Assisted Living and Memory Care
Majestic Pines
1614 Golf Course Road, Grand Rapids, MN 55744 · Map
Licensed for 101 residents · MAJESTIC PINES
Majestic Pines is a state-licensed assisted living, memory care community in Grand Rapids, Minnesota. It is licensed for 101 residents. Lilisity publishes no score or ranking for this community; the details below come from the state licensing record.
Prices
This community does not publish its prices.
Area costs
Care and services
From the community’s website
What Majestic Pines says about itself, quoted from its own site. We have not checked these claims against licensing records. Ask about each one on a tour.
- Has a separate memory care unit, wing or neighborhood.
Memory Care Neighborhood - Majestic Pines - Grand Rapids, MN
(page, checked Oct 15, 2026) - Provides transportation.
Assistance arranging transportation and appointments
(page, checked Oct 15, 2026) - Apartment types named: two-bedroom.
The open and spacious floor plans of our one and two-bedroom apartments make assisted senior living an excellent choice.
(page, checked Oct 12, 2026)
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.
License
Active, 101 residents
Assisted Living Facility Dementia Care 422232, current license dated Oct 1, 2025. Licensee MAJESTIC PINES.
Nearest emergency room
0.0 miles
Grand Itasca Clinic And 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 |
|---|---|---|---|---|---|
| Majestic Pines this community | 101 | Not published | Active | 2 substantiated | |
| Diamond Willow Assisted Living | 0.7 mi | 26 | Not published | Active | 0 substantiated |
| The Emeralds at Grand Rapids A | 1.7 mi | 55 | Not published | Active | 0 substantiated |
| River Grand Senior Living | 1.8 mi | 78 | Not published | Active | 1 substantiated |
| Brookstone Manor | 1.9 mi | 55 | Not published | Active | 1 substantiated |
State inspection record2 substantiated
- Last evaluation
- April 3, 2025
- Evaluations on record
- 2
- Investigations substantiated
- 2 kept 7 years
- Inconclusive
- 0 kept 4 years
- Unsubstantiated
- 1 kept 3 years
Most recent evaluation (April 3, 2025, state report VY3011)
MDH: “On March 31, 2025, through April 3, 2025, the Minnesota Department of Health conducted a full survey at the above provider.”
Survey completed April 3, 2025: 15 correction orders
- Tag 100: 144G.10 Subdivision 1 License required Level 2, widespread scope, scope/level letter F · correction period: Seven (7) days
Details
Summary: MDH found the licensee failed to demonstrate legal responsibility for the control and operation of the facility when the licensee allowed use of facility space by a vendor to provide therapy services to residents and to outside community members.
MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to demonstrate legal responsibility for the control and operation of the facility when the licensee allowed use of facility space by a vendor to provide therapy services to residents and to outside community members. This had the potential to affect all residents, staff, and visitors. [...]”
Rule cited: “(a)(1)Beginning August 1, 2021, no assisted living facility may operate in Minnesota unless it is licensed under this chapter. [...]”
- Tag 480: 144G.41 Subdivision 1 Subd. 1a (a-b) Minimum requirements; required food services Level 2, widespread scope, scope/level letter F · correction period: Please refer to the FBEIR for any compliance dates
Details
Summary: MDH found the licensee failed to ensure food was prepared and served according to the Minnesota Food Code.
MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure food was prepared and served according to the Minnesota Food Code. This practice resulted in a level two violation (a violation that did not harm a resident's health or safety but had the potential to have harmed a resident's health or safety, but was not likely to cause serious injury, impairment, or death), and is issued at a widespread scope (when problems are pervasive or represent a systemic failure that has [...]”
Rule cited: “(a) Except as provided in paragraph (b), food must be prepared and served according to the Minnesota Food Code, Minnesota Rules, chapter 4626. [...]”
- Tag 510: 144G.41 Subd. 3 Infection control program Level 2, isolated scope, scope/level letter D · correction period: Seven (7) days
Details
Summary: MDH found the licensee failed to ensure infection
MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure infection control standards were followed by one of three employees, unlicensed personnel (ULP-G), while providing health monitoring services to one of three residents (R5). [...]”
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. [...]”
- Tag 660: 144G.42 Subd. 9 Tuberculosis prevention and control Level 2, pattern scope, scope/level letter E · correction period: Twenty-One (21) days
Details
Summary: MDH found the licensee failed to ensure the provider established and maintained a tuberculosis (TB) prevention program based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC) which included the completion of baseline TB screenings for two of four employees (unlicensed personnel (ULP)-H, ULP-N).
MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the provider established and maintained a tuberculosis (TB) prevention program based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC) which included the completion of baseline TB screenings for two of four employees (unlicensed personnel (ULP)-H, ULP-N). [...]”
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 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 requirements of the Minnesota State Fire Code.
MDH’s finding, as written: “Based on observation and interview, the licensee failed to comply with the requirements of the Minnesota State Fire Code. 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:”
Show all 15
- Tag 780: 144G.45 Subd. 2 (a) (1) Fire protection and physical environment Level 2, isolated scope, scope/level letter D · correction period: Two (2) day
Details
Summary: MDH found the licensee failed to provide interconnected smoke alarms throughout the facility.
MDH’s finding, as written: “Based on observation and interview, the licensee failed to provide interconnected smoke alarms throughout the facility. This had the potential to affect a limited number of residents, staff, and visitors. [...]”
Rule cited: “for dwellings or sleeping units, as defined in the State Fire Code: (i) provide smoke alarms in each room used for sleeping purposes; (ii) provide smoke alarms outside each separate sleeping area in the immediate vicinity of bedrooms; (iii) provide smoke [...]”
- 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 provide required training for residents.
MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to provide required training for residents. 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 1540: 144G.64 (a) TRAINING IN DEMENTIA CARE REQUIRED Level 2, isolated scope, scope/level letter D · correction period: Twenty-One (21) days
Details
Summary: MDH found the licensee failed to ensure direct care employees received the required amount of dementia care training in the required time frame for one of three employees, clinical nurse supervisor (CNS-C).
MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure direct care employees received the required amount of dementia care training in the required time frame for one of three employees, clinical nurse supervisor (CNS-C). [...]”
Rule cited: “(3) for assisted living facilities with dementia care, direct-care employees must have completed at least eight hours of initial training on topics specified under paragraph (b) within 80 working hours of the employment start date. [...]”
- Tag 1560: 144G.64 (a, b, c) TRAINING IN DEMENTIA CARE REQUIRED Level 2, isolated scope, scope/level letter D · correction period: Twenty-One (21) days
Details
Summary: MDH found the licensee failed to ensure dementia training included all the required content for one of three employees (clinical nurse supervisor (CNS)-C).
MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure dementia training included all the required content for one of three employees (clinical nurse supervisor (CNS)-C). [...]”
Rule cited: “(5) new employees may satisfy the initial training requirements by producing written proof of previously completed required training within the past 18 months. [...]”
- Tag 1640: 144G.70 Subd. 4 (a-e) Service plan, implementation and revisions to Level 2, pattern scope, scope/level letter E · correction period: Twenty-One (21) days
Details
Summary: MDH found the licensee failed to ensure service plans were revised to include provided services for three of five residents (R3, R4, R5).
MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure service plans were revised to include provided services for three of five residents (R3, R4, R5). [...]”
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 1750: 144G.71 Subd. 7 Delegation of medication administration Level 2, widespread scope, scope/level letter F · correction period: Seven (7) days
Details
Summary: MDH found the licensee failed to provide specific resident instructions related to the administration of medications for three of four residents (R4, R3, R5).
MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to provide specific resident instructions related to the administration of medications for three of four residents (R4, R3, R5). [...]”
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, pattern scope, scope/level letter E · correction period: Seven (7) days
Details
Summary: MDH found the licensee failed to ensure the trained medication administration process was followed by one of two employees, unlicensed personnel (ULP)-J, for two of two residents (R9, R10).
MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the trained medication administration process was followed by one of two employees, unlicensed personnel (ULP)-J, for two of two residents (R9, R10). Further, the licensee failed to ensure one of two ULPs (ULP-E) followed registered nurse (RN) written instructions for one of two residents (R7). [...]”
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 1890: 144G.71 Subd. 20 Prescription drugs Level 2, pattern scope, scope/level letter E · correction period: Seven (7) days
Details
Summary: MDH found the licensee failed to ensure medications were maintained bearing the original prescription label with legible information, including the expiration date, for time sensitive medications for two of three medication storage areas (assisted living (AL), secured unit (SU).
MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medications were maintained bearing the original prescription label with legible information, including the expiration date, for time sensitive medications for two of three medication storage areas (assisted living (AL), secured unit (SU). In addition, the licensee failed to monitor for expired medication for one of five unidentified residents. [...]”
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 1950: 144G.72 Subd. 4 Administration of treatments and therapy Level 2, widespread scope, scope/level letter E · correction period: Seven (7) days
Details
Summary: MDH found the licensee failed to ensure the registered nurse (RN) prepared in writing specific instructions for each resident and documented those instructions for three of three residents (R5, R6, R3) receiving the treatment of blood glucose (BG) monitoring.
MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) prepared in writing specific instructions for each resident and documented those instructions for three of three residents (R5, R6, R3) receiving the treatment of blood glucose (BG) monitoring. [...]”
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 2410: 144G.91 Subd. 13 Personal and treatment privacy Level 2, isolated scope, scope/level letter D · correction period: Seven (7) days
Details
Summary: MDH found the licensee failed to ensure privacy was maintained for one of three residents (R6) observed during blood
MDH’s finding, as written: “Based on observation and interview, the licensee failed to ensure privacy was maintained for one of three residents (R6) observed during blood glucose (BG) monitoring. This practice resulted in a level two violation (a violation that did not harm a resident's health or safety but had the potential to have harmed a resident's health or safety, but was not likely to cause serious injury, impairment, or death), and was issued at an isolated scope (when one or a limited number of residents are [...]”
Rule cited: “(a) Residents have the right to consideration of their privacy, individuality, and cultural identity as related to their social, religious, and psychological well-being. [...]”
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.
Earlier evaluations (1)
- September 22, 2022: report WMKX11 · 11 correction orders
Details
Survey completed September 22, 2022: 11 correction orders
- 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 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: “(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 3, widespread scope, scope/level letter I · correction period: Two (2) days
Details
Summary: MDH found the licensee failed to establish and maintain an infection control program that complies with accepted health care, medical and nursing standards for infection control.
MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to establish and maintain an infection control program that complies with accepted health care, medical and nursing standards for infection control. This had the potential to affect all residents, staff and visitors. This resulted in an immediate correction order on September 19, 2022, at approximately 12:30 p.m. [...]”
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. [...]”
- Tag 800: 144G.45 Subd. 2 (a) (4) Fire protection and physical environment Level 2, widespread scope, scope/level letter F · correction period: One (1) day
Details
Summary: MDH found the licensee failed to provide the physical environment in a continuous state of good repair and operation with regard to the health, safety, and well-being of the residents.
MDH’s finding, as written: “Based on observation and interview, the licensee failed to provide the physical environment in a continuous state of good repair and operation with regard to the health, safety, and well-being of the residents. 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 licensee failed to maintain the plans for fire safety and evacuation.
MDH’s finding, as written: “Based on observation, document review, and interview, the licensee failed to maintain the plans for fire safety and evacuation. This had the potential to directly affect all residents and staff. [...]”
Rule cited: “(b) Each assisted living facility shall develop and maintain fire safety and evacuation plans. [...]”
- Tag 970: 144.50 Subd. 5 Waivers of liability prohibited Level 1, widespread scope, scope/level letter C · correction period: Twenty-One
Details
Summary: MDH found the licensee failed to ensure the assisted living contract did not include language waiving the
MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the assisted living contract did not include language waiving the facility's liability for health, safety, or personal property of a resident. This had the potential to affect all residents. This practice resulted in a level one violation 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 of the residents). [...]”
Rule cited: “The contract must not include a waiver of facility liability for the health and safety or personal property of a resident. [...]”
Show all 11
- 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) completed a comprehensive reassessment after a change of condition for one of one resident (R5).
MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the registered nurse (RN) completed a comprehensive reassessment after a change of condition for one of one resident (R5). [...]”
Rule cited: “(c) Resident reassessment and monitoring must be conducted no more than 14 calendar days after initiation of services. [...]”
- 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 as ordered for one of five residents (R5).
MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medications were administered as ordered for one of five residents (R5). 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 [...]”
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 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 resident (R1) upon discharge.
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 resident (R1) upon discharge. [...]”
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 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 a hazard vulnerability or safety risk assessment that included hazards identified on and around the property.
MDH’s finding, as written: “Based on document review and interview, the licensee failed to provide a hazard vulnerability or safety risk assessment that included hazards identified on and around the property. This had the potential to directly affect all residents and staff. [...]”
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 [...]”
- Tag 2310: 144G.91 Subd. 4 Appropriate care and services Level 2, isolated scope, scope/level letter D · correction period: Seven (7) days
Details
MDH’s finding, as written: “Based on observation, interview, and record review the licensee failed to ensure an oxygen cylinder was secured in a rack to prevent tipping or damage for one of one resident (R6). [...]”
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 2410: 144G.91 Subd. 13 Personal and treatment privacy Level 2, isolated scope, scope/level letter D · correction period: Seven (7) days
Details
Summary: MDH found the licensee failed to ensure privacy was maintained during medication administration, and blood glucose monitoring for two of five residents (R6 and R7).
MDH’s finding, as written: “Based on observation and interview, the licensee failed to ensure privacy was maintained during medication administration, and blood glucose monitoring for two of five residents (R6 and R7). [...]”
Rule cited: “(a) Residents have the right to consideration of their privacy, individuality, and cultural identity as related to their social, religious, and psychological well-being. [...]”
From MDH’s letter: the letter says the facility is in substantial compliance.
Total fines assessed, as printed in the letter: $3,000.00.
- 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
Substantiated investigations (state reports)
- October 26, 2023 · report HL309867509M · MDH finding: Substantiated, facility responsibility
Details
Allegation, as written: “The facility neglected three residents (R1, R2, and R3) when they failed to supervise residents with wandering and physically aggressive behaviors. R2 wandered into R3's room and was struck in the head by R3 with his wheelchair foot pedal causing multiple head lacerations and a hematoma. R2 received seven staples for treatment of his injuries. Nine days later R2 wandered into R1's room and had a verbal and physical altercation resulting in bruising injury to R1's lip and face.”
“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 identified R3 had physically and verbally aggressive behaviors but failed to implement identified interventions to prevent residents from wandering into R3's room. Following the incident with R2 and R3, the facility was aware R2 An equal opportunity employer. wandered into other resident rooms frequently but failed to implement interventions to ensure R2 was supervised by staff when wandering. R2 wandered into R1's room and had a physical and verbal altercation resulting in a bruising injury to R1's lip and face.”
Action taken by facility: “Facility staff responded then assessed R1 and R2's injuries, provided first aide, notified leadership and families, and called 911 for R2 to receive evaluation and treatment of his injuries. The facility ensured mental health services were provided for R2 and R3.”
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 September 27, 2023: 4 correction orders
- Tag 620: 144G.42 Subd. 6 (a) / 626.557, Subd. 3 Compliance with requirements for reporting ma Level 2, isolated scope, scope/level letter D · correction period: Seven (7) days
Details
Summary: MDH found the licensee failed to report to the Minnesota Adult Abuse Reporting Center (MAARC) suspected maltreatment for two of two residents (R2, and R3) reviewed.
MDH’s finding, as written: “Based on interview and record review, the licensee failed to report to the Minnesota Adult Abuse Reporting Center (MAARC) suspected maltreatment for two of two residents (R2, and R3) reviewed. The residents were neglected when the licensee failed to implement known interventions to prevent resident's from wandering into R3's room, and failed to identify and implement interventions to ensure safety with R2's wandering behaviors. [...]”
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 630: 144G.42 Subd. 6 (b) Compliance with requirements for reporting ma Level 3, pattern scope, scope/level letter H · correction period: Two (2) days
Details
Summary: MDH found the licensee failed to develop and implement an individual abuse prevention plan to ensure safety for 3 of 3 residents (R1, R2, and R3) with
MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop and implement an individual abuse prevention plan to ensure safety for 3 of 3 residents (R1, R2, and R3) with wandering and aggressive behaviors. The licensee failed to reassess and timely implement interventions following resident to resident altercations which caused harm to two of the three residents (R1, and R2). [...]”
Rule cited: “(b) The facility must develop and implement an individual abuse prevention plan for each vulnerable adult. [...]”
- Tag 2310: 144G.91 Subd. 4 (a) Appropriate care and services Level 3, widespread scope, scope/level letter I · correction period: Two (2) days
Details
Summary: MDH found the licensee failed to provide appropriate care, services, supervision, and monitoring for 1:1 residents (R4) who resided in a secure memory care unit with severe cognitive impairment and was harmed when R4 suffered heat stroke and was transferred to the emergency department by ambulance after he wandered out to a outdoor patio area and remained outside for two hours and 23 minutes unsupervised during an extremely hot day.
MDH’s finding, as written: “The licensee failed to provide appropriate care, services, supervision, and monitoring for 1:1 residents (R4) who resided in a secure memory care unit with severe cognitive impairment and was harmed when R4 suffered heat stroke and was transferred to the emergency department by ambulance after he wandered out to a outdoor patio area and remained outside for two hours and 23 minutes unsupervised during an extremely hot day. [...]”
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 4 of 4 residents reviewed, (R1, R2, R3, and R4) were free from maltreatment.
MDH’s finding, as written: “Based on interview and document review, the facility failed to ensure 4 of 4 residents reviewed, (R1, R2, R3, and R4) were free from maltreatment. R1, R2, R3, and R4 were neglected. Findings include: The Minnesota Department of Health (MDH) issued a determination maltreatment occurred, and the facility was responsible for the maltreatment, in connection with incidents which occurred at the facility. Please refer to the public maltreatment report for details. [...]”
Rule cited: “Residents have the right to be free from physical, sexual, and emotional abuse; neglect; financial exploitation; and all forms of maltreatment covered under the Vulnerable Adults Act.”
- Tag 620: 144G.42 Subd. 6 (a) / 626.557, Subd. 3 Compliance with requirements for reporting ma Level 2, isolated scope, scope/level letter D · correction period: Seven (7) days
- October 26, 2023 · report HL309868404M · MDH finding: Substantiated, facility responsibility
Details
Allegation, as written: “The facility neglected a resident when they failed to provide supervision for a resident with severe cognitive impairment when he wandered outside to an enclosed patio area unsupervised. The resident required treatment for heat stroke at the emergency department.”
“The Minnesota Department of Health determined neglect was substantiated.”
“The facility is 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 is responsible for the maltreatment. The resident wandered outside to the secured patio area on a hot summer afternoon, and remained outside unsupervised for approximately two and half hours before two staff brought the resident inside. The resident was unable to walk, hot to the touch, had a rapid heart rate, and respirations. The resident was transferred to the emergency department (ED) and received treatment for heat stroke.”
Action taken by facility: “Facility staff called 911 for the resident to get treatment of his heat stroke, barricaded the patio door to prevent other resident's from wandering out to the outdoor patio area. The facility changed the patio door lock system to require a fob to let the resident's in and out of the patio area.”
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 September 27, 2023: 4 correction orders
- Tag 620: 144G.42 Subd. 6 (a) / 626.557, Subd. 3 Compliance with requirements for reporting ma Level 2, isolated scope, scope/level letter D · correction period: Seven (7) days
Details
Summary: MDH found the licensee failed to report to the Minnesota Adult Abuse Reporting Center (MAARC) suspected maltreatment for two of two residents (R2, and R3) reviewed.
MDH’s finding, as written: “Based on interview and record review, the licensee failed to report to the Minnesota Adult Abuse Reporting Center (MAARC) suspected maltreatment for two of two residents (R2, and R3) reviewed. The residents were neglected when the licensee failed to implement known interventions to prevent resident's from wandering into R3's room, and failed to identify and implement interventions to ensure safety with R2's wandering behaviors. [...]”
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 630: 144G.42 Subd. 6 (b) Compliance with requirements for reporting ma Level 3, pattern scope, scope/level letter H · correction period: Two (2) days
Details
Summary: MDH found the licensee failed to develop and implement an individual abuse prevention plan to ensure safety for 3 of 3 residents (R1, R2, and R3) with
MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop and implement an individual abuse prevention plan to ensure safety for 3 of 3 residents (R1, R2, and R3) with wandering and aggressive behaviors. The licensee failed to reassess and timely implement interventions following resident to resident altercations which caused harm to two of the three residents (R1, and R2). [...]”
Rule cited: “(b) The facility must develop and implement an individual abuse prevention plan for each vulnerable adult. [...]”
- Tag 2310: 144G.91 Subd. 4 (a) Appropriate care and services Level 3, widespread scope, scope/level letter I · correction period: Two (2) days
Details
Summary: MDH found the licensee failed to provide appropriate care, services, supervision, and monitoring for 1:1 residents (R4) who resided in a secure memory care unit with severe cognitive impairment and was harmed when R4 suffered heat stroke and was transferred to the emergency department by ambulance after he wandered out to a outdoor patio area and remained outside for two hours and 23 minutes unsupervised during an extremely hot day.
MDH’s finding, as written: “The licensee failed to provide appropriate care, services, supervision, and monitoring for 1:1 residents (R4) who resided in a secure memory care unit with severe cognitive impairment and was harmed when R4 suffered heat stroke and was transferred to the emergency department by ambulance after he wandered out to a outdoor patio area and remained outside for two hours and 23 minutes unsupervised during an extremely hot day. [...]”
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 4 of 4 residents reviewed, (R1, R2, R3, and R4) were free from maltreatment.
MDH’s finding, as written: “Based on interview and document review, the facility failed to ensure 4 of 4 residents reviewed, (R1, R2, R3, and R4) were free from maltreatment. R1, R2, R3, and R4 were neglected. Findings include: The Minnesota Department of Health (MDH) issued a determination maltreatment occurred, and the facility was responsible for the maltreatment, in connection with incidents which occurred at the facility. Please refer to the public maltreatment report for details. [...]”
Rule cited: “Residents have the right to be free from physical, sexual, and emotional abuse; neglect; financial exploitation; and all forms of maltreatment covered under the Vulnerable Adults Act.”
- Tag 620: 144G.42 Subd. 6 (a) / 626.557, Subd. 3 Compliance with requirements for reporting ma Level 2, isolated scope, scope/level letter D · correction period: Seven (7) days
Unsubstantiated investigations (1)
- October 1, 2024 · report HL309865581C
Details
Survey completed October 1, 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 101 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 MAJESTIC PINES
- License type
- Assisted Living Facility Dementia Care
- License number
- 422232
- License status
- Active
- Current license dated
- 2025-10-01
- Licensed capacity
- 101
- Licensee
- MAJESTIC PINES
- County
- Itasca County
- Administrator/Authorized Agent
- Lindsey Wald
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 0.0 mi, nursing home 1.7 mi, pharmacy 1.3 mi
- Nearest hospital with an emergency room
- Grand Itasca Clinic And Hospital, Grand Rapids. 0.0 miles away, straight line. CMS overall hospital rating: 4 of 5 stars.
- Nearest Medicare nursing home
- The Emeralds at Grand Rapids LLC, Grand Rapids. 1.7 miles away, straight line.
- Nearest home health agency office
- Grand Itasca Home Care, Grand Rapids. 1.5 miles away, straight line. Agencies travel to clients, so ask which ones serve this address.
- Nearest pharmacy
- Walgreens. 1.3 miles away, straight line. From OpenStreetMap, which does not list every pharmacy, so one may be closer.
- Area
- USDA classes ZIP code 55744 as micropolitan (micropolitan core).
- Dialysis within 15 miles
- Fmc Dialysis - Grand Rapids, Grand Rapids, 1.4 miles away, straight line (CMS rating 2 of 5 stars)
- Hospice
- 6 Medicare hospices tell CMS they serve ZIP code 55744.
St Croix Hospice, office in Grand Rapids, 1.3 miles away, straight line (CMS family survey rating 4 of 5 stars) - Nearest geriatric medicine practice
- Polinsky Medical Rehabilitation Center, Duluth. 68.2 miles away, straight line. 3 geriatric medicine doctors 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 low; 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 low. By hazard: inland flooding relatively low, wildfire very low, tornado relatively low, heat wave relatively moderate, 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 current license dates from 2025. Has the owner or operator changed recently?
- What does the base rate include, and when did rates last go up?
- How many caregivers work in memory care during the day, the evening and overnight, and for how many residents?
- What dementia training does each caregiver get before working alone, and every year after?
- How do staff respond when a resident is agitated, frightened or tries to leave?
- 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?
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 | Only cases that look tied to an earlier operator (not shown) |
| 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 | See above |
Common questionsAnswers to 4 questions families ask
What type of care does Majestic Pines provide?
Majestic Pines is licensed by the state of Minnesota for assisted living, memory care in Grand Rapids, Minnesota. Its licensed capacity is 101 residents.
Does Lilisity rate Majestic Pines?
No. We publish state licensing details for Majestic Pines 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 Majestic Pines 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. Majestic Pines does not publish its prices.
How do I contact Majestic Pines?
Use Majestic Pines's website, majesticpinesmn.com, or visit at 1614 Golf Course Road, Grand Rapids, MN 55744.
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