Assisted Living

Inver Grove Heights Wp

9056 Buchanan Trail, Inver Grove Heights, MN 55076 · Map
Licensed for 67 residents · INVER GROVE HEIGHTS WP LLC

State license active

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Inver Grove Heights Wp is a state-licensed assisted living community in Inver Grove Heights, Minnesota. It is licensed for 67 residents. Lilisity publishes no score or ranking for this community; the details below come from the state licensing record.

Assisted LivingCare offered

67 residentsLicensed capacity

State licensedAssisted living facility

$2,200 to $4,800/moTypical assisted living start in Minnesota, from 74 communities that publish prices

Prices

This community does not publish its prices.

Area costs

Assisted Living in Minnesota typically starts at $2,200 to $4,800 a month. Based on 74 communities that publish prices. These are area figures, not this community's price.

Lilisity’s independent report

What the public record shows

Gathered by Lilisity from state and federal sources. Communities can’t edit this part of the page.

State inspections

5Substantiated investigations

Last evaluation: Jul 17, 2025. See the record

License

Active, 67 residents

Assisted Living Facility 425117, current license dated Jun 1, 2026. Licensee INVER GROVE HEIGHTS WP LLC.

Nearest emergency room

7.6 miles

M Health Fairview Woodwinds Hospital, rated 4 of 5 stars by CMS.

Side by side with nearby communities

The 4 nearest communities that offer assisted living, by straight-line distance. Prices are starting prices each community publishes; we never show estimates.

Community	Distance	Licensed capacity	Published starting price	License	Inspection citations
Inver Grove Heights Wp this community		67	Not published	Active	5 substantiated
Inver Grove Heights Wp II	0.0 mi	44	Not published	Active	0 substantiated
Amerigrace Care Services	0.3 mi	5	Not published	Active	0 substantiated
Ng&Ng Services Group	0.4 mi	5	Not published	Active	0 substantiated
American Nursing Care	1.2 mi	5	Not published	Active	No record

State inspection record5 substantiated

Last evaluation: July 17, 2025
Evaluations on record: 2
Investigations substantiated: 5 kept 7 years
Inconclusive: 1 kept 4 years
Unsubstantiated: 5 kept 3 years

Most recent evaluation (July 17, 2025, state report JVUK11)

MDH: “On July 14, 2025, through July 17, 205, the Minnesota Department of Health conducted a full survey at the above provider and the following correction orders are issued.”

Survey completed July 17, 2025: 23 correction orders

Tag 420: 144G.40 Subdivision 1 Responsibility for housing and services Level 2, widespread scope, scope/level letter F · correction period: Twenty-one (21) days
Details
Summary: MDH found the licensee failed to provide sufficient management, control, and operation of the housing and services provided by the facility.
MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to provide sufficient management, control, and operation of the housing and services provided by the facility. This had the potential to affect all residents. [...]”
Rule cited: “The facility is directly responsible to the resident for all housing and service-related matters provided, irrespective of a management contract. [...]”
Tag 480: 144G.41 Subdivision 1 Subd. 1a (a-b) Minimum requirements; required food services Level 2, widespread scope, scope/level letter F · correction period: Please refer to the FBEIR for any compliance dates
Details
Summary: MDH found the licensee failed to ensure food was prepared and served according to the Minnesota Food Code.
MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure food was prepared and served according to the Minnesota Food Code. This practice resulted in a level two violation (a violation that did not harm a resident's health or safety but had the potential to have harmed a resident's health or safety) and was issued at a widespread scope (when problems are pervasive or represent a systemic failure that has affected or has the potential to affect a large portion or all the [...]”
Rule cited: “(a) Except as provided in paragraph (b), food must be prepared and served according to the Minnesota Food Code, Minnesota Rules, chapter 4626. [...]”
Tag 630: 144G.42 Subd. 6 (b) Compliance with requirements for reporting ma Level 2, widespread scope, scope/level letter F · correction period: Seven (7) days
Details
Summary: MDH found the licensee failed to ensure an individual abuse prevention plan (IAPP) was developed to include the required content for three of three residents (R1, R2, and R3).
MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure an individual abuse prevention plan (IAPP) was developed to include the required content for three of three residents (R1, R2, and R3). [...]”
Rule cited: “(b) The facility must develop and implement an individual abuse prevention plan for each vulnerable adult. [...]”
Tag 640: 144G.42 Subd. 7 Posting information for reporting suspected c Level 2, widespread scope, scope/level letter F · correction period: Twenty-One
Details
Summary: MDH found the licensee failed to post the 911 emergency number in common areas and near telephones provided by the assisted living facility.
MDH’s finding, as written: “Based on observation and interview, the licensee failed to post the 911 emergency number in common areas and near telephones provided by the assisted living facility. This had the potential to affect all residents, staff, and visitors. [...]”
Rule cited: “The facility shall support protection and safety through access to the state's systems for reporting suspected criminal activity and suspected vulnerable adult maltreatment by: (1) posting the 911 emergency number in common areas and near telephones provided [...]”
Tag 700: 144G.43 Subdivision 1 Resident record Level 2, widespread scope, scope/level letter F · correction period: Twenty-one (21) days
Details
Summary: MDH found the licensee failed to ensure resident's personal health and medical information was kept private.
MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure resident's personal health and medical information was kept private. This had the potential to affect all residents residing within the facility. [...]”
Rule cited: “(b) Resident records, whether written or electronic, must be protected against loss, tampering, or unauthorized disclosure in compliance with chapter 13 and other applicable relevant federal and state laws. [...]”

Show all 23

Tag 775: 144G.45 Subd. 2. (a) Fire protection and physical environment Level 2, widespread scope, scope/level letter F · correction period: Seven (7) days · fine: $500.00 assessed
Details
Summary: MDH found the licensee failed to comply with the current Minnesota Fire Code Provisions.
MDH’s finding, as written: “Based on observation and interview, the licensee failed to comply with the current Minnesota Fire Code Provisions. This had the potential to directly affect all residents, staff, and visitors. [...]”
Rule cited: “Each assisted living facility must comply with the State Fire Code in Minnesota Rules, chapter 7511, and:”
Tag 800: 144G.45 Subd. 2 (a) (4) Fire protection and physical environment Level 2, widespread scope, scope/level letter F · correction period: Seven (7) days
Details
Summary: MDH found the licensee failed to maintain the facility's physical environment in a continuous state of good repair and operation regarding the health, safety, and well-being of the residents.
MDH’s finding, as written: “Based on observation and interview, the licensee failed to maintain the facility's physical environment in a continuous state of good repair and operation regarding the health, safety, and well-being of the residents. This had the potential to directly affect all residents, staff, and visitors. [...]”
Rule cited: “(4) keep the physical environment, including walls, floors, ceiling, all furnishings, grounds, systems, and equipment in a continuous state of good repair and operation with regard to the health, safety, comfort, and well-being of the residents in accordance [...]”
Tag 950: 144G.50 Subd. 3 Designation of representative Level 2, widespread scope, scope/level letter F · correction period: Twenty-One (21) days
Details
Summary: MDH found the licensee failed to ensure the licensee provided the required notice for right to a designated representative with the required verbiage on a document separate from the contract for three of three residents (R1, R2, and R3).
MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the licensee provided the required notice for right to a designated representative with the required verbiage on a document separate from the contract for three of three residents (R1, R2, and R3). [...]”
Rule cited: “(a) Before or at the time of execution of an assisted living contract, an assisted living facility must offer the resident the opportunity to identify a designated representative in writing in the contract and must provide the following verbatim notice on a [...]”
Tag 1060: 144G.52 Subd. 9 Emergency relocation Level 2, widespread scope, scope/level letter F
Details
Summary: MDH found the licensee failed to provide a written notice with the required content for an emergency relocation and failed to notify the Office of Ombudsman for Long-Term Care of the emergency relocation for one of one resident (R5).
MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide a written notice with the required content for an emergency relocation and failed to notify the Office of Ombudsman for Long-Term Care of the emergency relocation for one of one resident (R5). [...]”
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 1460: 144G.63 Subdivision 1 Orientation of staff and supervisors Level 2, isolated scope, scope/level letter D · correction period: Twenty-One (21) days
Details
Summary: MDH found the licensee failed to ensure one of three employees (unlicensed personnel (ULP)-F) completed an orientation to assisted living facility licensing requirements and regulations before providing services to residents.
MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure one of three employees (unlicensed personnel (ULP)-F) completed an orientation to assisted living facility licensing requirements and regulations before providing services to residents. [...]”
Rule cited: “(a) All staff providing and supervising direct services must complete an orientation to assisted living facility licensing requirements and regulations before providing assisted living services to residents. [...]”
Tag 1530: 144G.64 (a) (1-2) Training in Dementia, Mental Illness, and De- Level 2, isolated scope, scope/level letter D · correction period: Twenty-One (21) days
Details
Summary: MDH found the licensee failed to ensure one of three employees (unlicensed personnel (ULP)-F received the required amount of dementia, mental illness, and de-escalation training in the required time frame.
MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure one of three employees (unlicensed personnel (ULP)-F received the required amount of dementia, mental illness, and de-escalation training in the required time frame. [...]”
Rule cited: “(a) All assisted living facilities must meet the following dementia care, mental illness, and de-escalation training requirements: (1) supervisors of direct-care staff must have at least eight hours of initial training on dementia topics specified under [...]”
Tag 1620: 144G.70 Subd. 2 (c-e) Initial reviews, assessments, and monitoring Level 2, isolated scope, scope/level letter D · correction period: Twenty-one (21) days
Details
Summary: MDH found the licensee failed to ensure the registered nurse (RN) conducted ongoing nursing assessments not to exceed 14 days from admission for one of three residents (R1).
MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the registered nurse (RN) conducted ongoing nursing assessments not to exceed 14 days from admission for one of three residents (R1). [...]”
Rule cited: “(a) Residents who are not receiving any assisted living services shall not be required to undergo an initial nursing assessment. [...]”
Tag 1640: 144G.70 Subd. 4 (a-e) Service plan, implementation and revisions to Level 2, isolated scope, scope/level letter D · correction period: Twenty-one (21) days
Details
Summary: MDH found the licensee failed to ensure a written
MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure a written service plan was revised to reflect the current services provided for one of three residents (R2). [...]”
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 1700: 144G.71 Subd. 2 Provision of medication management services Level 2, isolated scope, scope/level letter D · correction period: Seven (7) days
Details
Summary: MDH found the licensee failed to ensure one of one resident (R2) who self-administered medications was assessed for self-administration of medications.
MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure one of one resident (R2) who self-administered medications was assessed for self-administration of medications. [...]”
Rule cited: “(a) For each resident who requests medication management services, the facility shall, prior to providing medication management services, have a registered nurse, licensed health professional, or authorized prescriber under section 151.37 conduct an [...]”
Tag 1730: 144G.71 Subd. 5 Individualized medication management plan Level 2, pattern scope, scope/level letter E · correction period: Seven (7) days
Details
Summary: MDH found the licensee failed to develop an
MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to develop an individualized medication management plan with the required content for three of three residents (R1, R2, and R3). [...]”
Rule cited: “(a) For each resident receiving medication management services, a registered nurse, advanced practice registered nurse, or qualified staff delegated the task by a registered nurse must prepare and include in the service plan a written statement of the [...]”
Tag 1750: 144G.71 Subd. 7 Delegation of medication administration Level 3, widespread scope, scope/level letter I · correction period: Immediate · fine: $1,000.00 assessed
Details
Summary: MDH found the facility failed to ensure unlicensed personnel (ULP) had been trained and competency tested by a licensed registered nurse (RN) prior to administering medications.
MDH’s finding, as written: “Based on interview and record review, the facility failed to ensure unlicensed personnel (ULP) had been trained and competency tested by a licensed registered nurse (RN) prior to administering medications. This resulted in an immediate correction order identified on July 15, 2025. In addition, the licensee failed to ensure the RN documented resident-specific instructions for three of three residents (R1, R2 and R3). [...]”
Rule cited: “When administration of medications is delegated to unlicensed personnel, the assisted living facility must ensure that the registered nurse has: (1) instructed the unlicensed personnel in the proper methods to administer the medications, and the unlicensed [...]”
Tag 1760: 144G.71 Subd. 8 Documentation of administration of medication Level 2, isolated scope, scope/level letter D · correction period: Seven (7) days
Details
Summary: MDH found the licensee failed to ensure medications were administered per prescriber's orders for one of two residents (R1) and failed to ensure medication administration was documented accurately for one of three residents (R3).
MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medications were administered per prescriber's orders for one of two residents (R1) and failed to ensure medication administration was documented accurately for one of three residents (R3). [...]”
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 1770: 144G.71 Subd. 9 Documentation of medication setup Level 2, widespread scope, scope/level letter F
Details
Summary: MDH found the licensee failed to ensure documentation of medication set up included all the required content for one of one resident (R6).
MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure documentation of medication set up included all the required content for one of one resident (R6). [...]”
Rule cited: “Documentation of dates of medication setup, name of medication, quantity of dose, times to be administered, route of administration, and name of person completing medication setup must be done at the time of setup.”
Tag 1890: 144G.71 Subd. 20 Prescription drugs Level 2, isolated scope, scope/level letter D · correction period: Seven (7) days
Details
Summary: MDH found the licensee failed to ensure insulin pens had a pharmacy label for one of two residents (R1).
MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure insulin pens had a pharmacy label for one of two residents (R1). 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 affected or one or a [...]”
Rule cited: “A prescription drug, prior to being set up for immediate or later administration, must be kept in the original container in which it was dispensed by the pharmacy bearing the original prescription label with legible information including the expiration or [...]”
Tag 1910: 144G.71 Subd. 22 Disposition of medications Level 2, isolated scope, scope/level letter D · correction period: Seven (7) days
Details
Summary: MDH found the licensee failed to document in the resident's record the disposition of the medications as required for one of one discharged resident (R5).
MDH’s finding, as written: “Based on interview and record review, the licensee failed to document in the resident's record the disposition of the medications as required for one of one discharged resident (R5). [...]”
Rule cited: “(a) Any current medications being managed by the assisted living facility must be provided to the resident when the resident's service plan ends or medication management services are no longer part of the service plan. [...]”
Tag 1940: 144G.72 Subd. 3 Individualized treatment or therapy managemen Level 2, isolated scope, scope/level letter D · correction period: Seven (7) days
Details
Summary: MDH found the licensee failed to develop and implement a treatment or therapy management plan to include all required content for two of three residents (R1 and R2).
MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to develop and implement a treatment or therapy management plan to include all required content for two of three residents (R1 and R2). [...]”
Rule cited: “For each resident receiving management of ordered or prescribed treatments or therapy services, the assisted living facility must prepare and include in the service plan a written statement of the treatment or therapy services that will be provided to the [...]”
Tag 1950: 144G.72 Subd. 4 Administration of treatments and therapy Level 2, widespread scope, scope/level letter F · correction period: Two (2) days
Details
Summary: MDH found the licensee failed to ensure unlicensed personnel (ULP) had been competency tested by a licensed registered nurse (RN) prior to administering treatments.
MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure unlicensed personnel (ULP) had been competency tested by a licensed registered nurse (RN) prior to administering treatments. [...]”
Rule cited: “Ordered or prescribed treatments or therapies must be administered by a nurse, physician, or other licensed health professional authorized to perform the treatment or therapy, or may be delegated or assigned to unlicensed personnel by the licensed health [...]”
Tag 1970: 144G.72 Subd. 6 Treatment and therapy orders Level 2, pattern scope, scope/level letter E · correction period: Seven (7) days
Details
Summary: MDH found the licensee failed to ensure up-to-date written or electronically recorded orders were maintained for three of three residents (R1, R2 and R3) receiving treatments.
MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure up-to-date written or electronically recorded orders were maintained for three of three residents (R1, R2 and R3) receiving treatments. [...]”
Rule cited: “There must be an up-to-date written or electronically recorded order from an authorized prescriber for all treatments and therapies. [...]”

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 775 (144g.45 Subd. 2. (a) - Fire Protection And Physical Environment): $500.00
Tag 1750 (144g.71 Subd. 7 - Delegation Of Medication Administration): $1,000.00

Total fines assessed, as printed in the letter: $1,500.00.

Earlier evaluations (1)

December 2, 2021: report MJFK11 · 16 correction orders
Details
Survey completed December 3, 2021: 16 correction orders
- Tag 430: 144G.40 Subd. 2 Uniform checklist disclosure of services Level 2, widespread scope, scope/level letter C · correction period: Twenty-One (21) days
  Details
  Summary: MDH found the licensee failed to provide a copy of the Uniform Disclosure of Assisted Living Services and Amenities (UDALSA) with the required content for four of four residents (R1, R2, R3, R4) with records reviewed.
  MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to provide a copy of the Uniform Disclosure of Assisted Living Services and Amenities (UDALSA) with the required content for four of four residents (R1, R2, R3, R4) with records reviewed. [...]”
  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 450: 144G.41 Subdivision 1 Minimum requirements Level 1, widespread scope, scope/level letter C · correction period: Twenty-one (21) days
  Details
  Summary: MDH found the licensee failed to provide current Minnesota Assisted Living Bill of Rights (BOR) for four of four residents (R1, R2, R3, R4) with records reviewed.
  MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide current Minnesota Assisted Living Bill of Rights (BOR) for four of four residents (R1, R2, R3, R4) with records reviewed. [...]”
  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 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 develop and implement 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 develop and implement a staffing plan to determine staffing levels to meet the needs of all residents. This had the potential to affect all fifty-two (52) residents. [...]”
  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 Subd 1 (13) (i) (B) Minimum requirements Level 2, widespread scope, scope/level letter F · correction period: Twenty-one (21) days
  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 had the potential to affect all fifty-two (52) residents. [...]”
  Rule cited: “(13) offer to provide or make available at least the following services to residents: (i) 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 [...]”
- Tag 510: 144G.41 Subd. 3 Infection control program Level 2, isolated scope, scope/level letter D
  Details
  Summary: MDH found the licensee failed to establish and maintain an effective infection control program
  MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to establish and maintain an effective infection control program that complied with accepted health care, medical and nursing standards for infection control related to COVID-19 per the Centers for Disease Control and Prevention (CDC) and Minnesota Department of Health (MDH) guidelines. This had the potential to affect all fifty-two (52) residents, visitors and staff. [...]”
  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. [...]”
Show all 16
- Tag 630: 144G.42 Subd. 6 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 ensure an individual abuse prevention plan (IAPP) was developed to include
  MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure an individual abuse prevention plan (IAPP) was developed to include all required content for two of four residents (R1, R2) with records reviewed. [...]”
  Rule cited: “(b) The facility must develop and implement an individual abuse prevention plan for each vulnerable adult. [...]”
- Tag 660: 144G.42 Subd. 9 Tuberculosis prevention and control Level 2, widespread scope, scope/level letter F · correction period: Twenty-one (21) days
  Details
  Summary: MDH found the licensee failed to establish and maintain a tuberculosis (TB) prevention program based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC) which included a facility TB risk assessment, baseline testing and screening for 2 of 3 employees (registered nurse (RN)-A, unlicensed personnel (ULP)-D) with employee records reviewed.
  MDH’s finding, as written: “Based on interview and record review, the licensee failed to establish and maintain a tuberculosis (TB) prevention program based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC) which included a facility TB risk assessment, baseline testing and screening for 2 of 3 employees (registered nurse (RN)-A, unlicensed personnel (ULP)-D) with employee records reviewed. [...]”
  Rule cited: “(a) The facility must establish and maintain a comprehensive tuberculosis infection control program according to the most current tuberculosis infection control guidelines issued by the United States Centers for Disease Control and Prevention (CDC), Division [...]”
- Tag 730: 144G.43 Subd. 3 Contents of resident record Level 2, pattern scope, scope/level letter E · correction period: Twenty-one (21) days
  Details
  Summary: MDH found the licensee failed to ensure the resident record included documentation of all provided services for four of four residents (R1, R2, R3, R4) with records reviewed.
  MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the resident record included documentation of all provided services for four of four residents (R1, R2, R3, R4) with records reviewed. [...]”
  Rule cited: “Contents of a resident record include the following for each resident: (1) identifying information, including the resident's name, date of birth, address, and telephone number; (2) the name, address, and telephone number of the resident's emergency contact, [...]”
- Tag 800: 144G.45 Subd. 2 (a) (4) 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 maintain the physical environment in a continuous state of good repair and operation.
  MDH’s finding, as written: “Based on observation and interview, the licensee failed to maintain the physical environment in a continuous state of good repair and operation. This had the potential to directly affect all residents and staff. [...]”
  Rule cited: “(4) keep the physical environment, including walls, floors, ceiling, all furnishings, grounds, systems, and equipment in a continuous state of good repair and operation with regard to the health, safety, comfort, and well-being of the residents in accordance [...]”
- 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 facility failed to provide documentation of policy, schedule, and log of staff training or resident training for fire safety and evacuation procedures.
  MDH’s finding, as written: “Based on interview and record review, the facility failed to provide documentation of policy, schedule, and log of staff training or resident training for fire safety and evacuation procedures. This had the potential to affect all current residents, staff and visitors. [...]”
  Rule cited: “(b) Each assisted living facility shall develop and maintain fire safety and evacuation plans. [...]”
- Tag 900: 144G.50 Subdivision 1 Contract required Level 2, widespread scope, scope/level letter F · correction period: Twenty-One (21) days
  Details
  Summary: MDH found the licensee failed to develop and execute a written assisted living contract with the required content for four of four residents (R1, R2, R3, R4) with records reviewed.
  MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop and execute a written assisted living contract with the required content for four of four residents (R1, R2, R3, R4) with records reviewed. [...]”
  Rule cited: “(a) An assisted living facility may not offer or provide housing or assisted living services to any individual unless it has executed a written contract with the resident. [...]”
- Tag 1440: 144G.62 Subd. 4 Supervision of staff providing delegated nurs Level 2, isolated scope, scope/level letter D · correction period: Seven (7) days
  Details
  Summary: MDH found the licensee failed to ensure a registered nurse (RN) conducted direct supervision of staff performing a delegated task within 30 days of providing services for one of one employee (unlicensed personnel (ULP)-D) with employee record reviewed.
  MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure a registered nurse (RN) conducted direct supervision of staff performing a delegated task within 30 days of providing services for one of one employee (unlicensed personnel (ULP)-D) with employee record reviewed. [...]”
  Rule cited: “(a) Staff who perform delegated nursing or therapy tasks must be supervised by an appropriate licensed health professional or a registered nurse according to the assisted living facility's policy where the services are being provided to verify that the work [...]”
- Tag 1470: 144G.63 Subd. 2 Content of required orientation Level 2, widespread scope, scope/level letter F · correction period: Twenty-one (21) days
  Details
  Summary: MDH found the licensee failed to ensure employees received orientation to include all required content for three of three employees (registered nurse (RN)-A, licensed practical nurse (LPN)-C, and unlicensed personnel (ULP)-D) with records reviewed.
  MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure employees received orientation to include all required content for three of three employees (registered nurse (RN)-A, licensed practical nurse (LPN)-C, and unlicensed personnel (ULP)-D) with records reviewed. [...]”
  Rule cited: “(a) The orientation must contain the following topics: (1) an overview of this chapter; (2) an introduction and review of the facility's policies and procedures related to the provision of assisted living services by the individual staff person; (3) handling [...]”
- Tag 1620: 144G.70 Subd. 2 Initial reviews, assessments, and monitoring Level 2, isolated scope, scope/level letter D · correction period: Twenty-one (21) days
  Details
  Summary: MDH found the licensee failed to ensure the registered nurse (RN) conducted ongoing resident monitoring and reassessment, not to exceed 90 calendar days from the last date of the assessment for one of four residents (R1) with records reviewed.
  MDH’s finding, as written: “Based on interview, and record review, the licensee failed to ensure the registered nurse (RN) conducted ongoing resident monitoring and reassessment, not to exceed 90 calendar days from the last date of the assessment for one of four residents (R1) with records reviewed. [...]”
  Rule cited: “(c) Resident reassessment and monitoring must be conducted no more than 14 calendar days after initiation of services. [...]”
- Tag 1650: 144G.70 Subd. 4 Service plan, implementation, and revisions t Level 2, isolated scope, scope/level letter D · correction period: Twenty-One (21) days
  Details
  Summary: MDH found the licensee failed to ensure the service plan included all required content for two of four residents (R2, R3) with records reviewed.
  MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure the service plan included all required content for two of four residents (R2, R3) with records reviewed. [...]”
  Rule cited: “(f) The service plan must include: (1) a description of the services to be provided, the fees for services, and the frequency of each service, according to the resident's current assessment and resident preferences; (2) the identification of staff or [...]”
- Tag 1730: 144G.71 Subd. 5 Individualized medication management plan Level 2, pattern scope, scope/level letter E · correction period: Seven (7) days
  Details
  Summary: MDH found the licensee failed to develop and maintain a current individualized medication management record for each resident to include all required content for three of four residents (R2, R3, R4) with records reviewed.
  MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to develop and maintain a current individualized medication management record for each resident to include all required content for three of four residents (R2, R3, R4) with records reviewed. [...]”
  Rule cited: “(a) For each resident receiving medication management services, the assisted living facility must prepare and include in the service plan a written statement of the medication management services that will be provided to the resident. [...]”
From MDH’s letter: the letter says the facility is in substantial compliance; no immediate fines.

Substantiated investigations (state reports)

March 31, 2025 · report HL306968104M · MDH finding: Substantiated, facility and individual responsibility
Details
Allegation, as written: “The alleged perpetrators (AP)-1 and AP-2 neglected the resident when they failed to complete safety checks per the resident's care plan during the night shift. The resident fell on the floor and was not found for an extended period. The resident later died at the hospital.”
“The Minnesota Department of Health determined neglect was substantiated.”
“The facility and AP-1 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 AP-1 were responsible for the maltreatment. The facility failed to ensure multiple staff were competent with policies and procedures including rounds at shift change, service plan development, and providing resident cares. AP-1 failed to provide safety checks per the resident's care plan which resulted in the resident lying on the floor in her urine for an extended period. The resident was diagnosed with hypothermia and other painful conditions as a result from lying on the floor for an extended period. The resident later died at the hospital.”
Action taken by facility: “The facility completed an internal investigation and re-educated all employees on multiple policies. The facility implemented multiple performance improvement plans on employees and employee audits.”
Action taken by MDH: “The facility was found to be in noncompliance.”
Survey completed March 12, 2025: 1 correction order
- Tag 2360: 144G.91 Subd. 8 Freedom from maltreatment
  Details
  Summary: MDH found the facility failed to ensure one of one resident reviewed (R1) was free from maltreatment.
  MDH’s finding, as written: “The facility failed to ensure one of one resident reviewed (R1) was free from maltreatment. Findings include: The Minnesota Department of Health (MDH) issued a determination maltreatment occurred, and the facility and an individual person 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 26, 2024 · report HL306965883C
Details
Survey completed October 9, 2023: 8 correction orders
- 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 develop and implement a staffing plan to determine staffing levels to meet the needs of all residents who reside in the facility.
  MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop and implement a staffing plan to determine staffing levels to meet the needs of all residents who reside in the facility. [...]”
  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, pattern scope, scope/level letter E · correction period: Seven (7) days
  Details
  Summary: MDH found the licensee failed to immediately report to the Minnesota Adult Abuse Reporting Center (MAARC) suspected maltreatment and complete a thorough investigation for two of four residents (R3, R4) with records reviewed.
  MDH’s finding, as written: “Based on interview and record review, the licensee failed to immediately report to the Minnesota Adult Abuse Reporting Center (MAARC) suspected maltreatment and complete a thorough investigation for two of four residents (R3, R4) with records reviewed. [...]”
  Rule cited: “(a) The assisted living facility must comply with the requirements for the reporting of maltreatment of vulnerable adults in section 626.557. [...]”
- Tag 1640: 144G.70 Subd. 4 (a-e) Service plan, implementation and revisions to Level 2, isolated scope, scope/level letter D · correction period: Twenty-One (21) days
  Details
  Summary: MDH found the licensee failed to ensure service plans were developed and implemented for one of four residents (R4) reviewed.
  MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure service plans were developed and implemented for one of four residents (R4) reviewed. 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 affected or one or [...]”
  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 1700: 144G.71 Subd. 2 Provision of medication management services Level 2, isolated scope, scope/level letter D · correction period: Seven (7) days
  Details
  Summary: MDH found the licensee failed to ensure an assessment was completed prior to initiating medication management services for one of four residents (R4) with records reviewed.
  MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure an assessment was completed prior to initiating medication management services for one of four residents (R4) with records reviewed. [...]”
  Rule cited: “(a) For each resident who requests medication management services, the facility shall, prior to providing medication management services, have a registered nurse, licensed health professional, or authorized prescriber under section 151.37 conduct an [...]”
- Tag 1880: 144G.71 Subd. 19 Storage of medications Level 2, widespread scope, scope/level letter F
  Details
  Summary: MDH found the licensee failed to ensure security and accountability for the overall management, control, and disposition of prescribed medication.
  MDH’s finding, as written: “Based on observation and interview, the licensee failed to ensure security and accountability for the overall management, control, and disposition of prescribed medication. This had the potential to affect all 63 residents. [...]”
  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.”
Show all 8
- Tag 1920: 144G.71 Subd. 23 Loss or spillage Level 2, pattern scope, scope/level letter E · correction period: Seven (7) days
  Details
  Summary: MDH found the licensee failed to follow the procedure for loss and spillage of a controlled substance for two of four residents (R3, R4), who received medication management.
  MDH’s finding, as written: “Based on interview and record review, the licensee failed to follow the procedure for loss and spillage of a controlled substance for two of four residents (R3, R4), who received medication management. [...]”
  Rule cited: “(a) Assisted living facilities providing medication management must develop and implement procedures for loss or spillage of all controlled substances defined in Minnesota Rules, part 6800.4220. [...]”
- 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 the care and services according to the acceptable health care medical or nursing standards of one of four resident (R1) who utilized a mechanical lift transfers for transfers.
  MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide the care and services according to the acceptable health care medical or nursing standards of one of four resident (R1) who utilized a mechanical lift transfers for transfers. In addition, the licensee failed to complete incontinence cares after a fall which resulted in R1 being left in his recliner for 24 hours. [...]”
  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 four residents reviewed (R1) was free from maltreatment.
  MDH’s finding, as written: “The facility failed to ensure one of four residents reviewed (R1) was free from maltreatment. Findings include: The Minnesota Department of Health (MDH) issued a determination maltreatment occurred, and the facility and an individual staff member, 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 8, 2024 · report HL306965563M · MDH finding: Substantiated, facility and individual responsibility
Details
Allegation, as written: “The alleged perpetrator (AP), a facility unlicensed staff member, neglected a resident when the AP transferred a resident with a sit to stand mechanical lift and the resident slipped and dislocated their hip.”
“The Minnesota Department of Health determined neglect was substantiated.”
“The individual and the facility 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 individual and the facility were responsible for the maltreatment. The individual staff member/alleged perpetrator (AP) failed to follow the resident's care plan during a transfer and the resident fell. Following the fall, the resident complained of right hip pain. Nursing staff failed to monitor and assess the resident's ongoing and worsening complaints of pain. The resident was left in a recliner chair for the next 24 hours, as staff were unable to move the resident due to the resident's level of pain. The next day, the resident was admitted to the hospital and required a closed reduction right total hip arthroplasty (a surgical procedure to restore the function of a joint). An equal opportunity employer.”
Action taken by facility: “The facility sent the resident to the emergency room, completed an internal investigation, and completed facility wide education after the incident.”
Action taken by MDH: “The facility was found to be in noncompliance.”
Survey completed October 9, 2023: 8 correction orders
- 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 develop and implement a staffing plan to determine staffing levels to meet the needs of all residents who reside in the facility.
  MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop and implement a staffing plan to determine staffing levels to meet the needs of all residents who reside in the facility. [...]”
  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, pattern scope, scope/level letter E · correction period: Seven (7) days
  Details
  Summary: MDH found the licensee failed to immediately report to the Minnesota Adult Abuse Reporting Center (MAARC) suspected maltreatment and complete a thorough investigation for two of four residents (R3, R4) with records reviewed.
  MDH’s finding, as written: “Based on interview and record review, the licensee failed to immediately report to the Minnesota Adult Abuse Reporting Center (MAARC) suspected maltreatment and complete a thorough investigation for two of four residents (R3, R4) with records reviewed. [...]”
  Rule cited: “(a) The assisted living facility must comply with the requirements for the reporting of maltreatment of vulnerable adults in section 626.557. [...]”
- Tag 1640: 144G.70 Subd. 4 (a-e) Service plan, implementation and revisions to Level 2, isolated scope, scope/level letter D · correction period: Twenty-One (21) days
  Details
  Summary: MDH found the licensee failed to ensure service plans were developed and implemented for one of four residents (R4) reviewed.
  MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure service plans were developed and implemented for one of four residents (R4) reviewed. 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 affected or one or [...]”
  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 1700: 144G.71 Subd. 2 Provision of medication management services Level 2, isolated scope, scope/level letter D · correction period: Seven (7) days
  Details
  Summary: MDH found the licensee failed to ensure an assessment was completed prior to initiating medication management services for one of four residents (R4) with records reviewed.
  MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure an assessment was completed prior to initiating medication management services for one of four residents (R4) with records reviewed. [...]”
  Rule cited: “(a) For each resident who requests medication management services, the facility shall, prior to providing medication management services, have a registered nurse, licensed health professional, or authorized prescriber under section 151.37 conduct an [...]”
- Tag 1880: 144G.71 Subd. 19 Storage of medications Level 2, widespread scope, scope/level letter F
  Details
  Summary: MDH found the licensee failed to ensure security and accountability for the overall management, control, and disposition of prescribed medication.
  MDH’s finding, as written: “Based on observation and interview, the licensee failed to ensure security and accountability for the overall management, control, and disposition of prescribed medication. This had the potential to affect all 63 residents. [...]”
  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.”
Show all 8
- Tag 1920: 144G.71 Subd. 23 Loss or spillage Level 2, pattern scope, scope/level letter E · correction period: Seven (7) days
  Details
  Summary: MDH found the licensee failed to follow the procedure for loss and spillage of a controlled substance for two of four residents (R3, R4), who received medication management.
  MDH’s finding, as written: “Based on interview and record review, the licensee failed to follow the procedure for loss and spillage of a controlled substance for two of four residents (R3, R4), who received medication management. [...]”
  Rule cited: “(a) Assisted living facilities providing medication management must develop and implement procedures for loss or spillage of all controlled substances defined in Minnesota Rules, part 6800.4220. [...]”
- 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 the care and services according to the acceptable health care medical or nursing standards of one of four resident (R1) who utilized a mechanical lift transfers for transfers.
  MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide the care and services according to the acceptable health care medical or nursing standards of one of four resident (R1) who utilized a mechanical lift transfers for transfers. In addition, the licensee failed to complete incontinence cares after a fall which resulted in R1 being left in his recliner for 24 hours. [...]”
  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 four residents reviewed (R1) was free from maltreatment.
  MDH’s finding, as written: “The facility failed to ensure one of four residents reviewed (R1) was free from maltreatment. Findings include: The Minnesota Department of Health (MDH) issued a determination maltreatment occurred, and the facility and an individual staff member, 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.”
June 6, 2023 · report HL306962888M · MDH finding: Substantiated, individual responsibility
Details
Allegation, as written: “The alleged perpetrator (AP), a facility pool staff, financially exploited a resident when the AP stole the resident's credit card and charged $420.”
“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. The facility trained the AP on maltreatment of vulnerable adults, resident rights, appropriate boundaries, and expectations to not steal. The AP stole the resident's credit card from their apartment and used it to purchase two gift cards. The store surveillance video showed the AP leaving the store with the purchase.”
Action taken by facility: “The AP no longer works at the facility.”
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 May 16, 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 resident(s) reviewed (R1) was free from maltreatment.
  MDH’s finding, as written: “The facility failed to ensure one of one resident(s) reviewed (R1) was free from maltreatment. Findings include: The Minnesota Department of Health (MDH) issued a determination maltreatment occurred, and an individual 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.”
March 22, 2022 · report HL30696001M

Inconclusive investigations (1)

January 8, 2024 · report HL306968887M · MDH finding: Inconclusive
Details
Allegation, as written: “The alleged perpetrator (AP), a facility unlicensed staff member, financially exploited a resident when the AP switched the resident's narcotic medication with a non-narcotic medication and took the narcotic for their own personal use.”
“The Minnesota Department of Health determined financial exploitation was inconclusive.”
Summary: MDH looked into an allegation and found: financial exploitation inconclusive.
MDH’s conclusion, as written: “The Minnesota Department of Health determined financial exploitation was inconclusive. Due to conflicting information provided it was unable to be determined if financial exploitation occurred. There was not enough evidence to determine if the staff member/alleged perpetrator (AP) took the resident's narcotic for their own personal use and/or if the resident received the incorrect medication.”
Action taken by facility: “The facility notified the police about the missing narcotics and terminated the AP.”
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 October 9, 2023: 8 correction orders
- 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 develop and implement a staffing plan to determine staffing levels to meet the needs of all residents who reside in the facility.
  MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop and implement a staffing plan to determine staffing levels to meet the needs of all residents who reside in the facility. [...]”
  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, pattern scope, scope/level letter E · correction period: Seven (7) days
  Details
  Summary: MDH found the licensee failed to immediately report to the Minnesota Adult Abuse Reporting Center (MAARC) suspected maltreatment and complete a thorough investigation for two of four residents (R3, R4) with records reviewed.
  MDH’s finding, as written: “Based on interview and record review, the licensee failed to immediately report to the Minnesota Adult Abuse Reporting Center (MAARC) suspected maltreatment and complete a thorough investigation for two of four residents (R3, R4) with records reviewed. [...]”
  Rule cited: “(a) The assisted living facility must comply with the requirements for the reporting of maltreatment of vulnerable adults in section 626.557. [...]”
- Tag 1640: 144G.70 Subd. 4 (a-e) Service plan, implementation and revisions to Level 2, isolated scope, scope/level letter D · correction period: Twenty-One (21) days
  Details
  Summary: MDH found the licensee failed to ensure service plans were developed and implemented for one of four residents (R4) reviewed.
  MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure service plans were developed and implemented for one of four residents (R4) reviewed. 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 affected or one or [...]”
  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 1700: 144G.71 Subd. 2 Provision of medication management services Level 2, isolated scope, scope/level letter D · correction period: Seven (7) days
  Details
  Summary: MDH found the licensee failed to ensure an assessment was completed prior to initiating medication management services for one of four residents (R4) with records reviewed.
  MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure an assessment was completed prior to initiating medication management services for one of four residents (R4) with records reviewed. [...]”
  Rule cited: “(a) For each resident who requests medication management services, the facility shall, prior to providing medication management services, have a registered nurse, licensed health professional, or authorized prescriber under section 151.37 conduct an [...]”
- Tag 1880: 144G.71 Subd. 19 Storage of medications Level 2, widespread scope, scope/level letter F
  Details
  Summary: MDH found the licensee failed to ensure security and accountability for the overall management, control, and disposition of prescribed medication.
  MDH’s finding, as written: “Based on observation and interview, the licensee failed to ensure security and accountability for the overall management, control, and disposition of prescribed medication. This had the potential to affect all 63 residents. [...]”
  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.”
Show all 8
- Tag 1920: 144G.71 Subd. 23 Loss or spillage Level 2, pattern scope, scope/level letter E · correction period: Seven (7) days
  Details
  Summary: MDH found the licensee failed to follow the procedure for loss and spillage of a controlled substance for two of four residents (R3, R4), who received medication management.
  MDH’s finding, as written: “Based on interview and record review, the licensee failed to follow the procedure for loss and spillage of a controlled substance for two of four residents (R3, R4), who received medication management. [...]”
  Rule cited: “(a) Assisted living facilities providing medication management must develop and implement procedures for loss or spillage of all controlled substances defined in Minnesota Rules, part 6800.4220. [...]”
- 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 the care and services according to the acceptable health care medical or nursing standards of one of four resident (R1) who utilized a mechanical lift transfers for transfers.
  MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide the care and services according to the acceptable health care medical or nursing standards of one of four resident (R1) who utilized a mechanical lift transfers for transfers. In addition, the licensee failed to complete incontinence cares after a fall which resulted in R1 being left in his recliner for 24 hours. [...]”
  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 four residents reviewed (R1) was free from maltreatment.
  MDH’s finding, as written: “The facility failed to ensure one of four residents reviewed (R1) was free from maltreatment. Findings include: The Minnesota Department of Health (MDH) issued a determination maltreatment occurred, and the facility and an individual staff member, 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.”

Unsubstantiated investigations (5)

November 6, 2025 · report HL306964405M · MDH finding: Not Substantiated
Details
Allegation, as written: “The facility neglected the resident when they failed to properly care for a wound, resulting in the amputation of a toe.”
“The Minnesota Department of Health determined neglect was not substantiated.”
Summary: MDH looked into an allegation and found: neglect not substantiated.
MDH’s conclusion, as written: “The Minnesota Department of Health determined neglect was not substantiated. The facility was made aware of new wounds to the resident's toes by the resident and responded by completing an assessment, notifying the resident's provider and family, obtaining and starting treatment with wound care per the provider's order.”
Action taken by facility: “The facility reported the wound to the resident's provider who ordered referrals and treatment. The facility monitored the wound and communicated with the skilled nursing wound care agency.”
Action taken by MDH: “No further action taken at this time.”
Survey completed October 21, 2025: no correction orders issued.
July 25, 2025 · report HL306962342M · MDH finding: Not Substantiated
Details
Allegation, as written: “The alleged perpetrator (AP) sexually abused the resident when he kissed her and touched her face, arms, legs, and inner thighs.”
“The Minnesota Department of Health determined sexual abuse was not substantiated.”
Summary: MDH looked into an allegation and found: sexual abuse not substantiated.
MDH’s conclusion, as written: “The Minnesota Department of Health determined sexual abuse was not substantiated. The facility manager observed video footage of the AP during the time the resident made the allegation and did not observe interactions as described by the resident. The resident's care plan was changed to allow female staff only provide cares. Additionally, the actions alleged by the resident did not meet the definition of sexual abuse.”
Action taken by facility: “The facility provided education to staff members regarding appropriate communication and contacted mental health providers to help them develop a plan of care.”
Action taken by MDH: “No further action taken at this time.”
Survey completed July 3, 2025: no correction orders issued.
March 31, 2025 · report HL306966522M · MDH finding: Not Substantiated
Details
Allegation, as written: “The facility neglected to supervise the residents when resident-2 groped resident-1's breast and grabbed her vagina during a resident gathering in resident-3's apartment.”
“The Minnesota Department of Health determined neglect was not substantiated.”
Summary: MDH looked into an allegation and found: neglect not substantiated.
MDH’s conclusion, as written: “The Minnesota Department of Health determined neglect was not substantiated. Several facility staff members observed the four resident's while in resident-3's apartment. Resident-3 and resident-4 had scheduled medication administered while they were in resident-3's apartment during the time of the incident. Resident-1's safety checks were completed and documented per the care plan.”
Action taken by facility: “The facility reported the incident to law enforcement and completed an internal investigation. The facility completed training with all staff and provided education to residents. Resident-1 was offered nursing assessments and the individual abuse prevention plan was updated.”
Action taken by MDH: “No further action taken at this time.”
Survey completed March 12, 2025: 1 correction order
- Tag 2360: 144G.91 Subd. 8 Freedom from maltreatment
  Details
  Summary: MDH found the facility failed to ensure one of one resident reviewed (R1) was free from maltreatment.
  MDH’s finding, as written: “The facility failed to ensure one of one resident reviewed (R1) was free from maltreatment. Findings include: The Minnesota Department of Health (MDH) issued a determination maltreatment occurred, and the facility and an individual person 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.”
August 25, 2024 · report HL306962040M · MDH finding: Not Substantiated
Details
Allegation, as written: “The facility neglected a resident when the resident developed a pressure sore which led to the resident's hospitalization.”
“The Minnesota Department of Health determined neglect was not substantiated.”
Summary: MDH looked into an allegation and found: neglect not substantiated.
MDH’s conclusion, as written: “The Minnesota Department of Health determined neglect was not substantiated. The facility identified the pressure sore and took appropriate action by contacting the resident's medical provider to seek further instructions. However, the resident was discharging to another facility, which occurred the following day and the facility was no longer involved with the resident's cares.”
Action taken by facility: “The facility took care of the wound when it was identified and called the residents provider for follow up.”
Action taken by MDH: “No further action at this time.”
Survey completed June 18, 2024: no correction orders issued.
August 25, 2024 · report HL306963622M · MDH finding: Not Substantiated
Details
Allegation, as written: “The alleged perpetrator (AP) financially exploited the resident when the AP took the resident's cash while in her apartment.”
“The Minnesota Department of Health determined financial exploitation was not substantiated.”
Summary: MDH looked into an allegation and found: financial exploitation not substantiated.
MDH’s conclusion, as written: “The Minnesota Department of Health determined financial exploitation was not substantiated. The AP, who worked at the facility as an unlicensed care giver, provided assistance to the resident when the resident stated that cash went missing from her room. The investigation did not identify evidence the AP stole the resident's money.”
Action taken by facility: “The facility called the police to report the event and also did an internal investigation.”
Action taken by MDH: “No further action taken at time.”
Survey completed June 18, 2024: no correction orders issued.

What the levels and scopes mean (MDH’s words)

Level 1: “a violation that has no potential to cause more than a minimal impact on the resident and does not affect health or safety”

Level 2: “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”

Level 3: “a violation that harmed a resident's health or safety, not including serious injury, impairment, or death, or a violation that has the potential to lead to serious injury, impairment, or death”

Isolated scope: “when one or a limited number of residents are affected or one or a limited number of staff are involved, or the situation has occurred only occasionally”

Pattern scope: “when more than a limited number of residents are affected, more than a limited number of staff are involved, or the situation has occurred repeatedly; but is not found to be pervasive”

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 of the residents”

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.

What these terms mean

MDH: “An evaluation is a process regulated by the division to ensure licensees comply with the laws, rules, and certifications for the type of care and services authorized under their license/certification.”

“An investigation may occur when the division is notified that care and services are not being provided by licensees as required by law. This may include allegations of abuse, neglect, or financial misuse.”

For maltreatment, Minnesota law defines substantiated as “a preponderance of the evidence shows that an act that meets the definition of maltreatment occurred” and inconclusive as “less than a preponderance of evidence to show that maltreatment did or did not occur” (Minn. Stat. 626.5572).

Correction orders, as MDH explains on each state form: “Tag numbers have been assigned to Minnesota State Statutes for Assisted Living Facilities.” “The letter in the left column is used for tracking purposes and reflects the scope and level issued pursuant to 144G.31 subd. 1, 2, and 3.” MDH adds that there is no requirement to submit a plan of correction for violations of Minnesota state statutes.

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 67 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.

License and ownershipActive license, licensee INVER GROVE HEIGHTS WP LLC

License type: Assisted Living Facility
License number: 425117
License status: Active
Current license dated: 2026-06-01
Licensed capacity: 67
Licensee: INVER GROVE HEIGHTS WP LLC
County: Dakota County
Administrator/Authorized Agent: Rhonda Schillinger

Source: Minnesota state licensing records (agency listing), retrieved 2026-09-09. Licensing status is a matter of public record; it is not a quality rating.

Administrator/Authorized Agent name from the Minnesota licensing record, as of Sep 9, 2026.

Paying with Medicaid and other programsHow Medicaid pays for care in Minnesota, and other programs

How Medicaid pays for care in Minnesota

Elderly Waiver (EW), customized living services. Minnesota's Elderly Waiver, part of Medical Assistance (Minnesota Medicaid), can pay for "customized living" services, and a provider of those services must hold an assisted living license (or meet certain exceptions). You must qualify for Medical Assistance and need a nursing-home level of care. (state page)

Ask the community whether it accepts Medicaid.

Location and nearby careNearest hospital 7.6 mi, nursing home 3.5 mi, pharmacy 3.2 mi

Nearest hospital with an emergency room: M Health Fairview Woodwinds Hospital, Woodbury. 7.6 miles away, straight line. CMS overall hospital rating: 4 of 5 stars.
Nearest Medicare nursing home: Woodlyn Heights Healthcare Center, Inver Grove Heights. 3.5 miles away, straight line.
Nearest home health agency office: Spectrum Community Health Inc, Inver Grove Heights. 3.0 miles away, straight line. Agencies travel to clients, so ask which ones serve this address.
Nearest pharmacy: Walgreens. 3.2 miles away, straight line. From OpenStreetMap, which does not list every pharmacy, so one may be closer.
Area: USDA classes ZIP code 55076 as metropolitan (metropolitan core).
Dialysis within 15 miles: Davita Cottage Grove Dialysis, Cottage Grove, 5.6 miles away, straight line (CMS rating 5 of 5 stars)
Fmc - West St Paul Dialysis, West St Paul, 5.8 miles away, straight line (CMS rating 3 of 5 stars)
Davita West St Paul Dialysis Unit, West St Paul, 5.9 miles away, straight line (CMS rating 3 of 5 stars)
Hospice: 22 Medicare hospices tell CMS they serve ZIP code 55076.
Hospice Of The Midwest, office in Woodbury, 8.0 miles away, straight line (CMS family survey rating 3 of 5 stars)
Healthpartners Hospice And Palliatice Care, office in Bloomington, 9.3 miles away, straight line (CMS family survey rating 3 of 5 stars)
St Croix Hospice, office in Oakdale, 10.2 miles away, straight line (CMS family survey rating 3 of 5 stars)
Nearest geriatric medicine practice: Fairview Clinics, Eagan. 6.2 miles away, straight line. 1 geriatric medicine doctor listed there.

Distances are straight lines from the community, not driving distance. Hospitals, home health, dialysis, hospice and doctors come from CMS provider data (CMS, hospital list updated Jul 22, 2026). Star ratings are CMS’s own.

Emergency and natural hazard riskFEMA overall risk relatively moderate; outside FEMA's high-risk flood areas

Public hazard maps for this location. Ask the community about its emergency plan, its generator and where residents would go in an evacuation.

Flood zone: Outside the high and moderate risk flood areas on FEMA's flood map (Zone X, minimal flood hazard, or not studied). (FEMA flood map)
FEMA National Risk Index: Overall: relatively moderate. By hazard: inland flooding relatively moderate, wildfire very low, tornado relatively high, heat wave relatively low, earthquake very low. These are FEMA’s ratings for the census tract, compared with tracts nationwide. (FEMA, December 2025)

A flood zone describes the map at this point, not the building's elevation. In an emergency, follow the local emergency management agency.

Questions to ask on a tour10 questions picked for this community from its record

Picked for this community from its record. Ask them in person and write down the answers.

The state recorded a finding in March 2025. What was it, and how was it fixed?
The current license dates from 2026. Has the owner or operator changed recently?
What does the base rate include, and when did rates last go up?
How many caregivers are on duty during the day and at night?
What happens if care needs increase? When would someone need to move?
What fees are charged at move-in?
How do you tell families about falls, illness or changes?
How long have the executive director and the head of care been here?
Who gives medications, and what training do they have?
For what reasons can a resident be asked to leave?

What we checked12 public sources we searched, with dates

Every public source we searched for this community. “Nothing on record” means we found no record that matched it. A record can be missed when a name or address differs.

Source	Data as of	What we found
Minnesota Department of Health, Health Regulation Division inspection records	Sep 28, 2026	See above
U.S. Department of Labor wage and hour cases	Oct 15, 2026	Nothing on record
OSHA workplace safety inspections since 2016	Oct 15, 2026	Nothing on record
FEMA flood map		See above
USDA wildfire risk	Apr 15, 2026	Not shown: FEMA rates wildfire risk here very low
FEMA National Risk Index		See above
CMS hospitals, home health, dialysis, hospice and doctors; OpenStreetMap pharmacies		See above
HUD Multifamily Properties - Assisted	Jul 6, 2026	Nothing on record
State Veterans Homes (NASVH directory)	Sep 20, 2026	Nothing on record
CMS Hospice - General Information	Aug 19, 2026	Nothing on record
CMS Home Health Care Agencies	May 27, 2026	Nothing on record
The community’s own website		Could not read the site

Common questionsAnswers to 4 questions families ask

What type of care does Inver Grove Heights Wp provide?

Inver Grove Heights Wp is licensed by the state of Minnesota for assisted living in Inver Grove Heights, Minnesota. Its licensed capacity is 67 residents.

Does Lilisity rate Inver Grove Heights Wp?

No. We publish state licensing details for Inver Grove Heights Wp but no score, rating, or ranking. Only communities on the Top Communities list or with a Senior Living Alliance Excellence Award, both based on phone-verified resident and family interviews, are ranked.

How much does Inver Grove Heights Wp cost?

Assisted Living in Minnesota typically starts at $2,200 to $4,800 a month. Based on 74 communities that publish prices. These are area figures, not this community's price. Inver Grove Heights Wp does not publish its prices.

How do I contact Inver Grove Heights Wp?

Use Inver Grove Heights Wp's website, wpseniorliving.com, or visit at 9056 Buchanan Trail, Inver Grove Heights, MN 55076.

Choosing assisted livingOur care guide: what to look for, what it costs, how families pay, and more questions to ask (PDF)

Report a wrong fact

How Lilisity works. The only scores or rankings Lilisity publishes are the Top Communities list and the Excellence Awards, both built from phone-verified resident and family interviews. Communities can pay Lilisity a flat monthly fee to manage their own listing: photos, prices, contact details, and receiving the inquiries families choose to send them. The fee is the same no matter how many families contact them or move in. Senior Living Alliance, which runs Lilisity, offers the same listing to its member communities as part of their membership; members pay SLA for its resident and family interview program. No community pays Lilisity per inquiry, per referral or per move-in. Payment never changes a testimonial, a rating, or the order of search results. The "Nearby Senior Living Alliance communities" box shows member communities only. How we verify testimonials · How we are paid

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