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 3, isolated scope, scope/level letter G
    Details

    Summary: MDH found the licensee failed to include documentation of significant changes in the resident's status, including incidents, actions taken in response, and communication pertinent to the resident's services for one of one residents (R1) reviewed.

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to include documentation of significant changes in the resident's status, including incidents, actions taken in response, and communication pertinent to the resident's services for one of one residents (R1) 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 1620: 144G.70 Subd. 2 (c-e) Initial reviews, assessments, and monitoring Level 3, isolated scope, scope/level letter G
    Details

    Summary: MDH found the licensee failed to ensure a registered nurse (RN) conducted assessments after each incident and completed a new comprehensive assessment every 90-days for one of one resident (R1) reviewed.

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure a registered nurse (RN) conducted assessments after each incident and completed a new comprehensive assessment every 90-days for one of one resident (R1) reviewed. As a result, the licensee failed to identify and implement interventions related to fall which resulted in subsequent falls for R1 with injuries. [...]”

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

  Show all 9

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

    Summary: MDH found the licensee failed to ensure new fall interventions were implemented following falls for one of one resident (R1) reviewed.

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure new fall interventions were implemented following falls for one of one resident (R1) reviewed. R1 had several falls with injuries and required hospital visits. R1's primary cause of death was falls and rib fracture. [...]”

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

    MDH’s finding, as written: “Based on interviews and document review the facility failed to ensure two of two residents (R1, R2) reviewed were free from maltreatment. R1 was neglected. R2 was abused. Findings include: The Minnesota Department of Health (MDH) issued a determination maltreatment occurred, and the facility was responsible for maltreatment of R1 and an individual staff person was responsible for the maltreatment of R2, in connection with incidents which occurred at the facility. [...]”

    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 3, isolated scope, scope/level letter G · correction period: Seven (7) Days
    Details

    Summary: MDH found the licensee failed to conduct cares discreetly with privacy and maintain confidentiality for one of one resident (R2) reviewed.

    MDH’s finding, as written: “Based on interview, and record review, the licensee failed to conduct cares discreetly with privacy and maintain confidentiality for one of one resident (R2) reviewed. This practice resulted in a level three violation (a violation that harmed a resident's health or safety, not including serious injury, impairment, or death, or a violation that has the potential to lead to serious injury, impairment, or death) and was issued at an isolated scope (when one or a limited number of residents are [...]”

    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 3000: 626.557 Subd. 3 Timing of report Level 2, widespread scope, scope/level letter F
    Details

    Summary: MDH found the licensee failed to comply with requirements to immediately report suspected maltreatment to Minnesota Adult Abuse Reporting Center (MAARC) for one of one resident (R1) reviewed.

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to comply with requirements to immediately report suspected maltreatment to Minnesota Adult Abuse Reporting Center (MAARC) for one of one resident (R1) reviewed. R1 had multiple falls with injury and fractures and an elopement. [...]”

    Rule cited: “(a) A mandated reporter who has reason to believe that a vulnerable adult is being or has been maltreated, or who has knowledge that a vulnerable adult has sustained a physical injury which is not reasonably explained shall immediately report the information [...]”

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 56 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.