Pathstone Crossing

Last evaluation

May 16, 2025

Evaluations on record

2

Investigations substantiated

3 kept 7 years

Inconclusive

1 kept 4 years

Unsubstantiated

2 kept 3 years

Most recent evaluation (May 16, 2025, state report UCES11)

MDH: “On May 13, 2025, through May 16, 2025, the Minnesota Department of Health conducted a full survey at the above provider and the following correction orders are issued.”

Survey completed May 16, 2025: 5 correction orders

• Tag 480: 144G.41 Subdivision 1 Subd. 1a (a-b) Minimum requirements; required food services Level 2, widespread scope, scope/level letter F · correction period: Please refer
  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 establish and maintain an effective infection control program that complies with accepted health care, medical and nursing standards for infection control by one of one unlicensed personnel (ULP-E) observed during medication administration.

  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 complies with accepted health care, medical and nursing standards for infection control by one of one unlicensed personnel (ULP-E) observed during medication administration. [...]”

  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 1290: 144G.60 Subdivision 1 Background studies required Level 2, widespread scope, scope/level letter F · correction period: Two (2) days
  Details

  Summary: MDH found the licensee failed to ensure a background study was submitted and received an affiliation with the assisted living license for staff from the attached nursing home providing care at the licensee for one of one employee (unlicensed personnel (ULP)-E)

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure a background study was submitted and received an affiliation with the assisted living license for staff from the attached nursing home providing care at the licensee for one of one employee (unlicensed personnel (ULP)-E) 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 [...]”

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

• Tag 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 three residents (R8) observed during medication administration.

  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 three residents (R8) observed during medication administration. [...]”

  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 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 one of three residents (R1).

  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 one of three residents (R1). [...]”

  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 [...]”

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

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

Substantiated investigations (state reports)

• February 9, 2024 · report HL304257165M · MDH finding: Substantiated, individual responsibility
  Details

  Allegation, as written: “The alleged perpetrator #1 (AP #1) and the alleged perpetrator #2 (AP #2) neglected two residents by leaving them on the floor throughout the entire night after discovering them in that condition.”

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

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

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

  MDH’s conclusion, as written: “The Minnesota Department of Health determined neglect was substantiated. AP #1 and AP #2 were responsible for the maltreatment. While working the night shift, they found two residents on the floor during their rounds. The two APs did not assist either resident up off the floor, nor did they inform the nurse of the situation. The residents remained on the floor until morning when the dayshift caregivers were informed the residents were on the floor.”

  Action taken by facility: “The facility investigated the incident and terminated AP #1 and AP #2.”

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

  Survey completed January 8, 2024: 2 correction orders

  • Tag 1480: 144G.63 Subd. 3 Orientation to resident Level 3, isolated scope, scope/level letter G · correction period: Seven (7) days
    Details

    Summary: MDH found the licensee failed to ensure staff providing assisted living services were oriented specifically to the residents (R3 and R4) and the services to be provided for an agency unlicensed personnel (ULP-A) with records reviewed.

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure staff providing assisted living services were oriented specifically to the residents (R3 and R4) and the services to be provided for an agency unlicensed personnel (ULP-A) with records reviewed. Additionally, the facility failed to ensure ULP-A had the pager or pager log-in to monitor the call light system on the assisted living unit she was floated on to work which led to delayed reponse to call lights. [...]”

    Rule cited: “Staff providing assisted living services must be oriented specifically to each individual resident and the services to be provided. This orientation may be provided in person, orally, in writing, or electronically.”

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

    Summary: MDH found the facility failed to ensure three of four residents reviewed (R1, R2 and R3) was free from maltreatment.

    MDH’s finding, as written: “The facility failed to ensure three of four residents reviewed (R1, R2 and R3) was free from maltreatment. Findings include: Regarding HL304257165M involving R1 and R2 the Minnesota Department of Health (MDH) issued a determination maltreatment occurred, and two individuals 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.”

• February 9, 2024 · report HL304258104M · MDH finding: Substantiated, facility responsibility
  Details

  Allegation, as written: “The alleged perpetrator (AP) neglected the resident by failing to log into the pendant system. Consequently, she was unaware the resident's call light had been on for over an hour resulting in a delay of care. The resident called 911 himself and transferred to the hospital for further evaluation.”

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

  “The facility was responsible for the maltreatment While the AP did not log into the pager system, it was also true the facility did not provide her a pager for the call light system for the first half of the shift.”

  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 While the AP did not log into the pager system, it was also true the facility did not provide her a pager for the call light system for the first half of the shift. The AP had not worked this unit before and was not familiar with the cares to be provided.”

  Action taken by facility: “The AP was no longer working for the facility.”

  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 January 8, 2024: 2 correction orders

  • Tag 1480: 144G.63 Subd. 3 Orientation to resident Level 3, isolated scope, scope/level letter G · correction period: Seven (7) days
    Details

    Summary: MDH found the licensee failed to ensure staff providing assisted living services were oriented specifically to the residents (R3 and R4) and the services to be provided for an agency unlicensed personnel (ULP-A) with records reviewed.

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure staff providing assisted living services were oriented specifically to the residents (R3 and R4) and the services to be provided for an agency unlicensed personnel (ULP-A) with records reviewed. Additionally, the facility failed to ensure ULP-A had the pager or pager log-in to monitor the call light system on the assisted living unit she was floated on to work which led to delayed reponse to call lights. [...]”

    Rule cited: “Staff providing assisted living services must be oriented specifically to each individual resident and the services to be provided. This orientation may be provided in person, orally, in writing, or electronically.”

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

    Summary: MDH found the facility failed to ensure three of four residents reviewed (R1, R2 and R3) was free from maltreatment.

    MDH’s finding, as written: “The facility failed to ensure three of four residents reviewed (R1, R2 and R3) was free from maltreatment. Findings include: Regarding HL304257165M involving R1 and R2 the Minnesota Department of Health (MDH) issued a determination maltreatment occurred, and two individuals 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.”

• April 26, 2022 · report HL30425001M

Summaries are ours and are marked “Summary”; quoted text is MDH’s own, shortened where marked [...]. Read the full reports at the links above or search every report on MDH’s site.

MDH keeps investigation results for seven years when allegations are substantiated, four years when inconclusive, and three years when unsubstantiated, so the counts cover different periods. This community is licensed for 93 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.