Highland Gw

Last evaluation

March 12, 2025

Evaluations on record

2

Investigations substantiated

8 kept 7 years

Inconclusive

1 kept 4 years

Unsubstantiated

1 kept 3 years

Most recent evaluation (March 12, 2025, state report T11K11)

MDH: “On March 10, 2025, through March 12, 2025, the Minnesota Department of Health conducted a survey at the above provider, and the following correction orders are issued.”

Survey completed March 12, 2025: 6 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 775: 144G.45 Subd. 2. (a) Fire protection and physical environment Level 2, widespread scope, scope/level letter F · correction period: Twenty-one (21) days · fine: $500.00 assessed
  Details

  MDH’s finding, as written: “Based on observation and interview, and record review the licensee failed comply with Minnesota State Fire Code in Minnesota Rules chapter 7511. This deficient condition had the ability to affect all staff and residents. [...]”

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

• 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 the required content.

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

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

• Tag 1060: 144G.52 Subd. 9 Emergency relocation Level 2, widespread scope, scope/level letter F · correction period: Twenty-one (21) days
  Details

  Summary: MDH found the licensee failed to provide a written notice with the required content for an emergency relocation to the resident, their legal representative, and designated representative, and failed to provide the notification to the Office of Ombudsman for Long-Term Care (OOLTC) when the resident did not return from the emergency relocation within four (4) days for two of two residents (R2, R4).

  MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to provide a written notice with the required content for an emergency relocation to the resident, their legal representative, and designated representative, and failed to provide the notification to the Office of Ombudsman for Long-Term Care (OOLTC) when the resident did not return from the emergency relocation within four (4) days for two of two residents (R2, R4). [...]”

  Rule cited: “(a) A facility may remove a resident from the facility in an emergency if necessary due to a resident's urgent medical needs or an imminent risk the resident poses to the health or safety of another facility resident or facility staff member. [...]”

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

  Summary: MDH found the licensee failed to ensure prescription medications were securely locked in a substantially constructed compartment and permitted only authorized personnel to have access.

  MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure prescription medications were securely locked in a substantially constructed compartment and permitted only authorized personnel to have access. This had the potential to affect all residents of the second-floor secured unit. [...]”

  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.”

• Tag 2040: 144G.81 Subdivision 1 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 provide mitigating factors for the hazard vulnerability assessment or safety risk assessment of the physical environment on and around the property.

  MDH’s finding, as written: “Based on record review and interview, the licensee failed to provide mitigating factors for the hazard vulnerability assessment or safety risk assessment of the physical environment on and around the property. This deficient practice had the ability to affect all staff, residents, and visitors. [...]”

  Rule cited: “An assisted living facility with dementia care that has a secured dementia care unit must meet the requirements of section 144G.45 and the following additional requirements: (1) a hazard vulnerability assessment or safety risk must be performed on and around [...]”

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

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)

• December 31, 2024 · report HL313376343M · MDH finding: Substantiated, individual responsibility
  Details

  Allegation, as written: “The alleged perpetrator (AP) abused the resident when the AP tied the resident to his wheelchair to prevent him from moving.”

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

  “The AP was responsible for the maltreatment.”

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

  MDH’s conclusion, as written: “The Minnesota Department of Health determined abuse was substantiated. The AP was responsible for the maltreatment. Although the facility was short staffed the day of the incident, the AP purposely tied the resident to his wheelchair to restrict his movement. The AP left at the end of his shift not reporting the restraint to the oncoming shift unlicensed personnel (ULP). Family found the resident tied to his wheelchair with his mechanical lift sling and reported to ULP 1.”

  Action taken by facility: “The facility completed an internal investigation. The AP no longer works at the facility.”

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

  Survey completed December 3, 2024: 5 correction orders

  • Tag 470: 144G.41 Subdivision 1 Minimum requirements Level 3, isolated scope, scope/level letter G · correction period: Seven (7) days
    Details

    Summary: MDH found the licensee failed to ensure the facility had sufficient staffing 24 hours per day to meet the scheduled and reasonably foreseeable unscheduled needs for 5 of 6 residents (R1, R3, R4, R6, R7) reviewed.

    MDH’s finding, as written: “Based on interview, and record review, the licensee failed to ensure the facility had sufficient staffing 24 hours per day to meet the scheduled and reasonably foreseeable unscheduled needs for 5 of 6 residents (R1, R3, R4, R6, R7) reviewed. The facility had insufficient staffing for at least one shift 12 out of 30 days in September. Additionally, the facility had insufficient staffing for at least one shift eight out of 31 days in the month of October. [...]”

    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, widespread scope, scope/level letter F · correction period: Seven (7) days
    Details

    Summary: MDH found the facility failed to report an incident of suspected abuse to the Minnesota Adult Abuse Reporting Center (MAARC) within 24 hours and concluded not to report for a witnessed incident of choking and failure to provide emergency aid resulting in death for one of two residents (R2) reviewed.

    MDH’s finding, as written: “Based on interview and record review, the facility failed to report an incident of suspected abuse to the Minnesota Adult Abuse Reporting Center (MAARC) within 24 hours and concluded not to report for a witnessed incident of choking and failure to provide emergency aid resulting in death for one of two residents (R2) reviewed. This deficient practice had the potential to affect all residents. [...]”

    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, widespread scope, scope/level letter F · correction period: Seven (7) days
    Details

    Summary: MDH found the licensee failed to administer medications as prescribed for four of six residents (R3, R4, R6, and R7) reviewed.

    MDH’s finding, as written: “Based on interview, and record review, the licensee failed to administer medications as prescribed for four of six residents (R3, R4, R6, and R7) reviewed. This had the potential to affect all residents currently receiving medication management services from the licensee. [...]”

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

    Summary: MDH found the licensee failed to ensure staff were properly trained and competent to provide necessary medical care, Heimlich Maneuver, to one of one resident (R2).

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure staff were properly trained and competent to provide necessary medical care, Heimlich Maneuver, to one of one resident (R2). R2 choked in the dining room with multiple licensee's staff present. The licensee's staff failed to perform chest thrusts (Heimlich Maneuver) or contact emergency medical services and R2 died. [...]”

    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 two of two resident(s) reviewed (R1 and R2) were free from maltreatment.

    MDH’s finding, as written: “The facility failed to ensure two of two resident(s) reviewed (R1 and R2) were 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 of R1. The facility and two individual persons were responsible for the maltreatment of R2. Both, 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 31, 2024 · report HL313376962M · MDH finding: Substantiated, facility and individual responsibility
  Details

  Allegation, as written: “The facility neglected the resident when the facility failed to provide supervision during a meal and the resident choked and died.”

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

  “The facility and alleged perpetrator (AP) #1 and AP #2 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. The facility and alleged perpetrator (AP) #1 and AP #2 were responsible for the maltreatment. Multiple unlicensed personnel (ULP), AP #1 and AP #2 (both registered nurses) failed to perform lifesaving medical care during an emergency after resident #1 choked during a meal in the dining room. Resident #1 required a pureed diet with honey thick liquids. Resident started to convulse in the dining room and ULP #1 lowered him to the floor. While resident #1 was on the floor in the dining room, resident #2 told multiple staff resident #1 stuffed another resident's food in his mouth. The staff failed to provide abdominal thrusts (Heimlich Maneuver), or call emergency medical services and resident #1 died.”

  Action taken by facility: “The facility conducted an internal investigation and reported the incident to the licensed assisted living director.”

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

  Survey completed December 3, 2024: 5 correction orders

  • Tag 470: 144G.41 Subdivision 1 Minimum requirements Level 3, isolated scope, scope/level letter G · correction period: Seven (7) days
    Details

    Summary: MDH found the licensee failed to ensure the facility had sufficient staffing 24 hours per day to meet the scheduled and reasonably foreseeable unscheduled needs for 5 of 6 residents (R1, R3, R4, R6, R7) reviewed.

    MDH’s finding, as written: “Based on interview, and record review, the licensee failed to ensure the facility had sufficient staffing 24 hours per day to meet the scheduled and reasonably foreseeable unscheduled needs for 5 of 6 residents (R1, R3, R4, R6, R7) reviewed. The facility had insufficient staffing for at least one shift 12 out of 30 days in September. Additionally, the facility had insufficient staffing for at least one shift eight out of 31 days in the month of October. [...]”

    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, widespread scope, scope/level letter F · correction period: Seven (7) days
    Details

    Summary: MDH found the facility failed to report an incident of suspected abuse to the Minnesota Adult Abuse Reporting Center (MAARC) within 24 hours and concluded not to report for a witnessed incident of choking and failure to provide emergency aid resulting in death for one of two residents (R2) reviewed.

    MDH’s finding, as written: “Based on interview and record review, the facility failed to report an incident of suspected abuse to the Minnesota Adult Abuse Reporting Center (MAARC) within 24 hours and concluded not to report for a witnessed incident of choking and failure to provide emergency aid resulting in death for one of two residents (R2) reviewed. This deficient practice had the potential to affect all residents. [...]”

    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, widespread scope, scope/level letter F · correction period: Seven (7) days
    Details

    Summary: MDH found the licensee failed to administer medications as prescribed for four of six residents (R3, R4, R6, and R7) reviewed.

    MDH’s finding, as written: “Based on interview, and record review, the licensee failed to administer medications as prescribed for four of six residents (R3, R4, R6, and R7) reviewed. This had the potential to affect all residents currently receiving medication management services from the licensee. [...]”

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

    Summary: MDH found the licensee failed to ensure staff were properly trained and competent to provide necessary medical care, Heimlich Maneuver, to one of one resident (R2).

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure staff were properly trained and competent to provide necessary medical care, Heimlich Maneuver, to one of one resident (R2). R2 choked in the dining room with multiple licensee's staff present. The licensee's staff failed to perform chest thrusts (Heimlich Maneuver) or contact emergency medical services and R2 died. [...]”

    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 two of two resident(s) reviewed (R1 and R2) were free from maltreatment.

    MDH’s finding, as written: “The facility failed to ensure two of two resident(s) reviewed (R1 and R2) were 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 of R1. The facility and two individual persons were responsible for the maltreatment of R2. Both, 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.”

• August 29, 2023 · report HL313372546M · MDH finding: Substantiated, facility and individual responsibility
  Details

  Allegation, as written: “The alleged perpetrator (AP) abused the resident when the AP slapped the resident.”

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

  “The facility and AP were responsible for the maltreatment.”

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

  MDH’s conclusion, as written: “The Minnesota Department of Health determined abuse was substantiated. The facility and AP were responsible for the maltreatment. The AP slapped the resident in the back near the upper shoulder. The abuse was witnessed by a facility staff member and the sound was captured on video surveillance. The facility took no corrective action to prevent further occurrence and no re-education or training was provided to facility staff.”

  Action taken by facility: “The ULP is no longer employed by the facility and the facility reported the incident to the state agency.”

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

  Survey completed August 7, 2023: 14 correction orders

  • Tag 250: 144G.20 Subdivision 1 Conditions Level 2, widespread scope, scope/level letter F · correction period: Twenty-one
    Details

    Summary: MDH found the licensee failed to show they met the requirements of licensure, by attesting the managerial officials who oversaw the day-to-day operations understood applicable statutes and rules; nor developed and/or implemented current policies and procedures as required with records reviewed.

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to show they met the requirements of licensure, by attesting the managerial officials who oversaw the day-to-day operations understood applicable statutes and rules; nor developed and/or implemented current policies and procedures as required with records reviewed. This had the potential to affect all residents, staff, and visitors. [...]”

    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 460: 144G.41 Subdivision 1 Minimum requirements Level 3, widespread scope, scope/level letter I · correction period: IMMEDIATE
    Details

    Summary: MDH found the licensee failed to ensure the call light system was fully functional and maintained to meet the scheduled and unscheduled needs of each resident and respond to requests for assistance of health or safety 24 hours a day, seven days a week as required.

    MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the call light system was fully functional and maintained to meet the scheduled and unscheduled needs of each resident and respond to requests for assistance of health or safety 24 hours a day, seven days a week as required. This had the potential to affect all 31 residents. [...]”

    Rule cited: “(5) provide a means for residents to request assistance for health and safety needs 24 hours per day, seven days per week; (6) allow residents the ability to furnish and decorate the resident's unit within the terms of the assisted living contract; (7) permit [...]”

  • Tag 470: 144G.41 Subdivision 1 Minimum requirements Level 2, widespread scope, scope/level letter F · correction period: Seven (7) days
    Details

    Summary: MDH found the licensee failed to ensure the required staffing plan was developed, implemented, and evaluated for appropriateness of staffing levels as required, potentially affecting all of the current residents, staff and visitors.

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the required staffing plan was developed, implemented, and evaluated for appropriateness of staffing levels as required, potentially affecting all of the current 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 530: 144G.41 Subd. 5 Resident councils Level 1, widespread scope, scope/level letter C · correction period: Twenty-One (21) Days
    Details

    Summary: MDH found the licensee failed to provide a resident council, and develop a process to consider resident council recommendations and grievances.

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide a resident council, and develop a process to consider resident council recommendations and grievances. This had the potential to affect all 31 residents. [...]”

    Rule cited: “The facility must provide a resident council with space and privacy for meetings, where doing so is reasonably achievable. Staff, visitors, and other guests may attend a resident council meeting only at the council's invitation. [...]”

  • Tag 540: 144G.41 Subd. 6 Family councils Level 1, widespread scope, scope/level letter C · correction period: Twenty-One (21) Days
    Details

    Summary: MDH found the licensee failed to designate a staff person who is approved by the family council to be responsible for providing assistance and responding to written requests that result from the resident council meetings.

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to designate a staff person who is approved by the family council to be responsible for providing assistance and responding to written requests that result from the resident council meetings. This had the potential to affect all 31 residents and their families. [...]”

    Rule cited: “The facility must provide a family council with space and privacy for meetings, where doing so is reasonably achievable. [...]”

  • 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 report suspected maltreatment to the Minnesota Adult Abuse Reporting Center (MAARC) for three of four residents (R1, R2, and R5) regarding suspected neglect.

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to report suspected maltreatment to the Minnesota Adult Abuse Reporting Center (MAARC) for three of four residents (R1, R2, and R5) regarding suspected neglect. [...]”

    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 1640: 144G.70 Subd. 4 (a-e) Service plan, implementation and revisions to Level 3, isolated scope, scope/level letter G
    Details

    Summary: MDH found the licensee failed to ensure service plans were implemented per the resident's assessments for two of two residents (R1, R6) with records reviewed.

    MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure service plans were implemented per the resident's assessments for two of two residents (R1, R6) with records reviewed. [...]”

    Rule cited: “(a) No later than 14 calendar days after the date that services are first provided, an assisted living facility shall finalize a current written service plan. [...]”

  • 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 medications were administered as prescribed for three of three residents (R7, R8, and R9) 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 (R7, R8, and R9) 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 2310: 144G.91 Subd. 4 (a) Appropriate care and services Level 3, isolated scope, scope/level letter G · correction period: Seven (7)
    Details

    Summary: MDH found the licensee failed to ensure appropriate care and services were provided based on the resident's needs and according to an up-to-date assessment and service plan subject to accepted health care standards when smoking assessment safety interventions were not implemented for one of one resident (R4) reviewed.

    MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure appropriate care and services were provided based on the resident's needs and according to an up-to-date assessment and service plan subject to accepted health care standards when smoking assessment safety interventions were not implemented for one of one resident (R4) reviewed. This had the potential to affect all four residents that smoked at the facility. [...]”

    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 four of four residents reviewed (R1, R2, R3, R5) were free from maltreatment.

    MDH’s finding, as written: “Based on observations, interviews, and document review, the facility failed to ensure four of four residents reviewed (R1, R2, R3, R5) were free from maltreatment. R1, R2, R5 were neglected and R3 was abused Findings include: The Minnesota Department of Health (MDH) issued a determination that abuse and neglect occurred, and that the facility and an individual staff person 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, widespread scope, scope/level letter F · correction period: Seven (7) Days
    Details

    Summary: MDH found the licensee failed to ensure residents not

    MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure residents not residing in memory care had the right to come and go freely. This had the potential to affect all 19 residents who did not reside in the dementia care unit and visitors of the facility. [...]”

    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.”

  • Tag 2480: 144G.91 Subd. 20 Grievances and inquiries Level 2, widespread scope, scope/level letter F · correction period: Twenty-One (21) Days
    Details

    Summary: MDH found the licensee failed to respond to grievances for two of two residents (R1, and R5) reviewed for grievances.

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to respond to grievances for two of two residents (R1, and R5) reviewed for grievances. R1 and R5 communicated several concerns to the licensee without resolution. [...]”

    Rule cited: “Residents have the right to make and receive a timely response to a complaint or inquiry, without limitation. [...]”

  • Tag 2560: 144G.92 Subdivision 1. Retaliation prohibited Level 2, isolated scope, scope/level letter D
    Details

    Summary: MDH found the licensee failed to ensure one of one unlicensed personal (ULP)-K did not experience retaliation after ULP-K shared concerns regarding staff sleeping while working, and service plans not being followed.

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure one of one unlicensed personal (ULP)-K did not experience retaliation after ULP-K shared concerns regarding staff sleeping while working, and service plans not being followed. Upon sharing these concerns ULP-K was taken off of the schedule without notice. [...]”

    Rule cited: “A facility or agent of a facility may not retaliate against a resident or employee if the resident, employee, or any person acting on behalf of the resident: (1) files a good faith complaint or grievance, makes a good faith inquiry, or asserts any right; (2) [...]”

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

    Summary: MDH found the licensee failed to report suspected maltreatment to the Minnesota Adult Abuse Reporting Center (MAARC) for three of four residents (R1, R2, and R5) regarding suspected neglect.

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to report suspected maltreatment to the Minnesota Adult Abuse Reporting Center (MAARC) for three of four residents (R1, R2, and R5) regarding suspected neglect. [...]”

    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 [...]”

• August 29, 2023 · report HL313372722M · MDH finding: Substantiated, facility responsibility
  Details

  Allegation, as written: “The facility neglected the resident when facility staff administered incorrect medications, the resident was hospitalized for 39 days, and did not return to their prior level of function.”

  “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 appropriate medication administration procedures were followed by facility staff and a medication error occurred. Following the incident, the facility failed to evaluate and identify the root cause of the error, failed to evaluate medication administration procedures, and failed to implement interventions to prevent further occurrence.”

  Action taken by facility: “The facility investigated the incident and re-educated the ULP involved in the incident.”

  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 7, 2023: 14 correction orders

  • Tag 250: 144G.20 Subdivision 1 Conditions Level 2, widespread scope, scope/level letter F · correction period: Twenty-one
    Details

    Summary: MDH found the licensee failed to show they met the requirements of licensure, by attesting the managerial officials who oversaw the day-to-day operations understood applicable statutes and rules; nor developed and/or implemented current policies and procedures as required with records reviewed.

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to show they met the requirements of licensure, by attesting the managerial officials who oversaw the day-to-day operations understood applicable statutes and rules; nor developed and/or implemented current policies and procedures as required with records reviewed. This had the potential to affect all residents, staff, and visitors. [...]”

    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 460: 144G.41 Subdivision 1 Minimum requirements Level 3, widespread scope, scope/level letter I · correction period: IMMEDIATE
    Details

    Summary: MDH found the licensee failed to ensure the call light system was fully functional and maintained to meet the scheduled and unscheduled needs of each resident and respond to requests for assistance of health or safety 24 hours a day, seven days a week as required.

    MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the call light system was fully functional and maintained to meet the scheduled and unscheduled needs of each resident and respond to requests for assistance of health or safety 24 hours a day, seven days a week as required. This had the potential to affect all 31 residents. [...]”

    Rule cited: “(5) provide a means for residents to request assistance for health and safety needs 24 hours per day, seven days per week; (6) allow residents the ability to furnish and decorate the resident's unit within the terms of the assisted living contract; (7) permit [...]”

  • Tag 470: 144G.41 Subdivision 1 Minimum requirements Level 2, widespread scope, scope/level letter F · correction period: Seven (7) days
    Details

    Summary: MDH found the licensee failed to ensure the required staffing plan was developed, implemented, and evaluated for appropriateness of staffing levels as required, potentially affecting all of the current residents, staff and visitors.

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the required staffing plan was developed, implemented, and evaluated for appropriateness of staffing levels as required, potentially affecting all of the current 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 530: 144G.41 Subd. 5 Resident councils Level 1, widespread scope, scope/level letter C · correction period: Twenty-One (21) Days
    Details

    Summary: MDH found the licensee failed to provide a resident council, and develop a process to consider resident council recommendations and grievances.

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide a resident council, and develop a process to consider resident council recommendations and grievances. This had the potential to affect all 31 residents. [...]”

    Rule cited: “The facility must provide a resident council with space and privacy for meetings, where doing so is reasonably achievable. Staff, visitors, and other guests may attend a resident council meeting only at the council's invitation. [...]”

  • Tag 540: 144G.41 Subd. 6 Family councils Level 1, widespread scope, scope/level letter C · correction period: Twenty-One (21) Days
    Details

    Summary: MDH found the licensee failed to designate a staff person who is approved by the family council to be responsible for providing assistance and responding to written requests that result from the resident council meetings.

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to designate a staff person who is approved by the family council to be responsible for providing assistance and responding to written requests that result from the resident council meetings. This had the potential to affect all 31 residents and their families. [...]”

    Rule cited: “The facility must provide a family council with space and privacy for meetings, where doing so is reasonably achievable. [...]”

  • 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 report suspected maltreatment to the Minnesota Adult Abuse Reporting Center (MAARC) for three of four residents (R1, R2, and R5) regarding suspected neglect.

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to report suspected maltreatment to the Minnesota Adult Abuse Reporting Center (MAARC) for three of four residents (R1, R2, and R5) regarding suspected neglect. [...]”

    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 1640: 144G.70 Subd. 4 (a-e) Service plan, implementation and revisions to Level 3, isolated scope, scope/level letter G
    Details

    Summary: MDH found the licensee failed to ensure service plans were implemented per the resident's assessments for two of two residents (R1, R6) with records reviewed.

    MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure service plans were implemented per the resident's assessments for two of two residents (R1, R6) with records reviewed. [...]”

    Rule cited: “(a) No later than 14 calendar days after the date that services are first provided, an assisted living facility shall finalize a current written service plan. [...]”

  • 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 medications were administered as prescribed for three of three residents (R7, R8, and R9) 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 (R7, R8, and R9) 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 2310: 144G.91 Subd. 4 (a) Appropriate care and services Level 3, isolated scope, scope/level letter G · correction period: Seven (7)
    Details

    Summary: MDH found the licensee failed to ensure appropriate care and services were provided based on the resident's needs and according to an up-to-date assessment and service plan subject to accepted health care standards when smoking assessment safety interventions were not implemented for one of one resident (R4) reviewed.

    MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure appropriate care and services were provided based on the resident's needs and according to an up-to-date assessment and service plan subject to accepted health care standards when smoking assessment safety interventions were not implemented for one of one resident (R4) reviewed. This had the potential to affect all four residents that smoked at the facility. [...]”

    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 four of four residents reviewed (R1, R2, R3, R5) were free from maltreatment.

    MDH’s finding, as written: “Based on observations, interviews, and document review, the facility failed to ensure four of four residents reviewed (R1, R2, R3, R5) were free from maltreatment. R1, R2, R5 were neglected and R3 was abused Findings include: The Minnesota Department of Health (MDH) issued a determination that abuse and neglect occurred, and that the facility and an individual staff person 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, widespread scope, scope/level letter F · correction period: Seven (7) Days
    Details

    Summary: MDH found the licensee failed to ensure residents not

    MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure residents not residing in memory care had the right to come and go freely. This had the potential to affect all 19 residents who did not reside in the dementia care unit and visitors of the facility. [...]”

    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.”

  • Tag 2480: 144G.91 Subd. 20 Grievances and inquiries Level 2, widespread scope, scope/level letter F · correction period: Twenty-One (21) Days
    Details

    Summary: MDH found the licensee failed to respond to grievances for two of two residents (R1, and R5) reviewed for grievances.

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to respond to grievances for two of two residents (R1, and R5) reviewed for grievances. R1 and R5 communicated several concerns to the licensee without resolution. [...]”

    Rule cited: “Residents have the right to make and receive a timely response to a complaint or inquiry, without limitation. [...]”

  • Tag 2560: 144G.92 Subdivision 1. Retaliation prohibited Level 2, isolated scope, scope/level letter D
    Details

    Summary: MDH found the licensee failed to ensure one of one unlicensed personal (ULP)-K did not experience retaliation after ULP-K shared concerns regarding staff sleeping while working, and service plans not being followed.

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure one of one unlicensed personal (ULP)-K did not experience retaliation after ULP-K shared concerns regarding staff sleeping while working, and service plans not being followed. Upon sharing these concerns ULP-K was taken off of the schedule without notice. [...]”

    Rule cited: “A facility or agent of a facility may not retaliate against a resident or employee if the resident, employee, or any person acting on behalf of the resident: (1) files a good faith complaint or grievance, makes a good faith inquiry, or asserts any right; (2) [...]”

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

    Summary: MDH found the licensee failed to report suspected maltreatment to the Minnesota Adult Abuse Reporting Center (MAARC) for three of four residents (R1, R2, and R5) regarding suspected neglect.

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to report suspected maltreatment to the Minnesota Adult Abuse Reporting Center (MAARC) for three of four residents (R1, R2, and R5) regarding suspected neglect. [...]”

    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 [...]”

• August 29, 2023 · report HL313372910M · MDH finding: Substantiated, facility responsibility
  Details

  Allegation, as written: “The facility neglected the resident when staff failed to provide care as directed by the resident's service plan, failed to respond to the resident's requests for assistance and follow up on call light system concerns, failed to follow-up on incidents and injuries, and failed to assess and monitor the resident with a change in condition.”

  “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 follow the plan of care and failed to provide services in accordance with the resident's service plan causing bruising, severe pain, and immobility. Facility staff also failed to respond to the resident's requests for assistance and despite awareness of ongoing concerns related to their call light response system, no system changes were made to ensure availability for residents to request assistance or ensure resident An equal opportunity employer. needs were met. In addition, facility staff failed to monitor and assess the resident following a change in condition and the resident was admitted to the intensive care unit (ICU) for septic shock related to norovirus.”

  Action taken by facility: “No action taken.”

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

  Survey completed August 7, 2023: 14 correction orders

  • Tag 250: 144G.20 Subdivision 1 Conditions Level 2, widespread scope, scope/level letter F · correction period: Twenty-one
    Details

    Summary: MDH found the licensee failed to show they met the requirements of licensure, by attesting the managerial officials who oversaw the day-to-day operations understood applicable statutes and rules; nor developed and/or implemented current policies and procedures as required with records reviewed.

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to show they met the requirements of licensure, by attesting the managerial officials who oversaw the day-to-day operations understood applicable statutes and rules; nor developed and/or implemented current policies and procedures as required with records reviewed. This had the potential to affect all residents, staff, and visitors. [...]”

    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 460: 144G.41 Subdivision 1 Minimum requirements Level 3, widespread scope, scope/level letter I · correction period: IMMEDIATE
    Details

    Summary: MDH found the licensee failed to ensure the call light system was fully functional and maintained to meet the scheduled and unscheduled needs of each resident and respond to requests for assistance of health or safety 24 hours a day, seven days a week as required.

    MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the call light system was fully functional and maintained to meet the scheduled and unscheduled needs of each resident and respond to requests for assistance of health or safety 24 hours a day, seven days a week as required. This had the potential to affect all 31 residents. [...]”

    Rule cited: “(5) provide a means for residents to request assistance for health and safety needs 24 hours per day, seven days per week; (6) allow residents the ability to furnish and decorate the resident's unit within the terms of the assisted living contract; (7) permit [...]”

  • Tag 470: 144G.41 Subdivision 1 Minimum requirements Level 2, widespread scope, scope/level letter F · correction period: Seven (7) days
    Details

    Summary: MDH found the licensee failed to ensure the required staffing plan was developed, implemented, and evaluated for appropriateness of staffing levels as required, potentially affecting all of the current residents, staff and visitors.

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the required staffing plan was developed, implemented, and evaluated for appropriateness of staffing levels as required, potentially affecting all of the current 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 530: 144G.41 Subd. 5 Resident councils Level 1, widespread scope, scope/level letter C · correction period: Twenty-One (21) Days
    Details

    Summary: MDH found the licensee failed to provide a resident council, and develop a process to consider resident council recommendations and grievances.

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide a resident council, and develop a process to consider resident council recommendations and grievances. This had the potential to affect all 31 residents. [...]”

    Rule cited: “The facility must provide a resident council with space and privacy for meetings, where doing so is reasonably achievable. Staff, visitors, and other guests may attend a resident council meeting only at the council's invitation. [...]”

  • Tag 540: 144G.41 Subd. 6 Family councils Level 1, widespread scope, scope/level letter C · correction period: Twenty-One (21) Days
    Details

    Summary: MDH found the licensee failed to designate a staff person who is approved by the family council to be responsible for providing assistance and responding to written requests that result from the resident council meetings.

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to designate a staff person who is approved by the family council to be responsible for providing assistance and responding to written requests that result from the resident council meetings. This had the potential to affect all 31 residents and their families. [...]”

    Rule cited: “The facility must provide a family council with space and privacy for meetings, where doing so is reasonably achievable. [...]”

  • 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 report suspected maltreatment to the Minnesota Adult Abuse Reporting Center (MAARC) for three of four residents (R1, R2, and R5) regarding suspected neglect.

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to report suspected maltreatment to the Minnesota Adult Abuse Reporting Center (MAARC) for three of four residents (R1, R2, and R5) regarding suspected neglect. [...]”

    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 1640: 144G.70 Subd. 4 (a-e) Service plan, implementation and revisions to Level 3, isolated scope, scope/level letter G
    Details

    Summary: MDH found the licensee failed to ensure service plans were implemented per the resident's assessments for two of two residents (R1, R6) with records reviewed.

    MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure service plans were implemented per the resident's assessments for two of two residents (R1, R6) with records reviewed. [...]”

    Rule cited: “(a) No later than 14 calendar days after the date that services are first provided, an assisted living facility shall finalize a current written service plan. [...]”

  • 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 medications were administered as prescribed for three of three residents (R7, R8, and R9) 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 (R7, R8, and R9) 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 2310: 144G.91 Subd. 4 (a) Appropriate care and services Level 3, isolated scope, scope/level letter G · correction period: Seven (7)
    Details

    Summary: MDH found the licensee failed to ensure appropriate care and services were provided based on the resident's needs and according to an up-to-date assessment and service plan subject to accepted health care standards when smoking assessment safety interventions were not implemented for one of one resident (R4) reviewed.

    MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure appropriate care and services were provided based on the resident's needs and according to an up-to-date assessment and service plan subject to accepted health care standards when smoking assessment safety interventions were not implemented for one of one resident (R4) reviewed. This had the potential to affect all four residents that smoked at the facility. [...]”

    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 four of four residents reviewed (R1, R2, R3, R5) were free from maltreatment.

    MDH’s finding, as written: “Based on observations, interviews, and document review, the facility failed to ensure four of four residents reviewed (R1, R2, R3, R5) were free from maltreatment. R1, R2, R5 were neglected and R3 was abused Findings include: The Minnesota Department of Health (MDH) issued a determination that abuse and neglect occurred, and that the facility and an individual staff person 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, widespread scope, scope/level letter F · correction period: Seven (7) Days
    Details

    Summary: MDH found the licensee failed to ensure residents not

    MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure residents not residing in memory care had the right to come and go freely. This had the potential to affect all 19 residents who did not reside in the dementia care unit and visitors of the facility. [...]”

    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.”

  • Tag 2480: 144G.91 Subd. 20 Grievances and inquiries Level 2, widespread scope, scope/level letter F · correction period: Twenty-One (21) Days
    Details

    Summary: MDH found the licensee failed to respond to grievances for two of two residents (R1, and R5) reviewed for grievances.

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to respond to grievances for two of two residents (R1, and R5) reviewed for grievances. R1 and R5 communicated several concerns to the licensee without resolution. [...]”

    Rule cited: “Residents have the right to make and receive a timely response to a complaint or inquiry, without limitation. [...]”

  • Tag 2560: 144G.92 Subdivision 1. Retaliation prohibited Level 2, isolated scope, scope/level letter D
    Details

    Summary: MDH found the licensee failed to ensure one of one unlicensed personal (ULP)-K did not experience retaliation after ULP-K shared concerns regarding staff sleeping while working, and service plans not being followed.

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure one of one unlicensed personal (ULP)-K did not experience retaliation after ULP-K shared concerns regarding staff sleeping while working, and service plans not being followed. Upon sharing these concerns ULP-K was taken off of the schedule without notice. [...]”

    Rule cited: “A facility or agent of a facility may not retaliate against a resident or employee if the resident, employee, or any person acting on behalf of the resident: (1) files a good faith complaint or grievance, makes a good faith inquiry, or asserts any right; (2) [...]”

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

    Summary: MDH found the licensee failed to report suspected maltreatment to the Minnesota Adult Abuse Reporting Center (MAARC) for three of four residents (R1, R2, and R5) regarding suspected neglect.

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to report suspected maltreatment to the Minnesota Adult Abuse Reporting Center (MAARC) for three of four residents (R1, R2, and R5) regarding suspected neglect. [...]”

    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 36 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.