Harmony Gardens (Assisted Living and Memory Care)

Last evaluation

November 4, 2025

Evaluations on record

2

Investigations substantiated

2 kept 7 years

Inconclusive

1 kept 4 years

Unsubstantiated

1 kept 3 years

Most recent evaluation (November 4, 2025, state report T3B411)

MDH: “On November 3, 2025, through November 4, 2025, the Minnesota Department of Health conducted a full survey at the above provider and the following correction orders are issued.”

Survey completed November 4, 2025: 3 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 was 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 1290: 144G.60 Subdivision 1 Background studies required Level 2, isolated scope, scope/level letter D · correction period: Two (2) days
  Details

  Summary: MDH found the licensee failed to ensure a background study was submitted and received in affiliation with the assisted living license for one of three staff (unlicensed personnel (ULP)-F).

  MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure a background study was submitted and received in affiliation with the assisted living license for one of three staff (unlicensed personnel (ULP)-F). [...]”

  Rule cited: “(a) Employees, contractors, and regularly scheduled volunteers of the facility are subject to the background study required by section 144.057 and may be disqualified under chapter 245C. [...]”

• Tag 1880: 144G.71 Subd. 19 Storage of medications Level 2, isolated scope, scope/level letter D · correction period: Seven (7) days
  Details

  Summary: MDH found the licensee failed to store prescription medication securely to permit only authorized personnel to have access.

  MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to store prescription medication securely to permit only authorized personnel to have access. This practice resulted in a level two violation (a violation that did not harm a resident's health or safety but had the potential to have harmed a resident's health or safety, but was not likely to cause serious injury, impairment, or death), and was issued at an isolated scope (when one or a limited number of residents are [...]”

  Rule cited: “An assisted living facility must store all prescription medications in securely locked and substantially constructed compartments according to the manufacturer's directions and permit only authorized personnel to have access.”

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

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

Substantiated investigations (state reports)

• March 31, 2025 · report HL394856281M · MDH finding: Substantiated, individual responsibility
  Details

  Allegation, as written: “The alleged perpetrators (AP 1 and AP 2) financially exploited residents when they stole the residents' controlled medications.”

  “The Minnesota Department of Health determined financial exploitation was substantiated for residents 1, 2, 3, 5, 6, 7, 8, 9, 11, 13, 14, 16, 18 and 21.”

  “The Minnesota Department of Health determined financial exploitation was inconclusive for Residents 4, 10, 12, 19, and 20.”

  “The Minnesota Department of Health determined financial exploitation was not substantiated for resident 15 and resident 17.”

  “AP 1 and AP 2 were responsible for the maltreatment.”

  Summary: MDH looked into 3 allegations and found: financial exploitation substantiated; financial exploitation inconclusive; financial exploitation not substantiated (individual responsibility).

  MDH’s conclusion, as written: “The Minnesota Department of Health determined financial exploitation was substantiated for residents 1, 2, 3, 5, 6, 7, 8, 9, 11, 13, 14, 16, 18 and 21. AP 1 and AP 2 were responsible for the maltreatment. AP 1 and AP 2 were nurses and AP 1 supervised AP 2. AP 1 and AP 2's drug diversion included documentation inconsistencies with pharmacy deliveries; inconsistencies or a lack of documentation in the narcotic records regarding scheduled and as needed (prn) narcotic medication counts, new, refilled or discontinued narcotic prescriptions, and legibility of entries. There were documentation inconsistencies in the electronic medication administration record (MAR). AP 1 and AP 2 failed to follow medication destruction policies and procedures. The Minnesota Department of Health determined financial exploitation was inconclusive for Residents 4, 10, 12, 19, and 20. [...]”

  Action taken by facility: “The facility conducted an internal investigation and contacted law enforcement. The facility changed their medication administration practices by changing log-ins and removed overflow storage from the nurses room. AP 1 no longer at facility. AP 2 no longer at facility.”

  Action taken by MDH: “The facility was issued a correction order regarding the vulnerable adult's right to be free from maltreatment.”

  Survey completed November 25, 2024: 1 correction order

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

    Summary: MDH found the facility failed to ensure 14 of 21 residents reviewed (R1, R2, R3, R5, R6, R7, R8, R9, R11, R13, R14, R16, R18, R21) were free from maltreatment.

    MDH’s finding, as written: “The facility failed to ensure 14 of 21 residents reviewed (R1, R2, R3, R5, R6, R7, R8, R9, R11, R13, R14, R16, R18, R21) were free from maltreatment. Findings include: The Minnesota Department of Health (MDH) issued a determination maltreatment occurred, and individual persons 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.”

• January 24, 2024 · report HL394855243M · MDH finding: Substantiated, individual responsibility
  Details

  Allegation, as written: “The alleged perpetrator (AP), unknown facility staff, financially exploited Resident #1 (R1), Resident #2 (R2), and Resident #3 (R3) when the AP stole the resident's rings.”

  “The Minnesota Department of Health determined financial exploitation was substantiated.”

  “The AP was responsible for the maltreatment.”

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

  MDH’s conclusion, as written: “The Minnesota Department of Health determined financial exploitation was substantiated. The AP was responsible for the maltreatment. Resident #1's wedding ring went missing from her finger. Resident #2 had a diamond ring missing from her apartment. Resident #3's wedding ring went missing from her finger. Based on a preponderance of evidence, the AP, a facility staff, took R1, R2, and R3's rings. The AP had recently worked with the residents, was described by resident #1 as the person who took the ring and was seen on video surveillance as the last staff to exit resident #3's apartment prior to the ring missing. In addition, the AP was previously determined to be responsible for financially exploiting a vulnerable adult when the AP took $25,000.00 from a resident who resided at a facility the AP was employed at. An equal opportunity employer.”

  Action taken by facility: “The facility investigated the missing rings, installed additional video surveillance, contacted authorities, made required reports, and provided additional staff training.”

  Action taken by MDH: “The facility was issued a correction order regarding the vulnerable adult's right to be free from maltreatment.”

  Survey completed November 27, 2023: 1 correction order

  • 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) was free from maltreatment.

    MDH’s finding, as written: “The facility failed to ensure three of three residents reviewed (R1, R2 and R3) was free from maltreatment. Findings include: The Minnesota Department of Health (MDH) issued a determination maltreatment occurred, 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.”

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 120 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.