6 Reports
Inspection Report — Apr 22, 2026
Routine
Date: Apr 22, 2026
Visit Reason
MDH assisted living licensing survey; Follow-up survey on 2026-07-15 verified the facility was in substantial compliance.
Findings
The survey resulted in 11 state correction orders addressing food service, emergency preparedness, fire protection/physical environment, portable fire extinguishers, smoke/carbon-monoxide detection, background studies, medication labeling/expiration, individualized treatment planning, and dementia-unit safety assessments; fines of $1,000 were assessed for fire protection and $1,000 for background studies, totaling $2,000.
Deficiencies (11)
0480 144G.41 Subdivision 1 Minimum requirements; required food services: The facility failed to ensure food was prepared and served according to the Minnesota Food Code, as documented in the Food & Beverage Inspection Report.
0680 144G.42 Subd. 10 Disaster planning and emergency preparedness: The facility's emergency preparedness plan lacked required content (for example, subsistence needs for staff and residents and the facility's role under a 1135 waiver).
0775 144G.45 Subd. 2 Fire protection and physical environment: The licensee failed to maintain the physical environment in compliance with 144G (see Physical Environment Inspection Report for specific deficiencies).
0780 144G.45 Subd. 2 (a)(1) Fire protection and physical environment: Smoke alarms were not properly installed/interconnected; testing showed a bedroom alarm did not actuate when the adjacent alarm was tested.
0790 144G.45 Subd. 2 (a)(2-3) Fire protection and physical environment: Portable fire extinguisher inspection tags were blank, monthly inspections were not documented, and some extinguishers were not visibly identified at their locations.
0800 144G.45 Subd. 2 (a)(4) Fire protection and physical environment: Various maintenance deficiencies were observed (nonworking exhaust fans, burned-out light bulbs, missing exterior covers/panels and missing sprinkler valve access panel, missing soffit) leaving elements of the physical environment unrepaired.
0810 144G.45 Subd. 2 (b-f) Fire protection and physical environment: Fire safety and evacuation plans lacked site-specific employee actions, contained inaccurate instructions for one building, omitted resident-specific evacuation procedures, and training/drill documentation was incomplete.
01290 144G.60 Subdivision 1 Background studies required: A background study under HFID 25455 had not been submitted/completed for one employee (maintenance M‑C).
01890 144G.71 Subd. 20 Prescription drugs: Over-the-counter/dietary supplement items in the medication area lacked resident names and/or opened/expiration dates (e.g., R4's fish oil) and some items were not in original labeled containers (R4, R5).
01940 144G.72 Subd. 3 Individualized treatment or therapy managemen: R2's service plan did not include the required written statement of the treatment service (compression stockings) identified in the treatment record.
02040 144G.81 Subdivision 1 Fire protection and physical environment: Safety risk assessments for the dementia-care unit failed to include mitigation strategies for identified hazards.
Report Facts
fine_assessed: 1000
fine_assessed: 1000
fine_total: 2000
Inspection Report — Oct 30, 2024
Complaint Investigation
Date: Oct 30, 2024
Visit Reason
MDH complaint investigation of alleged financial exploitation.
Complaint Details
HL254554442M | Finding: Substantiated, individual responsibility | The alleged perpetrator, a staff member, financially exploited the resident by making unauthorized and fraudulent charges from the resident’s bank account.
Findings
Maltreatment substantiated, individual responsibility. One correction order was issued addressing freedom from maltreatment.
Deficiencies (1)
02360 144G.91 Subd. 8 Freedom from maltreatment: The facility failed to ensure one of one resident reviewed (R1) was free from maltreatment.
Report Facts
amount of financial exploitation: 8401.97
Inspection Report — Jan 4, 2024
Complaint Investigation
Date: Jan 4, 2024
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MDH complaint investigation of alleged neglect.
Complaint Details
HL254558286M | Finding: Not Substantiated | The resident was neglected when the facility failed to assess the resident for injuries after a fall when the resident complained of pain; the resident died eight days later.
Findings
Maltreatment not substantiated. No correction orders were issued.
Inspection Report — Sep 1, 2023
Routine
Date: Sep 1, 2023
Visit Reason
MDH assisted living licensing survey (initial survey 2023-09-01) and follow-up survey on 2023-12-13 which found substantial compliance and removed the conditional license.
Findings
Multiple state correction orders were issued (the survey issued numerous tags spanning reporting/abuse prevention, emergency preparedness, fire safety and environment, staffing and training, medication and treatment management, contracts and recordkeeping). The initial survey identified widespread deficiencies in emergency/disaster planning, fire protection, staff training/competency, medication storage/management and background study/employee record compliance; a follow-up on 2023-12-13 found some orders reissued and the conditional license removed.
Deficiencies (43)
0110 144G.10 Subdivision 1 Assisted living director license required: The licensee failed to ensure the licensed assisted living director was listed as the Director of Record with the Board of Executives for Long Term Services and Supports.
0250 144G.20 Subdivision 1 Conditions: The licensee failed to demonstrate managerial officials understood applicable statutes and rules and had not developed/implemented numerous required policies and procedures.
0450 144G.41 Subdivision 1 Minimum requirements: The licensee failed to provide the Assisted Living Bill of Rights to multiple residents.
0470 144G.41 Subdivision 1 Minimum requirements (staffing plan): The licensee failed to develop and implement a staffing plan, and failed to post staff schedules as required.
0480 144G.41 Subd. 1 (13)(i)(B) Food Code: The licensee failed to ensure food was prepared and served according to the Minnesota Food Code (see MDH food inspection reports).
0485 144G.41 Subd. 1 (13)(i)(A)(C) Menu/Meals: The licensee failed to prepare and make available menus at least one week in advance to residents.
0550 144G.41 Subd. 7 Resident grievances; reporting maltreatment: The licensee failed to post required grievance/contact information (names, telephone, e-mail for grievance contacts and ombudsman contacts) in a conspicuous place.
0570 144G.42 Subd. 1 Display of license: The license was not posted at the main entrance of each building as required.
0580 144G.42 Subd. 2 Quality management: The licensee failed to engage in and document quality management activities appropriate to the size and services provided.
0620 144G.42 Subd. 6 (a) Compliance with requirements for reporting maltreatment: The licensee failed to timely report to the Minnesota Adult Abuse Reporting Center (MAARC) for incidents including an unwitnessed fall resulting in injury (R1) and an elopement (R6).
0640 144G.42 Subd. 7 Posting information for reporting suspected maltreatment: The licensee failed to post 911 and MAARC contact information in common areas and near facility phones.
0650 144G.42 Subd. 8 Employee records: Employee records for several staff lacked required elements (job descriptions, etc.).
0680 144G.42 Subd. 10 Disaster planning and emergency preparedness: The licensee failed to develop, post, and implement a complete emergency preparedness plan with required elements and training.
0780 144G.45 Subd. 2 (a)(1) Fire protection and physical environment: The licensee failed to ensure required interconnected smoke alarms throughout dwelling units.
0790 144G.45 Subd. 2 (a)(2)-(3) Fire protection: The licensee failed to ensure accessible, properly located portable fire extinguishers per code.
0800 144G.45 Subd. 2 (a)(4) Physical environment: The licensee failed to maintain the physical environment and systems (fire alarm and sprinkler testing, exit signage, leaks, electrical panel clearance) in good repair.
0810 144G.45 Subd. 2 (b)-(f) Fire safety and evacuation plans: The licensee failed to develop and make available fire safety & evacuation plans with required content, provide required training, and document required drills.
0820 144G.45 Subd. 2 (g) Existing construction/elements: The licensee had exterior doors with magnetic locks that were not documented to be fail-safe per fire code.
0910 144G.50 Subd. 2 (a-b) Contract information: Resident contracts lacked required identifying information including HFID and other facility contact details.
0930 144G.50 Subd. 2 (d-e;1-4) Contract information: Contracts lacked required complaint resolution language, ombudsman contacts, and transfer/appeal notices.
0940 144G.50 Subd. 2 (e;5-7) Contract information re: waivers/housing support: Contracts lacked required language regarding waivers, housing support, rent information and MAARC/toll-free contact info.
0950 144G.50 Subd. 3 Designation of representative: Contracts lacked the statutory notice and space for a designated representative and/or the option to decline.
1060 144G.52 Subd. 9 Emergency relocation: The facility failed to provide required written notice and to notify the Office of Ombudsman when a resident was relocated and did not return within four days (example R5 hospitalized).
1290 144G.60 Subd. 1 Background studies required: Several staff had background studies associated with a different (former) license and not affiliated with the current assisted living license.
1370 144G.61 Subd. 2 Training & competency of unlicensed personnel: Multiple ULP records lacked required training topics (falls prevention, nutrition/modified diets, etc.).
1470 144G.63 Subd. 2 Content of required orientation: Several staff lacked orientation content (overview of chapter 144G, Assisted Living Bill of Rights, person-centered planning, facility licensure category).
1500 144G.63 Subd. 5 Required annual training: Staff records lacked required annual trainings (reporting maltreatment, infection control, assisted living bill of rights, problem solving and dementia communications).
1540 144G.64 Training in dementia care (direct care): Direct-care staff lacked required initial and ongoing dementia training within required timeframes.
1550 144G.64 Training in dementia care (non-direct staff): Non-direct care staff (cook) lacked required dementia-related annual training.
1620 144G.70 Subd. 2 Initial reviews, assessments and monitoring: RN reassessments and 90-day uniform assessments were incomplete or missing for residents with changed risk (falls, elopement).
1650 144G.70 Subd. 4 Service plan, implementation and revisions: Resident service plans lacked required elements (fees) and did not reflect some treatments (example R4, TED stockings).
1750 144G.71 Subd. 7 Delegation of medication administration: Delegated medication administration lacked documented RN training/competency for an unlicensed person prior to administering medications (example ULP-E).
1760 144G.71 Subd. 8 Documentation of administration of medication: PRN medication effectiveness and certain medication administration documentation were incomplete for multiple residents (R1, R4).
1770 144G.71 Subd. 9 Documentation of medication setup: Medication setup documentation did not include required content (medication name, dose, times, route, person completing setup) for residents' weekly medication setups.
1880 144G.71 Subd. 19 Storage of medications: Refrigerated medications were stored in unsecured main kitchen refrigerators with food; refrigerator temperatures were not consistently monitored or logged for medication storage.
1890 144G.71 Subd. 20 Prescription drugs: Time-sensitive/opened prescription products (inhalers, eye drops, insulin) lacked opened/expiration dating and some expired/undated items were found in medication storage.
1940 144G.72 Subd. 3 Individualized treatment or therapy management: The licensee failed to develop individualized treatment/therapy management records for treatments such as TED stockings (example R4).
1960 144G.72 Subd. 5 Documentation of administration of treatments: The licensee failed to document administration of treatments as ordered and to document follow-up for omitted treatments (TED stockings example).
2040 144G.81 Subd. 1 Fire protection & physical environment for dementia care: A hazard vulnerability assessment / safety risk assessment for the property was not documented.
2140 144G.83 Subd. 3 Supervising staff training: The person(s) providing/overseeing dementia-care training lacked documented competency/knowledge testing evidence.
2310 144G.91 Subd. 4 (a) Appropriate care and services: Unsafe bed rail conditions, lack of bed-rail assessments/measurements and missing entrapment risk documentation (residents with bed rails R1, R2, R3) posed a direct resident safety risk.
3000 626.557 Subd. 3 Timing of report (MAARC): The licensee failed to timely report alleged incidents to the Minnesota Adult Abuse Reporting Center (MAARC) for significant injuries and elopement incidents.
3090 144.6502 Subd. 8 Notice to visitors: The facility failed to post signage at facility entrances notifying visitors that electronic monitoring devices may be present.
Report Facts
fines assessed: 1500
Inspection Report — Mar 22, 2022
Complaint Investigation
Date: Mar 22, 2022
Visit Reason
MDH complaint investigation of alleged neglect.
Complaint Details
HL25455003M | Finding: Substantiated, facility and individual responsibility | The resident was neglected when the alleged perpetrator (AP), facility staff, failed to transfer the resident according to the resident's individual assessed needs; the resident fell and sustained multiple injuries including a left hip fracture.
Findings
Substantiated, facility and individual responsibility. Five correction orders were issued addressing failures to report/timing of reporting, medication management and disposition of medications, and ensuring residents are free from maltreatment.
Deficiencies (5)
0620 144G.42 Subd. 6 Compliance with requirements for reporting maltreatment of vulnerable adults; abuse prevention plan: This Minnesota requirement is not met as evidenced by the licensee failed to immediately report alleged maltreatment of two residents to the Minnesota Adult Abuse Reporting Center (MAARC).
01690 144G.71 Subdivision 1 Medication management services: This Minnesota requirement is not met as evidenced by the licensee failed to develop, implement, and maintain current medication management policies and procedures, resulting in inconsistent medication administration for a resident (R2).
01910 144G.71 Subd. 22 Disposition of medications: This Minnesota requirement is not met as evidenced by the licensee failed to properly document and follow safe disposal/disposition procedures for discontinued and controlled medications, including narcotic logs and destruction practices.
02360 144G.91 Subd. 8 Freedom from maltreatment: This Minnesota requirement is not met as evidenced by the licensee failed to ensure two residents were free from maltreatment; one resident was financially exploited and another was neglected.
03000 626.557 Subd. 3 Timing of report: This Minnesota requirement is not met as evidenced by the licensee delayed reporting allegations of maltreatment to the common entry point/MAARC and did not report within required timeframes for two residents.
Report Facts
residents receiving services: 19
Inspection Report — Mar 1, 2022
Complaint Investigation
Date: Mar 1, 2022
Visit Reason
MDH complaint investigation of alleged financial exploitation.
Complaint Details
HL25455001M | Finding: Substantiated, individual responsibility | The resident was financially exploited when the alleged perpetrator (AP) used the resident's debit card to make purchases for their own personal use.
Findings
Maltreatment substantiated. Three correction orders were issued addressing failures to report/timing requirements and freedom from maltreatment related to financial exploitation.
Deficiencies (3)
0620 144G.42 Subd. 6 Compliance with requirements for reporting maltreatment: This Minnesota requirement is not met as evidenced by the licensee's failure to immediately report an allegation of maltreatment to the Minnesota Adult Abuse Reporting Center for two residents reviewed for financial exploitation and neglect.
02360 144G.91 Subd. 8 Freedom from maltreatment: This Minnesota requirement is not met as evidenced by R1 being financially exploited by a staff person.
03000 626.557 Subd. 3 Timing of report: This Minnesota requirement is not met as evidenced by the licensee's failure to immediately report allegations of maltreatment to the common entry point as required.
Report Facts
unauthorized purchases total: 128.9
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