Ashby Living Center.
Ashby Living Center is Grade C−, ranked in the bottom 43% of Minnesota memory care with 1 MDH citation on record; last inspected Apr 2025.
A medium home, reviewed on public record.
Ranked against 85 Minnesota facilities.
ALF memory care · 36-month window. Higher percentile = better. Source: Minnesota Dept. of Health · Health Regulation Division.
FACILITY WATCH · BETA
Ashby Living Center has 1 citation on record. Know the moment anything changes.
New findings, complaint investigations, or status changes — emailed to you free.
Citation history, plotted month by month.
1 deficiencie on record. Each bar is a month with a citation.
Finding distribution
1 total · 36 monthsScope × Severity (CMS A–L)
Questions to ask before you visit.
A short pre-tour checklist tailored to Ashby Living Center's record and state requirements.
The facility holds an Assisted Living Facility with Dementia Care license under Minnesota Statutes Chapter 144G — can you walk us through the specific dementia-care programming and environmental modifications required by that license, and show us the written policies that describe those supports?
Ask the operator on tour. Take notes and compare answers across facilities you visit.
Minnesota Department of Health records show 1 complaint was filed during the inspection period on file — was that complaint substantiated, and can you share the facility's own documentation of any corrective actions or policy changes that resulted from the complaint investigation?
Ask the operator on tour. Take notes and compare answers across facilities you visit.
The most recent MDH inspection on April 1, 2025 resulted in zero deficiencies across 3 total reports — what internal quality assurance processes does the facility use to maintain compliance, and can families review recent self-audit records or staff training logs related to dementia care?
Ask the operator on tour. Take notes and compare answers across facilities you visit.
Every MDH visit, verbatim.
2 inspections in the public record, most recent first. Click any row to expand — cited rows open automatically.
2026-04-10Complaint Investigation1 · Substantiated Finding
Plain-language summary
A complaint investigation found that the facility neglected a resident with Alzheimer's disease by failing to supervise him and monitor his wander guard bracelet, which he had removed before; the resident eloped, fell outside, and was hospitalized with a neck fracture. After his return, staff did not assess his ongoing elopement risk or implement additional safety measures, and he removed the wander guard again while the facility's assessment and service plan did not require staff to check that the device was in place. The facility was responsible for the maltreatment.
“MDH substantiated maltreatment or licensing violation finding”
Full inspector notes
Finding: Substantiated, facility responsibility Nature of Investigation: The Minnesota Department of Health investigated an allegation of maltreatment, in accordance with the Minnesota Reporting of Maltreatment of Vulnerable Adults Act, Minn. Stat. 626.557, and to evaluate compliance with applicable licensing standards for the provider type. Initial Investigation Allegation(s): The facility neglected the resident when staff failed to provide supervision for a resident with cognitive impairment. The resident cut off his wander guard (a bracelet designed to prevent him from leaving the building) eloped from the facility and fell. The resident was evaluated in the emergency room for a neck fracture. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was substantiated. The facility was responsible for the maltreatment. The facility failed to assess and implement interventions related to the resident’s risk for elopement. The resident eloped from the facility. The resident fell and was found outside a local business by a community member who contacted 911. The resident was sent to the hospital and diagnosed with a neck fracture. Upon return to the facility, nursing staff failed to implement additional interventions to prevent further elopements. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted law enforcement. The investigation included review of the resident record, hospital records, facility internal investigation documentation, facility incident reports, staff schedules, an ambulance report, and related facility policy and procedures. Also, the investigator observed the facility environment and exit doors at the time of the onsite investigation. The resident resided in an assisted living with dementia care facility; however, the facility did not have a locked memory care unit. The facility had three exit doors that were accessible to residents, however only two of the doors were secured with a wander guard system (an automatic door lock that would cause the exit doors to lock if a resident wearing a wander guard bracelet approached the door.) The resident’s diagnoses included Alzheimer’s disease. The resident’s unsigned service plan included assistance with managing wandering and elopement threat. The resident’s assessment indicated the resident was at risk for elopement. Interventions included a wander guard to his walker and Quetiapine (antipsychotic medication) 25 milligrams twice daily. The resident was noted to use his walker at times to assist with walking. The resident’s service plan did not include a service to check placement or location of the wander guard. The resident’s assessment did not include assessment of the resident’s risk for falls. Approximately one week after admission to the facility, staff documented the resident cut off his wander guard from his ankle. The resident refused to have it placed back on his ankle, so staff placed it on his walker. Approximately one month later, the resident eloped from the facility. The resident was found by a community member who called 911 and was the first to notify facility staff of the resident’s whereabouts. The resident was taken to the hospital. Hospital records indicated the resident eloped from the facility and was found on the ground outside. The resident had a laceration to his forehead and abrasions on his nose, forehead and hands. The resident was also diagnosed with a fracture in his neck and returned to the facility with orders to wear a cervical collar for six weeks. Following the resident’s elopement and return to the facility, a change in condition assessment was not completed. A progress note indicated the RN assessed the resident and implemented a bed and chair alarm as a fall prevention measure. There was no documentation of an assessment of the resident’s wander guard or evaluation of additional elopement interventions. Documentation from the facility indicated the resident again cut off his wander guard after returning to the facility. During an interview, the licensed practical nurse (LPN) stated she completed all the resident’s assessments, but a registered nurse reviewed them. The LPN stated she did not believe staff were checking that the wander guard was on the resident or that it was working at the time he eloped. The LPN confirmed the assessment failed to address the resident’s history of removing his wander guard and that the wander guard remained as an elopement intervention. The LPN stated the resident was wanting to cut off his wander guard so they moved his room closer to the main area so they could keep a better eye on him. During an interview, ULP #1 stated she was working the day the resident eloped. ULP #1 stated there had been a couple of instances where he had cut his wander guard off, so the device was placed on his walker instead of on him. ULP #1 stated at the time of the elopement, it was not part of the resident’s service plan to make sure the wander guard was intact and in place. ULP #1 stated the resident left a door that was near his room and staff were not aware that he had left until someone called the facility saying they had found him outside and he was going to a nearby hospital. During an interview, ULP #2 stated she was working the day the resident eloped. ULP #2 stated the resident did not take his walker when he eloped from the building and the wander guard was on his walker. ULP #2 stated the resident required reminders to use his walker and would not always use it. ULP #2 stated the resident had cut off his wander guard previously. ULP #2 stated they did not know the resident was missing until someone had called the facility and said he fell by a business in town. In conclusion, the Minnesota Department of Health determined neglect was substantiated. Substantiated: Minnesota Statutes, section 626.5572, Subdivision 19. “Substantiated” means a preponderance of evidence shows that an act that meets the definition of maltreatment occurred. Neglect: Minnesota Statutes, section 626.5572, subdivision 17 “Neglect” means neglect by a caregiver or self-neglect. (a) "Caregiver neglect" means the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to, food, clothing, shelter, health care, or supervision which is: (1) reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult; and (2) which is not the result of an accident or therapeutic conduct. Vulnerable Adult interviewed: Unable due to cognition. Family/Responsible Party interviewed: Yes Alleged Perpetrator interviewed: Not Applicable Action taken by facility: The facility investigated the elopement and reported it to MAARC. Action taken by the Minnesota Department of Health: The responsible party will be notified of their right to appeal the maltreatment finding. The facility was found to be in noncompliance. To view a copy of the Statement of Deficiencies and/or correction orders, please visit: https://www.health.state.mn.us/facilities/regulation/directory/provcompselect.html If you are viewing this report on the MDH website, please see the attached Statement of Deficiencies. You may also call 651-201-4200 to receive a copy via mail or email cc: The Office of Ombudsman for Long Term Care The Office of Ombudsman for Mental Health and Developmental Disabilities Grant County Attorney Ashby City Attorney Ashby Police Department Minnesota Board of Nursing PRINTED: 04/ 17/ 2026 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/ SUPPLIER/ CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ C B. WING _____________________________ 33447 02/ 05/ 2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 112 IVERSON AVENUE ASHBY LIVING CENTER ASHBY, MN 56309 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER' S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS- REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 000 Initial Comments 0 000 ******ATTENTION*** Minnesota Department of Health is documenting the State Correction Orders ASSISTED LIVING PROVIDER CORRECTION using federal software. Tag numbers have ORDER been assigned to Minnesota State Statutes for Assisted Living Facilities. The In accordance with Minnesota Statutes, section assigned tag number appears in the 144G. 08 to 144G. 95, these correction orders are far-left column entitled "ID Prefix Tag. " The issued pursuant to a complaint investigation.
2025-04-01Annual Compliance VisitNo findings
Plain-language summary
A routine licensing survey was conducted at Ashby Living Center on March 31 and April 1, 2025, with 16 residents receiving dementia care services; the survey resulted in state correction orders, with no immediate fines assessed. The facility must document the actions it takes to correct the violations identified in the state form, including how noncompliance related to staffing plan requirements was remedied for all affected residents and employees. The facility has the right to request reconsideration of the correction orders within 15 calendar days of receiving this notice.
Full inspector notes
correction orders and document the actions taken to comply in the facility's records. The Department reserves the right to return to the facility at any time should the Department receive a complaint or deem it necessary to ensure the health, safety, and welfare of residents in your care. STATE CORRECTION ORDERS The enclosed State Form documents the state correction orders. MDH documents state licensing correction orders using federal software. Tag numbers are assigned to Minnesota state statutes for Assisted Living Facilities. The assigned tag number appears in the far left column entitled "ID Prefix Tag." The state statute number and the corresponding text of the state statute out of compliance are listed in the "Summary Statement of Deficiencies" column. This column also includes the findings that are in violation of the state statute after the statement, "This MN Requirement is not met as evidenced by . . ." In accordance with Minn. Stat. § 144G.31 Subd. 4, MDH may assess fines based on the level and scope of the violations; h owever, no immediate fines are assessed for this survey of your facility. DOCUMENTATION OF ACTION TO COMPLY In accordance with Minn. Stat. § 144G.30, Subd. 5(c), the licensee must document actions taken to comply with the correction orders within the time period outlined on the state form; however, plans of correction are not required to be submitted for approval. The correction order documentation should include the following: Identify how the area(s) of noncompliance was corrected related to the An equal opportunity employer. Letter ID: IS7N REVISED 09/13/2021 Ashby Living Center April 28, 2025 Page 2 resident(s)/employee(s) identified in the correction order. Identify how the area(s) of noncompliance was corrected for all of the provider’s resident(s)/employees that may be affected by the noncompliance. Identify what changes to your systems and practices were made to ensure compliance with the specific statute(s). CORRECTION ORDER RECONSIDERATION PROCESS In accordance with Minn. Stat. § 144G.32, Subd. 2, you may challenge the correction order(s) issued, including the level and scope, and any fine assessed through the correction order reconsideration process. The request for reconsideration must be in writing and received by MDH within 15 calendar days of the correction order receipt date. To submit a reconsideration request, please visit: https://forms.web.health.state.mn.us/form/HRDAppealsForm The MDH Health Regulation Division (HRD) values your feedback about your experience during the survey and/or investigation process. Please fill out this anonymous provider feedback questionnaire at your convenience at this link: h ttps://forms.office.com/g/Bm5uQEpHVa. Your input is important to us and will enable MDH to improve its processes and communication with providers. If you have any questions regarding the questionnaire, please contact Susan Winkelmann at susan.winkelmann@state.mn.us or call 651-201-5952. You are encouraged to retain this document for your records. It is your responsibility to share the information contained in the letter and state form with your organization’s Governing Body. If you have any questions, please contact me. Sincerely, Jessie Chenze, Supervisor State Evaluation Team Email: Jessie.Chenze@state.mn.us Telephone: 218-332-5175 Fax: 1-866-890-9290 HHH PRINTED: 04/28/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 33447 04/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 112 IVERSON AVENUE ASHBY LIVING CENTER ASHBY, MN 56309 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 000 Initial Comments 0 000 ASSISTED LIVING PROVIDER LICENSING Minnesota Department of Health is CORRECTION ORDER(S) documenting the State Correction Orders using federal software. Tag numbers have In accordance with Minnesota Statutes, section been assigned to Minnesota State 144G.08 to 144G.95, these correction orders are Statutes for Assisted Living Facilities. The issued pursuant to a survey. assigned tag number appears in the far-left column entitled "ID Prefix Tag." The Determination of whether violations are corrected state Statute number and the requires compliance with all requirements corresponding text of the state Statute out provided at the Statute number indicated below. of compliance is listed in the "Summary When Minnesota Statute contains several items, Statement of Deficiencies" column. This failure to comply with any of the items will be column also includes the findings which considered lack of compliance. are in violation of the state requirement after the statement, "This Minnesota INITIAL COMMENTS: requirement is not met as evidenced by." Following the evaluators ' findings is the SL33447016-0 Time Period for Correction. On March 31, 2025, through April 1, 2025, the PLEASE DISREGARD THE HEADING OF survey at the above provider. At the time of the STATES,"PROVIDER'S PLAN OF survey, there were 16 residents; 16 receiving CORRECTION." THIS APPLIES TO services under the Assisted Living Facility with FEDERAL DEFICIENCIES ONLY. THIS Dementia Care license. WILL APPEAR ON EACH PAGE. THERE IS NO REQUIREMENT TO SUBMIT A PLAN OF CORRECTION FOR VIOLATIONS OF MINNESOTA STATE STATUTES. THE LETTER IN THE LEFT COLUMN IS USED FOR TRACKING PURPOSES AND REFLECTS THE SCOPE AND LEVEL ISSUED PURSUANT TO 144G.31 SUBDIVISION 1-3. 0 470 144G.41 Subdivision 1 Minimum requirements 0 470 SS=F (11) develop and implement a staffing plan for LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 T6TA11 If continuation sheet 1 of 40 PRINTED: 04/28/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 33447 04/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 112 IVERSON AVENUE ASHBY LIVING CENTER ASHBY, MN 56309 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 470 Continued From page 1 0 470 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 meet the scheduled and reasonably foreseeable unscheduled needs of each resident as required by the residents' assessments and service plans on a 24-hour per day basis; and (iii) ensures that the facility can respond promptly and effectively to individual resident emergencies and to emergency, life safety, and disaster situations affecting staff or residents in the facility; (12) ensure that one or more persons are available 24 hours per day, seven days per week, who are responsible for responding to the requests of residents for assistance with health or safety needs. Such persons must be: (i) awake; (ii) located in the same building, in an attached building, or on a contiguous campus with the facility in order to respond within a reasonable amount of time; (iii) capable of communicating with residents; (iv) capable of providing or summoning the appropriate assistance; and (v) capable of following directions; This MN Requirement is not met as evidenced by: Based on observation, interview, and record review, the licensee failed to ensure the licensee's Direct-Care Staffing Plan was evaluated at least twice a year, of the appropriateness of staffing levels in the facility. This had the potential to affect all residents, staff, and visitors. This practice resulted in a level two violation (a violation that did not harm a resident's health or STATE FORM 6899 T6TA11 If continuation sheet 2 of 40 PRINTED: 04/28/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 33447 04/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 112 IVERSON AVENUE ASHBY LIVING CENTER ASHBY, MN 56309 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 470 Continued From page 2 0 470 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 of the residents).
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