Prime Care Services

Last evaluation

June 29, 2022

Evaluations on record

1

Investigations substantiated

1 kept 7 years

Inconclusive

0 kept 4 years

Unsubstantiated

1 kept 3 years

Most recent evaluation (June 29, 2022, state report D9PM11)

MDH: “On June 29, 2022, the Minnesota Department of Health conducted an abbreviated survey at the above provider, no correction orders are issued.”

Survey completed June 29, 2022: no correction orders issued.

Substantiated investigations (state reports)

• March 24, 2025 · report HL368877422M · MDH finding: Substantiated, facility responsibility
  Details

  Allegation, as written: “The facility neglected the resident when they failed to provide supervision and monitoring to ensure the resident was safe. The resident eloped from the facility and 16 days later was found deceased from a drug overdose.”

  “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 resident had a well-known history of substance abuse, wandering, and impulsivity, yet the facility did not take reasonable steps to supervise the resident to ensure his well-being and safety. Overnight unlicensed personnel and morning incoming unlicensed personnel both arrived late for work and never checked the resident's room or facility to ensure the resident was in the facility which delayed the opportunity to immediately begin searching for the resident. The resident went unaccounted for until 12 hours later when the resident's family member arrived at the facility and requested staff check to see if the resident was in his room. In addition, unlicensed personnel slept during overnight shifts.”

  Action taken by facility: “The facility contacted the police department and conducted a search.”

  Action taken by MDH: “The facility was found to be in noncompliance.”

  Survey completed February 11, 2025: 2 correction orders

  • Tag 2310: 144G.91 Subd. 4 (a) Appropriate care and services Level 4, isolated scope, scope/level letter J
    Details

    Summary: MDH found the licensee failed to ensure they provided adequate supervision and monitoring for one of one residents (R1) with record reviewed to ensure he was in the facility and safe.

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure they provided adequate supervision and monitoring for one of one residents (R1) with record reviewed to ensure he was in the facility and safe. For over an hour during the overnight shift the licensee failed to ensure they had staff in the facility which left R1 unsupervised and able to leave the facility unnoticed. In addition, multiple staff stated the overnight shift was a sleep shift for staff to sleep. [...]”

    Rule cited: “(a) Residents have the right to care and assisted living services that are appropriate based on the resident's needs and according to an up-to-date service plan subject to accepted health care standards.”

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

    Summary: MDH found the facility failed to ensure one of one resident reviewed (R1) was free from maltreatment.

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

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 4 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.