Prelude Homes & Services

Last evaluation

January 8, 2025

Evaluations on record

2

Investigations substantiated

3 kept 7 years

Inconclusive

0 kept 4 years

Unsubstantiated

1 kept 3 years

Most recent evaluation (January 8, 2025, state report 77EY11)

MDH: “On January 6, 2024, through January 8, 2024, the Minnesota Department of Health conducted a full survey at the above provider.”

Survey completed January 8, 2025: 12 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, widespread scope, scope/level letter F · correction period: Seven (7) days · fine: $500.00 assessed
  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 gloving, hand hygiene, and catheter care for three of three employees (unlicensed personnel (ULP)-E, ULP-F, ULP-G).

  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 gloving, hand hygiene, and catheter care for three of three employees (unlicensed personnel (ULP)-E, ULP-F, ULP-G). [...]”

  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, widespread scope, scope/level letter F · 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), which included a two-step tuberculin skin test (TST) or other evidence of TB screening such as a blood test for three of three employees (clinical nurse supervisor (CNS)-C, unlicensed personnel (ULP)-E, ULP-G).

  MDH’s finding, as written: “Based on 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), which included a two-step tuberculin skin test (TST) or other evidence of TB screening such as a blood test for three of three employees (clinical nurse supervisor (CNS)-C, unlicensed personnel (ULP)-E, ULP-G). [...]”

  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 680: 144G.42 Subd. 10 Disaster planning and emergency preparedness Level 2, widespread scope, scope/level letter F · correction period: Twenty-one (21) days
  Details

  Summary: MDH found the licensee failed to maintain a written emergency preparedness plan (EPP) with all the required content as defined in Appendix Z. This had the potential to affect all residents, staff, and visitors.

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to maintain a written emergency preparedness plan (EPP) with all the required content as defined in Appendix Z. This had the potential to affect all residents, staff, and visitors. [...]”

  Rule cited: “(a) The facility must meet the following requirements: (1) have a written emergency disaster plan that contains a plan for evacuation, addresses elements of sheltering in place, identifies temporary relocation sites, and details staff assignments in the event [...]”

• Tag 780: 144G.45 Subd. 2 (a) (1) 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 provide reliable and unobstructed egress from the facility to the public way.

  MDH’s finding, as written: “Based on observation and interview, the licensee failed to provide reliable and unobstructed egress from the facility to the public way. This deficient condition had the ability to affect all staff and residents. [...]”

  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 [...]”

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

Fines assessed by MDH

• Tag 510 (144g.41 Subd. 3 - Infection Control Program): $500.00
• Tag 1290 (144g.60 Subdivision 1 - Background Studies Required): $3,000.00

Total fines assessed, as printed in the letter: $3,500.00.

Substantiated investigations (state reports)

• April 23, 2024 · report HL322768969M · MDH finding: Substantiated, individual responsibility
  Details

  Allegation, as written: “The alleged perpetrator (AP) emotionally abused and neglected the resident when the AP left the resident unattended and unassisted during cares. In addition, the AP physically abused the resident when she grabbed the resident's arm while trying to force the resident to stand up.”

  “The Minnesota Department of Health determined emotional, physical abuse, and neglect were substantiated.”

  “The AP was responsible for the maltreatment.”

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

  MDH’s conclusion, as written: “The Minnesota Department of Health determined emotional, physical abuse, and neglect were substantiated. The AP was responsible for the maltreatment. The resident was unable to stand without staff assistance, yet recorded camera footage showed the AP remove the resident's wheelchair and aggressively force the resident to stand and hold unto a bathroom grab bar without staff assistance. The AP ignored the resident as she cried stating she was unable to stand and needed to sit down. Additional recorded camera footage showed the AP roughly grab the resident's arm while trying to force the resident to stand up against the resident's wishes.”

  Action taken by facility: “The AP is no longer employed by the facility.”

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

  Survey completed March 20, 2024: 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 an individual person 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.”

• June 27, 2023 · report HL322766064M · MDH finding: Substantiated, individual responsibility
  Details

  Allegation, as written: “The alleged perpetrators (AP1, AP2, and AP3) neglected a resident when the resident had a fall resulting in fractures in her right leg and foot and the APs did not report the resident's changes of condition to the nurse.”

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

  “AP1, AP2, and AP3 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. AP1, AP2, and AP3 were responsible for the maltreatment. After the resident had an unwitnessed fall; the resident complained of pain, was unable to bare weight on her leg, and AP1 and AP2 were observed in the resident's room discussing the resident's right leg appearing abnormal. AP1 and AP2 did not notify the nurse of the resident pain and/or change of condition following the fall. AP3 worked the overnight shift which was approximately 2 hours following the residents fall. AP3 failed to check on the resident and/or complete any of the residents' cares. When the morning staff attempted to assist the resident with cares the resident was crying in pain. The resident was sent to the hospital and diagnosed with tibia and fibula (lower leg bones) fractures in her right An equal opportunity employer. [...]”

  Action taken by facility: “The facility conducted all staff training for falls, maltreatment reporting, and change of condition.”

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

  Survey completed April 18, 2023: 2 correction orders

  • Tag 2310: 144G.91 Subd. 4 (a) Appropriate care and services Level 3, isolated scope, scope/level letter G · correction period: Two (2) days
    Details

    Summary: MDH found the licensee failed to ensure assisted living services were provided based on the resident's needs and subject to accepted health care standards for one of one resident (R1) with a fall with leg injury, and one of one resident (R2) who was locked outside the facility for over six hours.

    MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure assisted living services were provided based on the resident's needs and subject to accepted health care standards for one of one resident (R1) with a fall with leg injury, and one of one resident (R2) who was locked outside the facility for over six 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 two of two resident(s) (R1 and R2) were free from maltreatment.

    MDH’s finding, as written: “The facility failed to ensure two of two resident(s) (R1 and R2) were free from maltreatment. Findings include: The Minnesota Department of Health (MDH) issued a determination maltreatment occurred, and individual(s) 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 27, 2023 · report HL322766184M · MDH finding: Substantiated, individual responsibility
  Details

  Allegation, as written: “The alleged perpetrator, (AP) neglected a resident when the AP did not provide necessary cares or safety checks to ensure the resident was safe. The resident was locked out of the building for several hours, sustained a fall, and was unable to call for staff assistance.”

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

  “The AP was 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. The AP was responsible for the maltreatment. The AP locked the courtyard door in the memory care unit without ensuring all of the residents were in the building. AP1 failed to complete any of the residents required evening cares or safety checks the remainder of the night. The following shift (overnights) discovered the resident outside in the courtyard laying on the concrete and landscaping rock. The resident had been outside over six hours.”

  Action taken by facility: “The facility investigated the incident and sent the resident to the hospital. The AP is no longer employed by 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 April 18, 2023: 2 correction orders

  • Tag 2310: 144G.91 Subd. 4 (a) Appropriate care and services Level 3, isolated scope, scope/level letter G · correction period: Two (2) days
    Details

    Summary: MDH found the licensee failed to ensure assisted living services were provided based on the resident's needs and subject to accepted health care standards for one of one resident (R1) with a fall with leg injury, and one of one resident (R2) who was locked outside the facility for over six hours.

    MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure assisted living services were provided based on the resident's needs and subject to accepted health care standards for one of one resident (R1) with a fall with leg injury, and one of one resident (R2) who was locked outside the facility for over six 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 two of two resident(s) (R1 and R2) were free from maltreatment.

    MDH’s finding, as written: “The facility failed to ensure two of two resident(s) (R1 and R2) were free from maltreatment. Findings include: The Minnesota Department of Health (MDH) issued a determination maltreatment occurred, and individual(s) 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.”

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 30 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.