Golden Horizons

Last evaluation

February 26, 2025

Evaluations on record

2

Investigations substantiated

3 kept 7 years

Inconclusive

1 kept 4 years

Unsubstantiated

1 kept 3 years

Most recent evaluation (February 26, 2025, state report FC1411)

MDH: “On February 24, 2025, through February 26, 2025, the Minnesota Department of Health conducted a full survey at the above provider.”

Survey completed February 26, 2025: 16 correction orders

• 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, which included reviewing the staffing plan at least twice per year and failed to post a daily work schedule at the beginning of each work shift.

  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, which included reviewing the staffing plan at least twice per year and failed to post a daily work schedule at the beginning of each work shift. 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 480: 144G.41 Subdivision 1 Subd. 1a (a-b) Minimum requirements; required food services Level 2, widespread scope, scope/level letter F · correction period: Please refer to the FBEIR for any compliance dates
  Details

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

  MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure food was prepared and served according to the Minnesota Food Code. This practice resulted in a level two violation (a violation that did not harm a resident's health or safety but had the potential to have harmed a resident's health or safety, but was not likely to cause serious injury, impairment, or death), and is issued at a widespread scope (when problems are pervasive or represent a systemic failure that has [...]”

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

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

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

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

  Rule cited: “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 500: 144G.41 Subd. 2 Policies and procedures Level 2, widespread scope, scope/level letter F · correction period: Twenty-One (21) days
  Details

  Summary: MDH found the licensee failed to show they had met the requirements of licensure, by attesting the managerial officials who were in charge of the day-to-day operations, had developed and implemented current policies and procedures, as required.

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to show they had met the requirements of licensure, by attesting the managerial officials who were in charge of the day-to-day operations, had developed and implemented current policies and procedures, as required. [...]”

  Rule cited: “Each assisted living facility must have policies and procedures in place to address the following and keep them current: (1) requirements in section 626.557, reporting of maltreatment of vulnerable adults; (2) conducting and handling background studies on [...]”

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

  Summary: MDH found the licensee failed to establish and maintain an infection control program to comply with accepted health care, medical, and nursing standards for infection control for one of one

  MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to establish and maintain an infection control program to comply with accepted health care, medical, and nursing standards for infection control for one of one employee (unlicensed personnel/ULP-F). [...]”

  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. [...]”

Fines assessed by MDH

• Tag 775 (144g.45 Subd. 2. (a) - Fire Protection And Physical Environment): $500.00

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

Substantiated investigations (state reports)

• July 28, 2026 · report HL306213467C
  Details

  Survey completed July 27, 2026: 1 correction order

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

    Summary: MDH found the licensee failed to ensure employment of an assisted living director licensed or permitted by the Board of Executives for Long Term Services and Supports.

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure employment of an assisted living director licensed or permitted by the Board of Executives for Long Term Services and Supports. This had the potential to affect all of the licensee's 33 residents receiving assisted living with dementia care services. [...]”

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

• December 10, 2024 · report HL306215162M · MDH finding: Allegation 1 Abuse - Not Substantiated
  Details

  Allegation, as written: “The facility abused resident #1 when the facility required resident #1's transfer to a memory care unit only because resident #1 required a two-person mechanical sling lift. In addition, the facility neglected resident #2 when they failed to provide supervision and resident #2 eloped from the facility.”

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

  “The facility was responsible for the maltreatment.”

  Summary: MDH looked into an allegation and found: abuse and neglect was substantiated.

  MDH’s conclusion, as written: “The Minnesota Department of Health determined abuse and neglect was were substantiated. The facility was responsible for the maltreatment. The facility abused resident #1 by unreasonably confining resident #1 in a secured unit, without a way to exit the unit, when resident #1 did not require a secured unit. The facility neglected resident #2 when the facility failed to provide interventions and supervision to prevent resident #2's elopements from the facility.”

  Action taken by facility: “The facility initiated seeking a facility that could meet the needs of resident #1 and held a care conference with resident #2's family.”

  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 22, 2024: 4 correction orders

  • Tag 450: 144G.41 Subdivision 1 Minimum requirements Level 3, isolated scope, scope/level letter G · correction period: Twenty-one (21) days
    Details

    Summary: MDH found the licensee failed to provide person-centered care, including using the least restrictive intervention, for one of one resident (R1) reviewed, when the licensee moved R1 into a secured unit to provide transfers with a mechanical lift.

    MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to provide person-centered care, including using the least restrictive intervention, for one of one resident (R1) reviewed, when the licensee moved R1 into a secured unit to provide transfers with a mechanical lift. The placement in the secured unit did not identify or support R1's preferences, and caused psychosocial harm to R1. [...]”

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

  • Tag 2340: 144G.91 Subd. 6 Participation in care and service planning Level 2, widespread scope, scope/level letter F · correction period: Twenty-one (21) days
    Details

    Summary: MDH found the licensee failed to allow the resident to actively participate in the planning, modification, and evaluation of their care and denied the resident the right to be told in advance of, and take part in decisions regarding recommended changes for one of one resident (R1).

    MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to allow the resident to actively participate in the planning, modification, and evaluation of their care and denied the resident the right to be told in advance of, and take part in decisions regarding recommended changes for one of one resident (R1). This had the potential to affect all residents. [...]”

    Rule cited: “Residents have the right to actively participate in the planning, modification, and evaluation of their care and services. [...]”

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

    Summary: MDH found the facility failed to ensure two of two residents reviewed (R1, R2) was free from maltreatment.

    MDH’s finding, as written: “Based on observations, interviews, and document review, the facility failed to ensure two of two residents reviewed (R1, R2) was free from maltreatment. R1 was emotionally abused, R2 was neglected. Findings include: On August 22, 2024, the Minnesota Department of Health (MDH) issued a determination that abuse and neglect occurred, and that the facility was responsible for the maltreatment, 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 2370: 144G.91 Subd. 9 Right to come and go freely Level 2, pattern scope, scope/level letter E · correction period: Seven (7) days
    Details

    Summary: MDH found the licensee failed to ensure one of one resident (R1) had the right to enter and leave the facility as they chose.

    MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure one of one resident (R1) had the right to enter and leave the facility as they chose. The facility practice had the potential to affect all residents in the facilty that required a two person mechanical lift transfer. [...]”

    Rule cited: “Residents have the right to enter and leave the facility as they choose. This right may be restricted only as allowed by other law and consistent with a resident's service plan.”

• February 28, 2023 · report HL306214743M · MDH finding: Substantiated, individual responsibility
  Details

  Allegation, as written: “The alleged perpetrator (AP), facility staff, neglected the resident when they failed to hold the resident's insulin as ordered causing the resident to have a dangerously low blood glucose level. The resident became unresponsive, fell, sustained laceration injuries, and was transferred to the emergency department.”

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

  “The AP was responsible for the maltreatment.”

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

  MDH’s conclusion, as written: “The Minnesota Department of Health determined neglect was substantiated. The AP was responsible for the maltreatment. The AP failed to hold and/or administer the resident's insulin according to physician orders. The day of the incident the AP failed to follow prescribed orders and gave the resident's insulin before the noon meal was served, and one hour and 17 minutes prior to the scheduled administration time. Later that day, the resident had a blood glucose An equal opportunity employer. reading of 49 (critically low), and bleeding lacerations to her left wrist and right head from a fall. 911 was called to transport the resident to the hospital.”

  Action taken by facility: “The facility identified and reported the medication error. The facility provided disciplinary action, re-education, and monitoring to ensure accurate medication administration of the AP.”

  Action taken by MDH: “The facility was issued a correction order regarding the vulnerable adult's right to be free from maltreatment. The responsible party will be notified of their right to appeal the maltreatment finding. [...]”

  Survey completed February 8, 2023: 1 correction order

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

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

    MDH’s finding, as written: “Based on observation, interview, and document review, the facility failed to ensure one of one of one residents reviewed, (R1) was free from maltreatment. R1 was neglected. Findings include: The Minnesota Department of Health (MDH) issued a determination maltreatment occurred, and an individual staff 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.”

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 35 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.