Garden Court Chateau

Last evaluation

October 16, 2025

Evaluations on record

2

Investigations substantiated

2 kept 7 years

Inconclusive

1 kept 4 years

Unsubstantiated

1 kept 3 years

Most recent evaluation (October 16, 2025, state report H5VD11)

MDH: “On October 13, 2025, through October 16, 2025, the Minnesota Department of Health conducted a change of ownership (CHOW) survey at the above provider.”

Survey completed October 16, 2025: 12 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 680: 144G.42 Subd. 10 Disaster planning and emergency preparedness Level 2, pattern scope, scope/level letter E · correction period: Seven (7) days
  Details

  Summary: MDH found the licensee failed to provide documentation to support the minimum frequency of inspections, maintenance, and load tests had been met for the emergency power generator as

  MDH’s finding, as written: “Based on observation, record review, and interview, the licensee failed to provide documentation to support the minimum frequency of inspections, maintenance, and load tests had been met for the emergency power generator as part of the emergency plan to ensure proper performance of the generator. This had the potential to directly affect all building occupants. [...]”

  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 [...]”

• Tag 775: 144G.45 Subd. 2. (a) Fire protection and physical environment Level 2, pattern scope, scope/level letter E · correction period: Seven (7)
  Details

  Summary: MDH found the licensee failed to comply with the requirements of Minnesota State Fire Code Rules, Chapter 7511.

  MDH’s finding, as written: “Based on observation, record review, and interview, the licensee failed to comply with the requirements of Minnesota State Fire Code Rules, Chapter 7511. This had the potential to directly affect all building occupants. [...]”

  Rule cited: “Each assisted living facility must comply with the State Fire Code in Minnesota Rules, chapter 7511, and:”

• Tag 780: 144G.45 Subd. 2 (a) (1) Fire protection and physical environment Level 2, widespread scope, scope/level letter F · correction period: Twenty-one (21) days · fine: $500.00 assessed
  Details

  Summary: MDH found the licensee failed to provide smoke alarms that complied with fire protection requirements.

  MDH’s finding, as written: “Based on observation and interview, the licensee failed to provide smoke alarms that complied with fire protection requirements. This had the potential to directly affect all building occupants. [...]”

  Rule cited: “(a) Each assisted living facility must comply with the State Fire Code in Minnesota Rules, chapter 7511, and: (1) for dwellings or sleeping units, as defined in the State Fire Code: (i) provide smoke alarms in each room used for sleeping purposes; (ii) [...]”

• Tag 810: 144G.45 Subd. 2 (b-f) Fire protection and physical environment Level 2, widespread scope, scope/level letter F · correction period: Twenty-one (21) days
  Details

  Summary: MDH found the licensee failed to develop the fire safety and evacuation plan with required content, and provide required drills.

  MDH’s finding, as written: “Based on record review and interview, the licensee failed to develop the fire safety and evacuation plan with required content, and provide required drills. This had the potential to directly affect all building occupants. [...]”

  Rule cited: “(b) Each assisted living facility shall develop and maintain fire safety and evacuation plans. [...]”

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 780 (144g.45 Subd.2 (a) (1) - Fire Protection And PhysicalEnvironment): $500.00

Total fines assessed, as printed in the letter: $500.00.

Substantiated investigations (state reports)

• October 4, 2024 · report HL305965002M · MDH finding: Substantiated, facility responsibility
  Details

  Allegation, as written: “The facility neglected the resident when the resident was forced to stay in a room without air conditioning after he was diagnosed with COVID-19. The resident suffered shortness of breath and difficulty breathing and transferred to the hospital.”

  “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 staff failed to implement appropriate isolation precautions and failed to assess and monitor the resident's change in condition. The resident was sent to the emergency room (ER) and diagnosed with heat exhaustion twice over a 24-hour period after being in isolation with the door shut and no access to outside airflow.”

  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 August 21, 2024: 3 correction orders

  • Tag 670: 144G.42 Subd. 9a Communicable diseases Level 2, widespread scope, scope/level letter F · correction period: Two (2) days
    Details

    Summary: MDH found the licensee failed to follow current state requirements for prevention, control, and reporting of communicable diseases when it did not report an outbreak of COVID-19 and failed to document information related to the outbreak.

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to follow current state requirements for prevention, control, and reporting of communicable diseases when it did not report an outbreak of COVID-19 and failed to document information related to the outbreak. The deficient practice had the potential to affect residents, employees, and visitors. [...]”

    Rule cited: “A facility must follow current state requirements for prevention, control, and reporting of communicable diseases as defined in Minnesota Rules, parts 4605.7040, 4605.7044, 4605.7050, 4605.7075, 4605.7080, and 4605.7090”

  • Tag 2310: 144G.91 Subd. 4 (a) Appropriate care and services Level 3, isolated scope, scope/level letter G · 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 when facility staff failed to assess a change in condition for one of one resident (R1) when staff placed a resident in COVID-19 isolation, which cut off his access to cool air when outdoor temperatures were in excess of 90 degrees Fahrenheit.

    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 when facility staff failed to assess a change in condition for one of one resident (R1) when staff placed a resident in COVID-19 isolation, which cut off his access to cool air when outdoor temperatures were in excess of 90 degrees Fahrenheit. R1 was sent to the emergency room twice within 24 hours and diagnosed with heat exhaustion. [...]”

    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 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.”

• January 12, 2024 · report HL305969387M · MDH finding: Substantiated, facility responsibility
  Details

  Allegation, as written: “The facility neglected the resident when the nurse failed to reassess the resident after he fell and reported ten out of ten pain for two days. Facility staff failed to immediately report the fall and the increasing complaints of pain to the nurse. The resident was diagnosed with a femur fracture and required surgery.”

  “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 was lowered to the floor during a staff-assisted transfer and later complained of severe pain. The resident was not assessed following the incident, as facility staff did not report the incident or the resident's complaints of pain to the registered nurse (RN) until the next day. The RN was notified of concerns by the resident's family the next day when they questioned why the resident was still in bed at noon and complaining of pain. The resident was sent to the hospital for further evaluation 17 hours after the initial fall, where he was diagnosed with a femur fracture that required surgical repair. An equal opportunity employer.”

  Action taken by facility: “The facility investigated the incident and retrained staff on nurse notification procedures.”

  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 December 26, 2023: 6 correction orders

  • Tag 430: 144G.40 Subd. 2 Uniform checklist disclosure of 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 uniform checklist disclosure of services (UDALSA) accurately reflected services provided by the licensee.

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the uniform checklist disclosure of services (UDALSA) accurately reflected services provided by the licensee. This had the potential to affect all residents. [...]”

    Rule cited: “(a) All assisted living facilities must provide to prospective residents: (1) a disclosure of the categories of assisted living licenses available and the category of license held by the facility; (2) a written checklist listing all services permitted under [...]”

  • Tag 470: 144G.41 Subdivision 1 Minimum requirements Level 2, widespread scope, scope/level letter F
    Details

    Summary: MDH found the licensee failed to ensure the clinical nurse supervisor (CNS) developed and implemented a staffing plan to determine staffing levels to meet the needs of all residents.

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the clinical nurse supervisor (CNS) developed and implemented a staffing plan to determine staffing levels to meet the needs of all residents. This had the potential to affect all residents, staff, and visitors. [...]”

    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 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

    Summary: MDH found the licensee failed to submit a report to the Minnesota Adult Abuse Reporting Center (MAARC) for one of one resident (R1) who had a delay in care after staff failed to immediately report a fall and reports of increased pain to the nurse.

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to submit a report to the Minnesota Adult Abuse Reporting Center (MAARC) for one of one resident (R1) who had a delay in care after staff failed to immediately report a fall and reports of increased pain to the nurse. The resident experienced ten out of ten pain but was not sent to the emergency room until 17 hours after falling. [...]”

    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 1350: 144G.60 Subd. 5 Temporary staff Level 3, widespread scope, scope/level letter I · correction period: Twenty-One (21) Days
    Details

    Summary: MDH found the licensee failed to ensure contracted staff met all requirements for training and competency evaluation for four of four temporary unlicensed personnel ((ULP)-D, ULP-E, ULP-F, ULP-G) with records reviewed.

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure contracted staff met all requirements for training and competency evaluation for four of four temporary unlicensed personnel ((ULP)-D, ULP-E, ULP-F, ULP-G) with records reviewed. [...]”

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

    Summary: MDH found the licensee failed to ensure care was provided by staff who were properly trained and competent when a change in condition was not reported to the appropriate supervisor or health care professional following a fall with reports of increased pain for one of one resident (R1) reviewed.

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure care was provided by staff who were properly trained and competent when a change in condition was not reported to the appropriate supervisor or health care professional following a fall with reports of increased pain for one of one resident (R1) reviewed. The resident fell during a transfer and complained of ongoing ten out of ten pain for approximately 17 hours. [...]”

    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.”

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 24 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.