The Waters of Plymouth

Last evaluation

October 18, 2024

Evaluations on record

2

Investigations substantiated

2 kept 7 years

Inconclusive

0 kept 4 years

Unsubstantiated

0 kept 3 years

Most recent evaluation (October 18, 2024, state report HYU611)

MDH: “On October 14, 2024, through October 18, 2024, the Minnesota Department of Health conducted a change of ownership survey at the above provider.”

Survey completed October 18, 2024: 4 correction orders

• Tag 1640: 144G.70 Subd. 4 (a-e) Service plan, implementation and revisions to Level 2, isolated scope, scope/level letter D · correction period: Twenty-one (21) days
  Details

  MDH’s finding, as written: “Based on observation, interview, and record review the licensee failed to implement and provide all services required by the current service plan for one of four residents (R11). [...]”

  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 1750: 144G.71 Subd. 7 Delegation of medication administration Level 2, widespread scope, scope/level letter F · correction period: Seven (7) days
  Details

  Summary: MDH found the licensee failed to ensure the registered nurse (RN) had instructed the unlicensed personnel (ULP) in the proper methods to administer medications and verified the ULP had demonstrated the ability to competently follow the procedures for ULPs who administered topical medications for two of five employees (ULP-L, ULP-O).

  MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) had instructed the unlicensed personnel (ULP) in the proper methods to administer medications and verified the ULP had demonstrated the ability to competently follow the procedures for ULPs who administered topical medications for two of five employees (ULP-L, ULP-O). [...]”

  Rule cited: “When administration of medications is delegated to unlicensed personnel, the assisted living facility must ensure that the registered nurse has: (1) instructed the unlicensed personnel in the proper methods to administer the medications, and the unlicensed [...]”

• Tag 1760: 144G.71 Subd. 8 Documentation of administration of medication Level 2, widespread scope, scope/level letter F · correction period: Seven (7) days
  Details

  Summary: MDH found the licensee failed to ensure documentation for medication administration included the signature and title of the person who administered medications for three of five residents (R1, R13, R12).

  MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure documentation for medication administration included the signature and title of the person who administered medications for three of five residents (R1, R13, R12). [...]”

  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 2410: 144G.91 Subd. 13 Personal and treatment privacy Level 2, widespread scope, scope/level letter F · correction period: Seven (7) days
  Details

  Summary: MDH found the licensee failed to ensure the resident's rights were respected when staff failed to provide privacy while providing confidential treatment and assisting with activities of personal hygiene.

  MDH’s finding, as written: “Based on observation and interview, the licensee failed to ensure the resident's rights were respected when staff failed to provide privacy while providing confidential treatment and assisting with activities of personal hygiene. [...]”

  Rule cited: “(a) Residents have the right to consideration of their privacy, individuality, and cultural identity as related to their social, religious, and psychological well-being. [...]”

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

Substantiated investigations (state reports)

• July 29, 2025 · report HL295562123M · MDH finding: Substantiated, individual responsibility
  Details

  Allegation, as written: “The alleged perpetrator (AP) emotionally abused the resident during an interaction involving her adult massager device.”

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

  “The AP was responsible for the maltreatment.”

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

  MDH’s conclusion, as written: “The Minnesota Department of Health determined abuse was substantiated. The AP was responsible for the maltreatment. The AP approached the resident regarding a personal adult massager device located in a private drawer by her nightstand. The AP commented someone had said he would be willing to "help her out" because she was lonely. A handwritten note indicated the resident should use the AP for her sexual needs appeared to be similar to the AP's handwriting compared to his training records.”

  Action taken by facility: “The facility did an internal investigation and the AP no longer works at 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 May 15, 2025: 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.”

• April 13, 2023 · report HL295565244M · MDH finding: Substantiated, individual responsibility
  Details

  Allegation, as written: “The alleged perpetrator (AP) financially exploited three residents (resident #1, resident #2, and resident #3) when the AP took the residents Morphine (narcotic pain medication) for her own personal use.”

  “The Minnesota Department of Health determined financial exploitation was substantiated.”

  “The AP is responsible for the maltreatment.”

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

  MDH’s conclusion, as written: “The Minnesota Department of Health determined financial exploitation was substantiated. The AP is responsible for the maltreatment. The AP was observed on video surveillance taking multiple doses of resident narcotic medications then put them in her pocket. The AP documented administering multiple doses of PRN Morphine to three residents, however, on video surveillance the AP never enter the resident rooms to administer the medication. Several months of resident records indicated the AP documented administering 117 of 120 doses of PRN Morphine to the three residents. The AP was the only staff to ever document administering Morphine to two of the three residents. The resident records lacked indications for administering the PRN Morphine including pain or shortness of breath. The resident record An equal opportunity employer. lacked utilization of PRN Morphine unless the AP worked. [...]”

  Action taken by facility: “The facility identified potential drug diversion, investigated, and reported to Minnesota Adult Abuse Protection (MAARC), and law enforcement. The facility now audits PRN narcotic medication administration for patterns of potential diversion. [...]”

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

  Survey completed March 20, 2023: 1 correction order

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

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

    MDH’s finding, as written: “The facility failed to ensure three of three resident reviewed (R1, R2, and R3) were free from maltreatment. Findings include: The Minnesota Department of Health (MDH) issued a determination maltreatment occurred, and an individual staff person was responsible for the maltreatment of R1, R2, and R3, 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.”

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 105 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.