Mendota Heights Wp

Survey completed January 20, 2022: 13 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 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 according to the Minnesota Food Code. This had the potential to affect all 38 current residents of the facility. [...]”

  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, widespread scope, scope/level letter F
  Details

  Summary: MDH found 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.

  MDH’s finding, as written: “Based on observation, interview, and document 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. The licensee failed to ensure staff wore recommended personal protective equipment (PPE), ensure personal protective equipment was available to staff, and ensure adequate procedures for isolation of COVID-19 positive residents. [...]”

  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 630: 144G.42 Subd. 6 Compliance with requirements for reporting ma Level 2, isolated scope, scope/level letter D
  Details

  MDH’s finding, as written: “Based on observation, document review, and interview, the licensee's individual abuse prevention plan (IAPP) failed to include an assessment of a resident's susceptibility to abuse by another resident; a resident's risk to abuse another resident; and interventions of the specific measures to be taken by staff to minimize the risk of abuse for one of three residents (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, isolated scope, scope/level letter D · correction period: Twenty-One (21) days
  Details

  Summary: MDH found the licensee failed to maintain a tuberculosis (TB) prevention and control program based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC).

  MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to maintain a tuberculosis (TB) prevention and control program based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC). The licensee failed to ensure history and symptoms screenings and screening for active TB (either a two-step tuberculin skin test (TST) or blood test) was completed and documented for one of two unlicensed personnel (ULP-H) 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, widespread scope, scope/level letter F · correction period: Twenty-one (21) days
  Details

  Summary: MDH found the licensee failed to ensure staff documented resident cares provided in the resident record for two of three residents (R1 and R2) with records reviewed.

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure staff documented resident cares provided in the resident record for two of three residents (R1 and R2) 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, [...]”

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

Allegation, as written: “AP1 and AP2 emotionally abused the resident when the resident asked for help and AP2 said she was not going to get the resident "shit, ask someone else." When the resident reported the exchange to a supervisor, AP1 and AP2 followed the resident and AP1 told the resident she would show the resident how "hood" she can be. AP1 physically abused the resident when she physically pushed him for getting "in her space."”

“The Minnesota Department of Health determined emotional abuse was not substantiated.”

“The Minnesota Department of Health determined physical abuse was inconclusive.”

Summary: MDH looked into 2 allegations and found: emotional abuse not substantiated; physical abuse inconclusive.

MDH’s conclusion, as written: “The Minnesota Department of Health determined emotional abuse was not substantiated. Although foul language was exchanged between the resident and AP1 and AP2, the language did not meet the statutory definition of abuse. The Minnesota Department of Health determined physical abuse was inconclusive. Although AP1 and AP2 entered a verbal altercation with the resident, written and verbal witness accounts varied regarding a physical altercation. AP1 and AP2 denied hitting or pushing the resident.”

Action taken by facility: “The facility completed an internal investigation. The staff members are no longer employed by the facility.”

Action taken by MDH: “No further action taken at this time.”

Survey completed February 18, 2026: no correction orders issued.

Allegation, as written: “The facility neglected resident-1, resident-2, and resident-3 when the facility failed to supervise the residents and resident-3 sexually assaulted resident-1 and resident-2.”

“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. Resident-3 exhibited no prior inappropriate sexual behaviors before the incident and the incidents occurred on the same day. Once the incidents of resident-3 suspected sexually touching of resident-1 and resident-2 were discovered, the facility implemented several interventions including moving resident-3's apartment closer to the nurse's station and away from resident-1 and resident-2's apartments. The facility locked resident-2's apartment door when she was in her apartment, and increased observations for all three residents. Behavioral interventions were added to resident-3's care plan including monitoring and reporting alcohol consumption and inappropriate sexual behaviors. The facility consulted with law enforcement and the ombudsman. [...]”

Action taken by facility: “The facility contacted the police, sent the other residents to the hospital for evaluation, completed an internal investigation, and moved resident-3's room closer to the nurse's station and away from resident-1 and resident-2.”

Action taken by MDH: “No further action taken at this time.”

Survey completed February 11, 2026: no correction orders issued.

Allegation, as written: “The facility neglected the resident when the facility failed to provide medical care to maintain the resident's weight, mental health symptoms, and wounds.”

“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 monitored and assessed the resident's mental and physical health needs appropriately. The facility sent the resident to the hospital multiple times due to mental and physical health concerns. An outside provider managed the resident's wounds including dressing changes and some wounds had improvement. The facility monitored the resident's intake and his weight remained stable until the end of his life. The facility made several referrals for outside services and petitioned for a guardian.”

Action taken by facility: “The facility provided appropriate assessment, evaluation, and medical care to the resident timely.”

Action taken by MDH: “No further action taken at this time.”

Survey completed February 11, 2026: no correction orders issued.

Allegation, as written: “The facility neglected the resident when they failed to report a change in condition and failed to administer scheduled medications as prescribed. The resident did not receive medication as prescribed for a period exceeding four days. The resident passed away on the fifth day.”

“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. Although a medication administration error occurred, it was an isolated incident. The resident was monitored and treated according to the resident's individual assessed needs. There was not a preponderance of evidence to support that the actions of the facility staff met the definition of neglect.”

Action taken by facility: “The facility conducted an internal investigation, and the unlicensed personnel involved were provided reeducation and review by the facility nursing staff, along with letters of discipline.”

Action taken by MDH: “No further action taken at this time.”

Survey completed June 25, 2025: no correction orders issued.

Allegation, as written: “The facility neglected the resident when they failed to administer a pain medication as scheduled. The resident did not receive the medication as prescribed for a period exceeding three days.”

“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. Although a medication administration error occurred, the error was an isolated incident. The resident was monitored and treated according to the resident's individual assessed needs. There was not a preponderance of evidence to support that the actions of the facility staff met the definition of neglect.”

Action taken by facility: “The facility conducted an internal investigation, and the unlicensed personnel involved were provided reeducation and review by the facility nursing staff, along with letters of discipline.”

Action taken by MDH: “No further action taken at this time.”

Survey completed June 25, 2025: no correction orders issued.

Survey completed April 14, 2025: 2 correction orders

• Tag 2310: 144G.91 Subd. 4 (a) Appropriate care and services Level 2, isolated scope, scope/level letter D · correction period: Seven (7) days
  Details

  Summary: MDH found the licensee failed to ensure care and services were provided according to a suitable and up to date assessment, service plan, and individualized abuse prevention plan (IAPP) for 2 of 2 (R1 and R2) residents reviewed.

  MDH’s finding, as written: “Based on interview, and document review, the licensee failed to ensure care and services were provided according to a suitable and up to date assessment, service plan, and individualized abuse prevention plan (IAPP) for 2 of 2 (R1 and R2) residents reviewed. [...]”

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

  MDH’s finding, as written: “The facility failed to ensure two of two residents reviewed (R1 and R2) were free from maltreatment. 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.”

Allegation, as written: “The facility neglected the resident when the facility administered incorrect medications to the resident.”

“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. Although the resident was given the wrong medications, the facility took appropriate action when the error was identified. After monitoring in the hospital, the resident returned to her healthcare baseline. The error was an isolated incident, and no harm occurred to the resident and returned to their baseline health condition. An equal opportunity employer.”

Action taken by facility: “The facility retrained the unlicensed caregiver on medication administration.”

Action taken by MDH: “No further action taken at this time.”

Survey completed October 25, 2023: no correction orders issued.

Allegation, as written: “The facility neglected the resident when the facility administered incorrect medications to the resident.”

“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. Although the resident was given incorrect medications, the error was an isolated incident, and no harm occurred to the resident and returned to their baseline health condition.”

Action taken by facility: “The facility retrained the unlicensed caregiver on medication administration.”

Action taken by MDH: “No further action taken at this time.”

Survey completed October 25, 2023: no correction orders issued.