Universal Healthcare Solutions

Last evaluation

March 12, 2025

Evaluations on record

2

Investigations substantiated

2 kept 7 years

Inconclusive

0 kept 4 years

Unsubstantiated

0 kept 3 years

Most recent evaluation (March 12, 2025, state report OB4N11)

MDH: “On June 10, 2025, the Minnesota Department of Health conducted a licensing order follow-up related to correction orders issued for SL38008016-1.”

Survey completed June 10, 2025: 7 correction orders

• Tag 480: 144G.41 Subdivision 1 Subd. 1a (a-b) Minimum requirements; required food services (re-issued) scope/level letter F
  Details

  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 630: 144G.42 Subd. 6 (b) Compliance with requirements for reporting ma Level 2, pattern scope, scope/level letter F
  Details

  MDH’s finding, as written: “Based on interview and document review the licensee failed to ensure an individual abuse prevention plan (IAPP) included individualized measures for vulnerabilities for 2 of 4 residents (R1, R3) reviewed. [...]”

  Rule cited: “(b) The facility must develop and implement an individual abuse prevention plan for each vulnerable adult. [...]”

• Tag 810: 144G.45 Subd. 2 (b-f) Fire protection and physical environment (re-issued) Level 3, widespread scope, scope/level letter I
  Details

  Summary: MDH found the licensee failed to develop the fire safety and evacuation plan with the required content.

  MDH’s finding, as written: “Based on interview, and record review, the licensee failed to develop the fire safety and evacuation plan with the required content. This directly affected 3 of 4 residents (R1, R2, R3) and staff when a fire occurred at the facility. Staff failed to evacuate the mobility dependent residents firsts and evacuated the ambulatory resident. R2 had to crawl out of the home and R1 died in the fire. [...]”

  Rule cited: “(b) Each assisted living facility shall develop and maintain fire safety and evacuation plans. [...]”

• Tag 970: 144G.50 Subd. 5 Waivers of liability prohibited (re-issued) scope/level letter C
  Details

  Rule cited: “The contract must not include a waiver of facility liability for the health and safety or personal property of a resident. [...]”

• Tag 1620: 144G.70 Subd. 2 (c-e) Initial reviews, assessments, and monitoring Level 4, isolated scope, scope/level letter J
  Details

  MDH’s finding, as written: “Based on interview and document review the licensee failed to accurately assess the smoking safety needs of the resident and implement new interventions for continued smoking non-compliance for 1 of 4 residents (R1) reviewed. R1 started a fire in his room with oxygen and died. [...]”

  Rule cited: “(a) Residents who are not receiving any assisted living services shall not be required to undergo an initial nursing assessment. [...]”

• Tag 1640: 144G.70 Subd. 4 (a-e) Service plan, implementation and revisions to (re-issued) scope/level letter D
  Details

  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 1790: 144G.71 Subd. 10 Medication management for residents who will (re-issued) scope/level letter F
  Details

  Rule cited: “(2) for unplanned time away, when the pharmacy is not able to provide the medications, a licensed nurse or unlicensed personnel shall provide medications in amounts and dosages needed for the length of the anticipated absence, not to exceed seven calendar [...]”

Survey completed March 12, 2025: 9 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 to the FBEIR for any compliance
  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 630: 144G.42 Subd. 6 (b) Compliance with requirements for reporting ma Level 2, widespread scope, scope/level letter F · correction period: Seven (7) days
  Details

  Summary: MDH found the licensee failed to ensure an individual abuse prevention plan (IAPP) was developed to include the required content for two of two residents (R1, R2).

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure an individual abuse prevention plan (IAPP) was developed to include the required content for two of two residents (R1, R2). [...]”

  Rule cited: “(b) The facility must develop and implement an individual abuse prevention plan for each vulnerable adult. [...]”

• Tag 810: 144G.45 Subd. 2 (b-f) Fire protection and physical environment Level 2, widespread scope, scope/level letter F · correction period: Twenty-one (21) days
  Details

  Summary: MDH found the licensee failed to develop the fire safety and evacuation plan with the required content and provide the required training.

  MDH’s finding, as written: “Based on interview, and record review, the licensee failed to develop the fire safety and evacuation plan with the required content and provide the required training. This had the potential to directly affect all residents, staff, and visitors. [...]”

  Rule cited: “(b) Each assisted living facility shall develop and maintain fire safety and evacuation plans. [...]”

• Tag 970: 144G.50 Subd. 5 Waivers of liability prohibited Level 1, widespread scope, scope/level letter C · correction period: Twenty-one (21) days
  Details

  Summary: MDH found the licensee failed to ensure the assisted living contract did not include language waiving the facility's liability for health, safety, or personal

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the assisted living contract did not include language waiving the facility's liability for health, safety, or personal property of a resident for one of one resident (R1). [...]”

  Rule cited: “The contract must not include a waiver of facility liability for the health and safety or personal property of a resident. [...]”

• Tag 1290: 144G.60 Subdivision 1 Background studies required Level 3, pattern scope, scope/level letter H · correction period: Immediate · fine: $3,000.00 assessed
  Details

  Summary: MDH found the licensee failed to re-run a COVID-19 expired background study (BGS) in NETStudy 2.0 (web-based system use to submit BGS requests to the Department of Human Services (DHS)) and failed to ensure the BGS was affiliated to the licensee's health facility identification number (HFID) for three of eight employees (unlicensed personnel (ULP-A, ULP-B, ULPD).

  MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to re-run a COVID-19 expired background study (BGS) in NETStudy 2.0 (web-based system use to submit BGS requests to the Department of Human Services (DHS)) and failed to ensure the BGS was affiliated to the licensee's health facility identification number (HFID) for three of eight employees (unlicensed personnel (ULP-A, ULP-B, ULPD). [...]”

  Rule cited: “(a) Employees, contractors, and regularly scheduled volunteers of the facility are subject to the background study required by section 144.057 and may be disqualified under chapter 245C. [...]”

Fines assessed by MDH

• Tag 1290 (144g.60 Subdivision 1 - Background Studies Required): $3,000.00
• Tag 2310 (144g.91 Subd. 4 (a) - Appropriate Care And Services): $3,000.00

Total fines assessed, as printed in the letter: $8,000.00.

Total fines assessed, as printed in the letter: $6,000.00.

Substantiated investigations (state reports)

• July 24, 2025 · report HL380083402M · MDH finding: Substantiated, facility and individual responsibility
  Details

  Allegation, as written: “The facility and AP neglected the resident when they failed to properly supervise the resident, which resulted in a facility fire and the death of the resident.”

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

  “The facility and the AP were responsible for the maltreatment.”

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

  MDH’s conclusion, as written: “The Minnesota Department of Health determined neglect was substantiated. The facility and the AP were responsible for the maltreatment. While the AP, the facility licensed assisted living director, registered nurse (RN) and owner, completed room checks for smoking materials three times a week and provided education to the resident about smoking safety, the AP failed to assess the resident as he continued with non-compliance with the smoking policy and implement new interventions. Additionally, the facility failed to document and the resident's observed behaviors of smoking in his room prior to the about fire safety. The AP's documentation of room checks being clear from contraband did not match staff's documentation of finding smoking materials on the resident. The resident used oxygen and started a fire in his room. Staff were unable to evacuate the resident and he died.”

  Action taken by facility: “The facility completed fire drills as required and completed room checks for smoking materials.”

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

  Survey completed June 10, 2025: 4 correction orders

  • Tag 100: 144G.10 Subdivision 1 License required Level 2, widespread scope, scope/level letter F · correction period: Twenty-One (21) days
    Details

    Summary: MDH found the licensee failed to have a building to operate at the address location of their assisted living license and provide services to three of three residents (R2, R3, R4) reviewed.

    MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to have a building to operate at the address location of their assisted living license and provide services to three of three residents (R2, R3, R4) reviewed. [...]”

    Rule cited: “(a)(1) Beginning August 1, 2021, no assisted living facility may operate in Minnesota unless it is licensed under this chapter. [...]”

  • Tag 250: 144G.20 Subdivision 1 Conditions Level 2, widespread scope, scope/level letter F · correction period: Twenty-One (21) days
    Details

    Summary: MDH found the licensee failed to provide a habitable facility for residents after the facility sustained a fire.

    MDH’s finding, as written: “Based on interview and observation, the licensee failed to provide a habitable facility for residents after the facility sustained a fire. This affected all residents, staff, and visitors. [...]”

    Rule cited: “(a) The commissioner may refuse to grant a provisional license, refuse to grant a license as a result of a change in ownership, refuse to renew a license, suspend or revoke a license, or impose a conditional license if the owner, controlling individual, or [...]”

  • Tag 1060: 144G.52 Subd. 9 Emergency relocation Level 2, widespread scope, scope/level letter F · correction period: Seven (7) days
    Details

    Summary: MDH found the licensee failed to timely provide written notices of emergency relocation of residents to their families, case managers, and the Ombudsman, as required, for three of three residents (R2, R3, R4) reviewed.

    MDH’s finding, as written: “Based on interview and document review, the licensee failed to timely provide written notices of emergency relocation of residents to their families, case managers, and the Ombudsman, as required, for three of three residents (R2, R3, R4) reviewed. [...]”

    Rule cited: “(a) A facility may remove a resident from the facility in an emergency if necessary due to a resident's urgent medical needs or an imminent risk the resident poses to the health or safety of another facility resident or facility staff member. [...]”

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

    Summary: MDH found the facility failed to ensure two of two resident(s)

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

• July 24, 2025 · report HL380083462M · MDH finding: Substantiated, facility and individual responsibility
  Details

  Allegation, as written: “The alleged perpetrator (AP 1), who is a registered nurse (RN), licensed assisted living director (LALD), and owner of the facility neglected the resident (resident 2) when they failed to provide a safe environment for the resident when a fire occurred, resulting in the resident going to the hospital.”

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

  “The facility, AP 1 and AP 2 were responsible for the maltreatment.”

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

  MDH’s conclusion, as written: “The Minnesota Department of Health determined neglect was substantiated. The facility, AP 1 and AP 2 were responsible for the maltreatment. AP 2 was identified during the investigation and worked as an unlicensed personnel. A fire occurred at the facility due to a resident (resident 1) who used oxygen therapy attempted to smoke in his room. AP 2 failed to develop a fire evacuation plan that provided directive to staff on the proper steps to take on determining evacuation of residents. Fire drills and staff training were documented completed at the facility and AP 2 participated in evacuation drills. During the fire, AP 2 left a transfer and mobility dependent resident (resident 2) in bed to go assist an independent mobile resident (resident 3) out of the facility during the fire.”

  Action taken by facility: “The facility activated emergency services and relocated the resident to a safe location.”

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

  Survey completed June 10, 2025: 4 correction orders

  • Tag 100: 144G.10 Subdivision 1 License required Level 2, widespread scope, scope/level letter F · correction period: Twenty-One (21) days
    Details

    Summary: MDH found the licensee failed to have a building to operate at the address location of their assisted living license and provide services to three of three residents (R2, R3, R4) reviewed.

    MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to have a building to operate at the address location of their assisted living license and provide services to three of three residents (R2, R3, R4) reviewed. [...]”

    Rule cited: “(a)(1) Beginning August 1, 2021, no assisted living facility may operate in Minnesota unless it is licensed under this chapter. [...]”

  • Tag 250: 144G.20 Subdivision 1 Conditions Level 2, widespread scope, scope/level letter F · correction period: Twenty-One (21) days
    Details

    Summary: MDH found the licensee failed to provide a habitable facility for residents after the facility sustained a fire.

    MDH’s finding, as written: “Based on interview and observation, the licensee failed to provide a habitable facility for residents after the facility sustained a fire. This affected all residents, staff, and visitors. [...]”

    Rule cited: “(a) The commissioner may refuse to grant a provisional license, refuse to grant a license as a result of a change in ownership, refuse to renew a license, suspend or revoke a license, or impose a conditional license if the owner, controlling individual, or [...]”

  • Tag 1060: 144G.52 Subd. 9 Emergency relocation Level 2, widespread scope, scope/level letter F · correction period: Seven (7) days
    Details

    Summary: MDH found the licensee failed to timely provide written notices of emergency relocation of residents to their families, case managers, and the Ombudsman, as required, for three of three residents (R2, R3, R4) reviewed.

    MDH’s finding, as written: “Based on interview and document review, the licensee failed to timely provide written notices of emergency relocation of residents to their families, case managers, and the Ombudsman, as required, for three of three residents (R2, R3, R4) reviewed. [...]”

    Rule cited: “(a) A facility may remove a resident from the facility in an emergency if necessary due to a resident's urgent medical needs or an imminent risk the resident poses to the health or safety of another facility resident or facility staff member. [...]”

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

    Summary: MDH found the facility failed to ensure two of two resident(s)

    MDH’s finding, as written: “The facility failed to ensure two of two resident(s) reviewed (R1, R2) was free from maltreatment. Findings include: The Minnesota Department of Health (MDH) issued a determination maltreatment occurred, and the facility and individual persons were responsible for the maltreatment for R1 and R2, 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 5 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.