Edina Heights Senior Living

Last evaluation

December 12, 2024

Evaluations on record

2

Investigations substantiated

7 kept 7 years

Inconclusive

0 kept 4 years

Unsubstantiated

2 kept 3 years

Most recent evaluation (December 12, 2024, state report CQVU11)

MDH: “On December 9, 2024, through December 12, 2024, the Minnesota Department of Health conducted a full survey at the above provider.”

Survey completed December 12, 2024: 10 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) 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: “(a) Except as provided in paragraph (b), food must be prepared and served according to the Minnesota Food Code, Minnesota Rules, chapter 4626. [...]”

• Tag 630: 144G.42 Subd. 6 (b) Compliance with requirements for reporting ma Level 2, pattern scope, scope/level letter E · 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 one of four residents (R4).

  MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure an individual abuse prevention plan (IAPP) was developed to include the required content for one of four residents (R4). [...]”

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

• Tag 650: 144G.42 Subd. 8 (a) Staff records Level 2, isolated scope, scope/level letter D · correction period: Twenty-One
  Details

  Summary: MDH found the licensee failed to ensure employee records contained the required content for one of three employees (licensed practical nurse (LPN)-E).

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure employee records contained the required content for one of three employees (licensed practical nurse (LPN)-E). [...]”

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

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

  Summary: MDH found the licensee failed to maintain a tuberculosis (TB) prevention and control program, based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC), which included a history and symptom screening for two of three employees (licensed practical nurse (LPN)-E) and (unlicensed personnel (ULP)-D)

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to maintain a tuberculosis (TB) prevention and control program, based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC), which included a history and symptom screening for two of three employees (licensed practical nurse (LPN)-E) and (unlicensed personnel (ULP)-D) This practice resulted in a level two violation (a violation that did not harm a resident's health or safety but had the potential [...]”

  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 2, widespread scope, scope/level letter F · correction period: Twenty-one (21) days
  Details

  Summary: MDH found the licensee failed to develop a written emergency disaster preparedness (EP) plan including all required content.

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop a written emergency disaster preparedness (EP) plan including all required content. This affected all residents, staff and visitors. [...]”

  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.

Fines assessed by MDH

• Tag 1290 (144g.60 Subdivision 1 - Background Studies Required): $3,000.00

Total fines assessed, as printed in the letter: $3,000.00.

Substantiated investigations (state reports)

• April 29, 2024 · report HL203812800M · MDH finding: Substantiated, facility responsibility
  Details

  Allegation, as written: “The facility neglected a resident when they failed to ensure nursing follow-up when staff reported the resident skin issues. Several weeks later, the resident was sent to the hospital and had her toe amputated due to infection in the bone.”

  “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. Staff reported their observations of the resident's toe wound to several facility nurses, however, nursing failed to followed-up with assessments or notification to the resident's primary care provider. The resident's toe infection infiltrated the bone and up the resident's leg. The resident required hospitalization and surgery to amputate the toe. The hospital staff discovered an additional open wound on the resident's upper arm.”

  Action taken by facility: “The facility reported they initiated new skin assessments of all residents, provided training to all nurses on the facility skin assessment procedure, training to unlicensed staff, and corrective action to nurses involved.”

  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 16, 2024: 2 correction orders

  • Tag 2310: 144G.91 Subd. 4 (a) Appropriate care and services Level 4, pattern scope, scope/level letter K · correction period: Seven (7) Days
    Details

    Summary: MDH found the licensee failed to provide appropriate care and services for one of one resident (R1) reviewed for pressure ulcers.

    MDH’s finding, as written: “Based on interview and document review, the licensee failed to provide appropriate care and services for one of one resident (R1) reviewed for pressure ulcers. The licensee failed to have a system in place to ensure nursing followed up on changes in the condition of R1's skin when several unlicensed staff notified nursing, three times in two weeks, of a wound on R1's lower extremity. Harm occurred when R1 developed an infection infiltrating bone, which required amputation of R1's toe. [...]”

    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

    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. 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. No plan of correction is required for this tag.”

    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.”

• February 12, 2024 · report HL203819965M · MDH finding: Substantiated, facility responsibility
  Details

  Allegation, as written: “The facility neglected a resident when they failed to ensure staff followed the plan of care for toileting and failed to monitor the resident. Staff left the resident sitting on the toilet for an unknown number of hours and the resident developed wounds on her bottom, leg, elbow, knee, finger, and toes.”

  “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 neglected to ensure staff completed safety checks every two hours or provided toileting to the resident per the service plan. Morning staff found the resident sitting on the toilet for an unknown amount of time, the resident was weak and unable to stand up, and staff called 911. The resident was admitted to the hospital with significant skin breakdown including pressure injuries in the shape of a toilet seat on the resident's bottom and thighs, a 5-inch skin tear on the back of her thigh, pressure injuries on her right elbow and right knee, and injuries to her left pinky and middle toes with missing nails and bleeding.”

  Action taken by facility: “The facility investigated the incident and implemented a form for safety check documentation.”

  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 February 5, 2024: 3 correction orders

  • Tag 250: 144G.20 Subdivision 1 Conditions Level 3, widespread scope, scope/level letter I
    Details

    Summary: MDH found the licensee demonstrated systemic failures in the operation of the facility when the licensee failed to ensure staff provided appropriate care and services, failed to have a system in place to ensure staff completed cares, failed to have a system in place to ensure staff assignments included up to date information on required services based on assessed needs of residents, and failed to ensure staff monitored residents.

    MDH’s finding, as written: “Based on interview and document review, the licensee demonstrated systemic failures in the operation of the facility when the licensee failed to ensure staff provided appropriate care and services, failed to have a system in place to ensure staff completed cares, failed to have a system in place to ensure staff assignments included up to date information on required services based on assessed needs of residents, and failed to ensure staff monitored 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 2310: 144G.91 Subd. 4 (a) Appropriate care and services Level 3, widespread scope, scope/level letter I · correction period: Two (2) days
    Details

    Summary: MDH found the licensee failed to ensure staff provided appropriate care and services as required in the individualized service plan of one of one resident (R1) reviewed for maltreatment.

    MDH’s finding, as written: “Based on interview and document review, the licensee failed to ensure staff provided appropriate care and services as required in the individualized service plan of one of one resident (R1) reviewed for maltreatment. The licensee failed to have a system in place to ensure staff assignment sheets included up to date services based on assessed needs of residents. The licensee failed to have a system in place to verify if staff completed cares/services. [...]”

    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

    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 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.”

• December 18, 2023 · report HL203816844M · MDH finding: Substantiated, facility responsibility
  Details

  Allegation, as written: “The facility neglected a resident when staff failed to ensure the residents increase in pain was assessed, reported to the physician, and medications were administered to relieve the residents' pain.”

  “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 an increase in pain and the facility staff failed to notify the physician of the resident change in increased pain and failed to implement physician orders to treat the resident's pain. The resident was hospitalized for uncontrolled pain and diagnosed with a lumbar compression fracture.”

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

  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 19, 2023: 4 correction orders

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

    Summary: MDH found the licensee failed to immediately report to the Minnesota Adult Abuse Reporting Center (MAARC) suspected maltreatment 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 immediately report to the Minnesota Adult Abuse Reporting Center (MAARC) suspected maltreatment for three of three residents (R1, R2, and R3) with records reviewed. [...]”

    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 1620: 144G.70 Subd. 2 (c-e) Initial reviews, assessments, and monitoring Level 2, isolated scope, scope/level letter D · correction period: Seven (7) days
    Details

    Summary: MDH found the facility failed to ensure a registered nurse (RN) reassessed one of one resident (R3) for a change in condition with records reviewed.

    MDH’s finding, as written: “Based on interview and record review, the facility failed to ensure a registered nurse (RN) reassessed one of one resident (R3) for a change in condition with records reviewed. R3 complained of pain that was not well-managed with her current medication regimen. An RN failed to assess R3's pain and medication regimen for its effectiveness and failed to ensure physician orders to relieve the residents pain was administered and implemented. [...]”

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

  • Tag 1760: 144G.71 Subd. 8 Documentation of administration of medication Level 3, isolated scope, scope/level letter G · correction period: Seven (7) days
    Details

    MDH’s finding, as written: “Based on interview and document review, facility staff failed to document and administer medication as prescribed for two of three residents (R1 and R3) with records reviewed. R1 missed 22 days of Depakote and experienced behavioral exacerbations. R3 was prescribed a Medrol (steroid) 4 milligram (mg) taper and received only one dose out of 21 doses prescribed. [...]”

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

    Summary: MDH found the facility failed to ensure three of three residents reviewed (R1, R2, and R3) were free from maltreatment.

    MDH’s finding, as written: “The facility failed to ensure three of three residents reviewed (R1, R2, and R3) were 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.”

• December 18, 2023 · report HL203817344M · MDH finding: Substantiated, facility responsibility
  Details

  Allegation, as written: “The facility neglected the resident when staff failed to follow the resident's plan of care and provide necessary care and service including toileting and showering.”

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

  “The facility is 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 is responsible for the maltreatment. Review of recorded video from the resident's room indicated numerous times when facility staff denied the resident the opportunity to use the toilet. In addition, showers were not provided according to the resident's plan of care.”

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

  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 19, 2023: 4 correction orders

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

    Summary: MDH found the licensee failed to immediately report to the Minnesota Adult Abuse Reporting Center (MAARC) suspected maltreatment 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 immediately report to the Minnesota Adult Abuse Reporting Center (MAARC) suspected maltreatment for three of three residents (R1, R2, and R3) with records reviewed. [...]”

    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 1620: 144G.70 Subd. 2 (c-e) Initial reviews, assessments, and monitoring Level 2, isolated scope, scope/level letter D · correction period: Seven (7) days
    Details

    Summary: MDH found the facility failed to ensure a registered nurse (RN) reassessed one of one resident (R3) for a change in condition with records reviewed.

    MDH’s finding, as written: “Based on interview and record review, the facility failed to ensure a registered nurse (RN) reassessed one of one resident (R3) for a change in condition with records reviewed. R3 complained of pain that was not well-managed with her current medication regimen. An RN failed to assess R3's pain and medication regimen for its effectiveness and failed to ensure physician orders to relieve the residents pain was administered and implemented. [...]”

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

  • Tag 1760: 144G.71 Subd. 8 Documentation of administration of medication Level 3, isolated scope, scope/level letter G · correction period: Seven (7) days
    Details

    MDH’s finding, as written: “Based on interview and document review, facility staff failed to document and administer medication as prescribed for two of three residents (R1 and R3) with records reviewed. R1 missed 22 days of Depakote and experienced behavioral exacerbations. R3 was prescribed a Medrol (steroid) 4 milligram (mg) taper and received only one dose out of 21 doses prescribed. [...]”

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

    Summary: MDH found the facility failed to ensure three of three residents reviewed (R1, R2, and R3) were free from maltreatment.

    MDH’s finding, as written: “The facility failed to ensure three of three residents reviewed (R1, R2, and R3) were 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.”

• December 18, 2023 · report HL203817508M · MDH finding: Substantiated, facility responsibility
  Details

  Allegation, as written: “The facility neglected the resident when psychiatric medication ordered by the resident's provider was not initiated until 26 days after the medication order date.”

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

  “The facility is 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 is responsible for the maltreatment. The resident's provider prescribed Depakote to treat anger, agitation, and frustration intolerance. The facility did not initiate the Depakote until 19 days after the provider wrote the prescription. The resident experienced a significant increase in anger and agitation because of the delay.”

  Action taken by facility: “No action taken.”

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

  Survey completed September 19, 2023: 4 correction orders

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

    Summary: MDH found the licensee failed to immediately report to the Minnesota Adult Abuse Reporting Center (MAARC) suspected maltreatment 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 immediately report to the Minnesota Adult Abuse Reporting Center (MAARC) suspected maltreatment for three of three residents (R1, R2, and R3) with records reviewed. [...]”

    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 1620: 144G.70 Subd. 2 (c-e) Initial reviews, assessments, and monitoring Level 2, isolated scope, scope/level letter D · correction period: Seven (7) days
    Details

    Summary: MDH found the facility failed to ensure a registered nurse (RN) reassessed one of one resident (R3) for a change in condition with records reviewed.

    MDH’s finding, as written: “Based on interview and record review, the facility failed to ensure a registered nurse (RN) reassessed one of one resident (R3) for a change in condition with records reviewed. R3 complained of pain that was not well-managed with her current medication regimen. An RN failed to assess R3's pain and medication regimen for its effectiveness and failed to ensure physician orders to relieve the residents pain was administered and implemented. [...]”

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

  • Tag 1760: 144G.71 Subd. 8 Documentation of administration of medication Level 3, isolated scope, scope/level letter G · correction period: Seven (7) days
    Details

    MDH’s finding, as written: “Based on interview and document review, facility staff failed to document and administer medication as prescribed for two of three residents (R1 and R3) with records reviewed. R1 missed 22 days of Depakote and experienced behavioral exacerbations. R3 was prescribed a Medrol (steroid) 4 milligram (mg) taper and received only one dose out of 21 doses prescribed. [...]”

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

    Summary: MDH found the facility failed to ensure three of three residents reviewed (R1, R2, and R3) were free from maltreatment.

    MDH’s finding, as written: “The facility failed to ensure three of three residents reviewed (R1, R2, and R3) were 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.”

• May 26, 2023 · report HL203811461M · MDH finding: Substantiated, facility responsibility
  Details

  Allegation, as written: “It is alleged: The facility neglected the resident when the resident fell and staff did not assist the resident off the floor per resident care plan or facility policy. It is alleged: It is alleged that abuse occurred when the resident was found with multiple facial injuries not consistent with the fall incidents that were reported.”

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

  “However, the Minnesota Department of Health determined that neglect was substantiated.”

  Summary: MDH looked into 2 allegations and found: abuse inconclusive; neglect substantiated (facility responsibility).

  MDH’s conclusion, as written: “The Minnesota Department of Health determined abuse was inconclusive. An alleged perpetrator was not identified, and the cause of the resident's unexplained injuries could not be explained. However, the Minnesota Department of Health determined that neglect was substantiated. The facility failed to assess and evaluate the resident after she had two consecutive falls with unexplained injury and increased pain. In addition, the facility failed to administer the resident's ordered medications when supply ran out and the resident missed medications. An equal opportunity employer.”

  Action taken by facility: “The facility conducted an internal investigation after the resident was sent to the hospital.”

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

  Survey completed March 7, 2023: 4 correction orders

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

    Summary: MDH found the licensee failed to immediately report to the Minnesota Adult Abuse Reporting Center (MAARC) suspected maltreatment for two of three residents (R4, R5) with records reviewed.

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to immediately report to the Minnesota Adult Abuse Reporting Center (MAARC) suspected maltreatment for two of three residents (R4, R5) with records reviewed. [...]”

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

    Summary: MDH found the licensee failed to ensure medications were administered as prescribed for three of three residents (R1, R2, R3) with records reviewed.

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure medications were administered as prescribed for three of three residents (R1, R2, R3) with records reviewed. In addition, the licensee failed to ensure medication orders were transcribed to the medication administration record (MAR) accurately for one of one resident (R2) with records 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 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 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 3000: 626.557 Subd. 3 Timing of report Level 2, isolated scope, scope/level letter D
    Details

    Summary: MDH found the licensee failed to immediately report to the Minnesota Adult Abuse Reporting Center (MAARC) suspected maltreatment for two of three residents (R4, R5) with records reviewed.

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to immediately report to the Minnesota Adult Abuse Reporting Center (MAARC) suspected maltreatment for two of three residents (R4, R5) with records reviewed. [...]”

    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 [...]”

• September 19, 2022 · report HL20381001M

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 377 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.