River Oaks at Shady Ridge

Last evaluation

January 30, 2025

Evaluations on record

2

Investigations substantiated

4 kept 7 years

Inconclusive

0 kept 4 years

Unsubstantiated

2 kept 3 years

Most recent evaluation (January 30, 2025, state report VWGE11)

MDH: “On January 27, 2025, through January 30, 2025, the Minnesota Department of Health conducted a full survey at the above provider, and the following correction orders are issued.”

Survey completed January 30, 2025: 14 correction orders

• Tag 470: 144G.41 Subdivision 1 Minimum requirements Level 2, widespread scope, scope/level letter F · correction period: Seven (7) days
  Details

  Summary: MDH found the licensee failed to develop and implement a staffing plan for determining the staffing level, that included an evaluation conducted at least twice a year of the appropriateness of staffing levels in the facility.

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop and implement a staffing plan for determining the staffing level, that included an evaluation conducted at least twice a year of the appropriateness of staffing levels in the facility. [...]”

  Rule cited: “(11) develop and implement a staffing plan for determining its staffing level that: (i) includes an evaluation, to be conducted at least twice a year, of the appropriateness of staffing levels in the facility; (ii) ensures sufficient staffing at all times to [...]”

• Tag 550: 144G.41 Subd. 7 Resident grievances; reporting maltreatment Level 2, widespread scope, scope/level letter F · correction period: Twenty-one (21) days
  Details

  Summary: MDH found the licensee failed to post the required contact information for the individuals who were responsible for handling resident grievances.

  MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to post the required contact information for the individuals who were responsible for handling resident grievances. This had the potential to affect all current residents, staff, and visitors. [...]”

  Rule cited: “All facilities must post in a conspicuous place information about the facilities' grievance procedure, and the name, telephone number, and email contact information for the individuals who are responsible for handling resident grievances. [...]”

• 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 have a written emergency preparedness (EP) plan with all of the required content.

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to have a written emergency preparedness (EP) plan with all of the required content. 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 730: 144G.43 Subd. 3 Contents of resident record Level 2, widespread scope, scope/level letter F
  Details

  Summary: MDH found the licensee failed to ensure resident records included a discharge summary with the required content for one of one discharged resident (R4).

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure resident records included a discharge summary with the required content for one of one discharged resident (R4). [...]”

  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, [...]”

• Tag 910: 144G.50 Subd. 2 (a-b) Contract information Level 1, widespread scope, scope/level letter C · correction period: Twenty-One (21) days
  Details

  Summary: MDH found the licensee failed to execute a written contract with the required content for three of three residents (R1, R2, R3).

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to execute a written contract with the required content for three of three residents (R1, R2, R3). This practice resulted in a level one violation (a violation that has no potential to cause more than a minimal impact on the resident and does not affect health or safety), and was issued at a widespread scope (when problems are pervasive or represent a systemic failure that has affected or has potential to affect a large portion or all of [...]”

  Rule cited: “(a) The contract must include in a conspicuous place and manner on the contract the legal name and the health facility identification of the facility. [...]”

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

Substantiated investigations (state reports)

• March 22, 2024 · report HL326819248M · MDH finding: Substantiated, facility responsibility
  Details

  Allegation, as written: “Allegation #1: The facility neglected resident #1 and resident #2 when the facility did not provide supervision and interventions, which resulted in resident #1 hitting resident #2. Allegation #2: The facility neglected resident #1 and resident #3 when the facility did not provide supervision and interventions, which resulted in a verbal and physical altercation between resident #1 and resident #3.”

  “Allegation #1: The Minnesota Department of Health determined neglect was substantiated.”

  “Allegation #2: The Minnesota Department of Health determined neglect was substantiated.”

  “The facility was responsible for the maltreatment.”

  “The facility was responsible for the maltreatment.”

  Summary: MDH looked into 2 allegations and found: neglect substantiated; neglect substantiated (facility responsibility).

  MDH’s conclusion, as written: “Allegation #1: The Minnesota Department of Health determined neglect was substantiated. The facility was responsible for the maltreatment. The facility did not develop and implement interventions despite multiple altercations involving resident #1 prior to the incident with resident #2. Allegation #2: The Minnesota Department of Health determined neglect was substantiated. The facility was responsible for the maltreatment. The facility did not develop and implement interventions despite multiple altercations involving resident #1 prior to the incident with resident #3.”

  Action taken by facility: “Resident #1 was transferred to a different 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 February 22, 2024: 1 correction order

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

    Summary: MDH found the facility failed to ensure three of four residents reviewed (R2, R3 and R4) were free from maltreatment.

    MDH’s finding, as written: “The facility failed to ensure three of four residents reviewed (R2, R3 and R4) 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.”

• January 12, 2023 · report HL326813123M · MDH finding: Substantiated, facility responsibility
  Details

  Allegation, as written: “The resident was neglected when facility staff failed to update and implement changes following a resident change resulting in a need for increased staff assistance. In addition, the facility failed to identify, assess, and implement interventions to ensure the resident's ability to smoke safely.”

  “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. Despite staff's knowledge of the resident's change in condition and assessed increase in need for assistance with activities of daily living (ADL)s, the facility failed to ensure the resident's service plan was updated and staff were aware of the changes in level of assistance required to care for the resident. In addition, the facility failed to assess the resident's ability to smoke independently despite knowledge of the resident's change in condition, multiple falls in the designated smoking area, and burns on the resident's body. An equal opportunity employer.”

  Action taken by facility: “After the hospice nurse reported concerns with the resident not receiving assistance with ADL's including dressing, the facility added dressing assistance to the resident's services check list. The facility reassessed the resident's safety and ability to smoke independently a week after burns were found on the resident's body. [...]”

  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 December 5, 2022: 6 correction orders

  • Tag 730: 144G.43 Subd. 3 Contents of resident record Level 2, isolated scope, scope/level letter D · correction period: Seven (7) days
    Details

    Summary: MDH found the licensee failed to ensure documentation and wound monitoring for one of one residents (R1) with cigarette burns.

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure documentation and wound monitoring for one of one residents (R1) with cigarette burns. 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 an 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 [...]”

    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, [...]”

  • Tag 800: 144G.45 Subd. 2 (a) (4) Fire protection and physical environment Level 2, isolated scope, scope/level letter D · correction period: Seven (7) days
    Details

    MDH’s finding, as written: “Based on interview, and record review the licensee failed to keep the physical environment in a continuous state of good repair with regard to the health, safety, comfort, and well-being for one of one resident (R1) when was repeatedly observed to be in an unkempt state in visibly soiled clothing, with piles of urine soaked clothing in her room causing a fly infestation and flies crawled on R1's body while she laid unresponsive and dying. [...]”

    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 1620: 144G.70 Subd. 2 (c-e) Initial reviews, assessments, and monitoring Level 3, isolated scope, scope/level letter G · correction period: Seven (7)
    Details

    MDH’s finding, as written: “Based on interview, and record review the licensee failed to provide individualized reassessment and monitoring based on changes in the needs for one of one resident's (R1) when she had a change in condition following a pelvic fracture. As a result, the resident was harmed when she continued to smoke independently and sustained cigarette burns on her body. [...]”

    Rule cited: “(c) Resident reassessment and monitoring must be conducted no more than 14 calendar days after initiation of services. [...]”

  • Tag 1640: 144G.70 Subd. 4 (a-e) Service plan, implementation and revisions to Level 3, isolated scope, scope/level letter G · correction period: Seven (7) days
    Details

    Summary: MDH found the licensee failed to ensure a service plan was revised, entered into the resident record, and implemented for one of one resident (R1) when R1 had a change in condition following a pelvic fracture.

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure a service plan was revised, entered into the resident record, and implemented for one of one resident (R1) when R1 had a change in condition following a pelvic fracture. As a result, the resident sustained numerous falls, multiple abrasions, bruises, and was repeatedly observed to be in a unkempt state in visibly soiled clothing. [...]”

    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 2310: 144G.91 Subd. 4 (a) Appropriate care and services Level 3, isolated scope, scope/level letter G · correction period: Seven (7) days
    Details

    MDH’s finding, as written: “Based on observation, interview, and record review the licensee failed to provide appropriate care and services according to an up-to-date service plan and accepted health care standards for one of one resident's (R1) when the R1 experienced a change in condition following a pelvic fracture. As a result, R1 sustained numerous falls, multiple abrasions, bruises, and cigarette burns on her body. R1 was repeatedly observed to be in a unkempt state in visibly soiled clothing. [...]”

    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 of one residents reviewed, (R1) was free from maltreatment.

    MDH’s finding, as written: “Based on interview and document review, the facility failed to ensure one of one of one residents reviewed, (R1) was free from maltreatment. R1 was 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. No plan of correction is required for this tag.”

    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.”

• July 20, 2022 · report HL326813167C
  Details

  Survey completed July 15, 2022: 1 correction order

  • Tag 830: 144G.45 Subd. 3 Local laws apply Level 3, widespread scope, scope/level letter I · correction period: Seven (7) days
    Details

    Summary: MDH found the licensee failed to comply with all applicable state and local governing laws, regulations, standards, ordinances, and codes for fire safety, building, and zoning requirements.

    MDH’s finding, as written: “Based on observation and interview, the licensee failed to comply with all applicable state and local governing laws, regulations, standards, ordinances, and codes for fire safety, building, and zoning requirements. This deficient condition had the ability to affect a large number of staff and residents. [...]”

    Rule cited: “Assisted living facilities shall comply with all applicable state and local governing laws, regulations, standards, ordinances, and codes for fire safety, building, and zoning requirements.”

• November 3, 2021 · report HL32681001C

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 42 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.