The Legacy of Delano

Last evaluation

December 5, 2025

Evaluations on record

2

Investigations substantiated

2 kept 7 years

Inconclusive

0 kept 4 years

Unsubstantiated

0 kept 3 years

Most recent evaluation (December 5, 2025, state report EJPB11)

MDH: “On December 1, 2025, through December 5, 2025, the Minnesota Department of Health conducted a full survey at the above provider and the following correction orders are issued.”

Survey completed December 5, 2025: 18 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 written staffing plan that included an evaluation completed by the clinical nurse supervisor in

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop and implement a written staffing plan that included an evaluation completed by the clinical nurse supervisor in accordance with Minnesota Administrative Rule 4659.0180 Subpart 3., at least twice a year. This had the potential to affect all residents, staff, and visitors. [...]”

  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 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 to the FBEIR for any compliance dates
  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) and was issued at a widespread scope (when problems are pervasive or represent a systemic failure that has affected or has the potential to affect a large portion or all the [...]”

  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 maintain an effective infection control program to comply with acceptable health care, medical, and nursing standards for infection control by one of three employees (unlicensed personnel (ULP)-E).

  MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to maintain an effective infection control program to comply with acceptable health care, medical, and nursing standards for infection control by one of three employees (unlicensed personnel (ULP)-E). [...]”

  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 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 the resident record included a discharge summary with the required content for two of two discharged resident (R1 and R8).

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the resident record included a discharge summary with the required content for two of two discharged resident (R1 and R8). [...]”

  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 775: 144G.45 Subd. 2. (a) Fire protection and physical environment 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 ensure the physical environment of the facility was maintained in compliance with the requirements of Minnesota Statute 144G.

  MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the physical environment of the facility was maintained in compliance with the requirements of Minnesota Statute 144G. [...]”

  Rule cited: “Each assisted living facility must comply with the State Fire Code in Minnesota Rules, chapter 7511, and:”

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

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

Fines assessed by MDH

• Tag 775 (144g.45 Subd. 2. (a) - Fire Protection And Physical Environment): $500.00
• Tag 1290 (144g.60 Subdivision 1 - Background Studies Required): $1,000.00
• Tag 2310 (144g.91 Subd. 4 (a) - Appropriate Care And Services): $1,000.00

Total fines assessed, as printed in the letter: $2,500.00.

Substantiated investigations (state reports)

• January 15, 2025 · report HL291896923M · MDH finding: Substantiated, facility responsibility
  Details

  Allegation, as written: “The resident was neglected when she was observed walking unassisted, fell backwards, and sustained a head strike. The resident died.”

  “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 facility failed to ensure staff were aware of the residents assessed needs. The resident had reoccurring falls and the facility failed to implement interventions to prevent further falls. The resident fell while walking without staff assistance and sustained a head strike. The resident's death record indicated the resident died from complications of a subdural and subarachnoid hemorrhage as a result of the fall.”

  Action taken by facility: “The facility called 911, and transferred the resident to the ED.”

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

  Survey completed December 5, 2024: 6 correction orders

  • Tag 470: 144G.41 Subdivision 1 Minimum requirements Level 3, widespread scope, scope/level letter I · correction period: Seven (7) days
    Details

    Summary: MDH found the licensee failed to ensure the required staffing plan evaluation was conducted and implemented to determine the appropriateness of staffing levels to meet the scheduled and unscheduled needs of each resident as required.

    MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the required staffing plan evaluation was conducted and implemented to determine the appropriateness of staffing levels to meet the scheduled and unscheduled needs of each resident as required. One of one resident's (R1) was harmed when she had recurring falls resulting in head strike and death at times when the licensee failed to ensure the minimum number of staffing was available on the memory care unit. [...]”

    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 1640: 144G.70 Subd. 4 (a-e) Service plan, implementation and revisions to 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 ensure one of one resident's (R1)s assessment and service plan were signed and finalized no later than 14 days after the date services were provided. R1's unsigned admission assessment was not finalized until 25 days after R1 was admitted to the facility, and following R1's death. [...]”

    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 1650: 144G.70 Subd. 4 (f) Service plan, implementation and revisions to Level 4, isolated scope, scope/level letter J · correction period: seven (7) days
    Details

    MDH’s finding, as written: “Based on record review and interview the licensee failed to ensure one of one resident's (R1)s service plan included a description of the services to be provided, and the frequency of each service, according to R1's assessed needs for staff to implement. R1 had recurring falls while ambulating independently, and the facility failed to implement identified interventions to help prevent recurring falls. [...]”

    Rule cited: “(f) The service plan must include: (1) a description of the services to be provided, the fees for services, and the frequency of each service, according to the resident's current assessment and resident preferences; (2) the identification of staff or [...]”

  • 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

    MDH’s finding, as written: “Based on record review and interview the licensee failed to implement ordered therapy services timely for one of one resident's (R1) reviewed for falls. 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 was issued at an isolated scope (when one or a limited number of residents are affected or one or a [...]”

    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 [...]”

  • 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 record review and interview the licensee failed to provide appropriate care and service according to an up to date service plan, and accepted health care standard for one of one resident (R1). R1 was harmed when she was admitted with orders for OT/PT, and assessed to require assistance on admission from 1 staff with mobility, transfers, ambulation, and toileting using a wheel chair and walker. [...]”

    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 licensee failed to ensure one of one residents (R1) reviewed was free from maltreatment.

    MDH’s finding, as written: “Based on interviews and document review, the licensee failed to ensure one of one residents (R1) reviewed 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 tag 2360.”

    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 13, 2024 · report HL291899565M · MDH finding: Substantiated, facility responsibility
  Details

  Allegation, as written: “The facility neglected Resident #1(R1) and Resident #2 (R2) when they failed to provide the appropriate level of supervision when R1 and R2 had sexual contact.”

  “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 facility discovered R1 and R2 had sexual contact and assessed R1 was unable to consent to a sexual relationship related to R1's cognitive ability. R1's family requested R1 and R2 have no further sexual contact. The facility failed to ensure R1 and R2 were supervised, and interventions were implemented to prevent further sexual contact between R1 and R2. Approximately one month later, R1 and R2 were found in R1's apartment having another sexual encounter. An equal opportunity employer.”

  Action taken by facility: “The facility moved R2 to another area until R1 could move to a higher level of care/supervision.”

  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 November 29, 2023: 1 correction order

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

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

    MDH’s finding, as written: “The facility failed to ensure two of two residents reviewed (R1, R2) 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 59 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.