White Bear Lake Coh Care

Last evaluation

February 26, 2025

Evaluations on record

2

Investigations substantiated

3 kept 7 years

Inconclusive

2 kept 4 years

Unsubstantiated

0 kept 3 years

Most recent evaluation (February 26, 2025, state report I0RO11)

MDH: “On February 24, 2025, through February 26, 2025, the Minnesota Department of Health conducted a full survey at the above provider.”

Survey completed February 26, 2025: 8 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
  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, but was not likely to cause serious injury, impairment, or death), and is issued at a widespread scope (when problems are pervasive or represent a systemic failure that has [...]”

  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 660: 144G.42 Subd. 9 Tuberculosis prevention and control Level 2, widespread scope, scope/level letter F · correction period: Twenty-one (21) days
  Details

  Summary: MDH found the licensee failed to establish and maintain a tuberculosis (TB) prevention and control program based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC) which included baseline testing for three of three employees (registered nurse (RN)-D, unlicensed personnel (ULP)-E, ULP-F).

  MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to establish and maintain a tuberculosis (TB) prevention and control program based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC) which included baseline testing for three of three employees (registered nurse (RN)-D, unlicensed personnel (ULP)-E, ULP-F). [...]”

  Rule cited: “(a) The facility must establish and maintain a comprehensive tuberculosis infection control program according to the most current tuberculosis infection control guidelines issued by the United States Centers for Disease Control and Prevention (CDC), Division [...]”

• Tag 775: 144G.45 Subd. 2. (a) Fire protection and physical environment Level 2, widespread scope, scope/level letter F · correction period: Twenty-one (21) days · fine: $500.00 assessed
  Details

  Summary: MDH found the licensee failed to provide egress windows in compliance with Minnesota State Fire Code in Minnesota Rules chapter 7511.

  MDH’s finding, as written: “Based on observation and interview, the licensee failed to provide egress windows in compliance with Minnesota State Fire Code in Minnesota Rules chapter 7511. This deficient condition had the ability to affect all staff and residents. [...]”

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

• Tag 1290: 144G.60 Subdivision 1 Background studies required Level 2, widespread scope, scope/level letter F · correction period: Two (2) days
  Details

  Summary: MDH found the licensee failed to obtain a cleared Department of Health and Human Services (DHS) background study, associated with the licensee's health facility identification number (HFID) 30557 for two of two unlicensed personnel ((ULP)-E and ULP-F).

  MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to obtain a cleared Department of Health and Human Services (DHS) background study, associated with the licensee's health facility identification number (HFID) 30557 for two of two unlicensed personnel ((ULP)-E and ULP-F). [...]”

  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. [...]”

• Tag 1610: 144G.70 Subd. 2 (a-b) Initial reviews, assessments, and monitoring Level 2, isolated scope, scope/level letter D · correction period: Twenty-one
  Details

  Summary: MDH found the licensee failed to ensure the registered nurse (RN) completed an initial nursing assessment prior to signing the assisted living contract and providing services for one of three residents (R2).

  MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) completed an initial nursing assessment prior to signing the assisted living contract and providing services for one of three residents (R2). [...]”

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

Fines assessed by MDH

• Tag 775 (144g.45 Subd. 2. (a) - Fire Protection And Physical Environment): $500.00

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

Substantiated investigations (state reports)

• April 12, 2024 · report HL305572346M
• August 23, 2023 · report HL305573643M · MDH finding: Substantiated, individual responsibility
  Details

  Allegation, as written: “The alleged perpetrator (AP), facility staff, neglected a resident when the AP failed to complete provider referral orders for skilled nursing wound care. As a result, the resident did not receive wound care for an extended period of time and required emergency medical attention.”

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

  “The AP was responsible for the maltreatment.”

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

  MDH’s conclusion, as written: “The Minnesota Department of Health determined neglect was substantiated. The AP was responsible for the maltreatment. The AP failed to ensure the resident's provider referral orders for a contracted skilled nursing service to complete sacral ulcer wound care was received and accepted by an agency. As a result, the resident did not receive wound care for an extended period of time and was hospitalized with complaints of pain at the wound site and an elevated temperature. An equal opportunity employer.”

  Action taken by facility: “The facility investigated the incident and sent the resident to the hospital. The AP was no longer employed by 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 17, 2023: 1 correction order

  • Tag 2360: 144G.91 Subd. 8 Freedom from maltreatment scope/level letter G
    Details

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

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

• February 1, 2023 · report HL305573743M · MDH finding: Substantiated, individual responsibility
  Details

  Allegation, as written: “The facility neglected a resident when the resident had significant, unexplained injuries including a broken clavicle and subdural hematoma resulting in the resident's death.”

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

  “Based on a preponderance of evidence, the alleged perpetrator (AP), a facility unlicensed staff, was responsible for the maltreatment.”

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

  MDH’s conclusion, as written: “The Minnesota Department of Health determined neglect was substantiated. Based on a preponderance of evidence, the alleged perpetrator (AP), a facility unlicensed staff, was responsible for the maltreatment. The resident was sent to the hospital with significant bleeding of her wrist/arm. At the hospital the resident was found to have a broken clavicle and a subdural hematoma (bleeding on the brain). The AP transferred the resident with a EZ stand mechanical lift that morning without the assistance of a second staff. Although the AP denied the resident was injured during the transfer, the resident was not observed to have any injury until she had been transferred independently by the AP out of bed to the toilet. An equal opportunity employer.”

  Action taken by facility: “No action was taken by the 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 January 10, 2023: 3 correction orders

  • Tag 1290: 144G.60 Subdivision 1 Background studies required Level 3, widespread scope, scope/level letter I · correction period: Two (2) Days
    Details

    Summary: MDH found the facility failed to complete a background study prior to staff providing direct care services, for one of three unlicensed personnel, (ULP)-B, of employee records reviewed.

    MDH’s finding, as written: “Based on interview and record review, the facility failed to complete a background study prior to staff providing direct care services, for one of three unlicensed personnel, (ULP)-B, of employee records reviewed. This had potential to affect all 36 residents receiving services from the facility. [...]”

    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. [...]”

  • Tag 2310: 144G.91 Subd. 4 (a) Appropriate care and services Level 4, isolated scope, scope/level letter J · correction period: Two (2) days
    Details

    Summary: MDH found the facility failed to provide care and services according to acceptable health care standards, medical or nursing standards for one of one resident, R1, reviewed with an injury of unknown source.

    MDH’s finding, as written: “Based on interview and document review, the facility failed to provide care and services according to acceptable health care standards, medical or nursing standards for one of one resident, R1, reviewed with an injury of unknown source. R1 experienced significant cuts and skin tears on her right arm, a broken clavicle, and a subdural hematoma. [...]”

    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 residents reviewed (R1) was free from maltreatment.

    MDH’s finding, as written: “Based on interviews and document review, the facility failed to ensure one of one residents reviewed (R1) was free from maltreatment. R1 was neglected. Findings include: The Minnesota Department of Health (MDH) issued a determination that neglect occurred, and an individual staff member was responsible for the maltreatment in connection with incidents which occurred at the facility. The MDH concluded there was a preponderance of evidence that maltreatment occurred.”

    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 44 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.