Goodneighbors-maplewood Manor.
Goodneighbors-maplewood Manor is Grade C−, ranked in the bottom 48% of Minnesota memory care with 1 MDH citation on record; last inspected Mar 2025.
A medium home, reviewed on public record.
Ranked against 187 Minnesota facilities.
ALF memory care · 36-month window. Higher percentile = better. Source: Minnesota Dept. of Health · Health Regulation Division.
FACILITY WATCH · BETA
Goodneighbors-maplewood Manor 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 Goodneighbors-maplewood Manor's record and state requirements.
The most recent Minnesota Department of Health inspection on March 5, 2025 found zero deficiencies across 3 reports on file — can you walk us through the facility's internal quality assurance process that supports this compliance record, and how often do you conduct your own internal audits?
Ask the operator on tour. Take notes and compare answers across facilities you visit.
One complaint was filed with MDH during the inspection period on file — was that complaint substantiated, and can you share the facility's own documentation of how it was resolved?
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This facility holds an Assisted Living Facility with Dementia Care license under Minnesota Statute Chapter 144G — can you show prospective families the written dementia care program and explain how staff competency in dementia care is assessed and documented?
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Every MDH visit, verbatim.
2 inspections in the public record, most recent first. Click any row to expand — cited rows open automatically.
2026-04-13Complaint Investigation1 · Substantiated Finding
Plain-language summary
A Minnesota Department of Health complaint investigation substantiated that the facility neglected a resident by failing to administer his Parkinson's medication (Sinemet) for four consecutive days due to a supply shortage, resulting in the resident missing 11.5 doses, after which he fell, experienced a decline in condition, and required emergency department evaluation. The ED record confirmed the resident's change in mental status and disorientation were caused by not receiving the medication for several days. The facility was found 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 they failed to administer his Sinemet as ordered to treat Parkinson’s for four days leading to a decline, falls, and likely bruising. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was substantiated. The facility was responsible for the maltreatment. The resident missed 4 days (11.5 doses) of Sinemet (a medication for Parkinson’s disease) as ordered, then sustained a fall with a decline in condition requiring evaluation in the emergency department (ED). The ED record indicated the residents decline was caused by the resident not receiving Sinemet as ordered. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted the resident’s family. The investigation included review of the resident record(s), ED/hospital records, pharmacy records, facility incident reports, personnel files, staff schedules, and related facility policy and procedures. Also, the investigator observed the resident and medication administration practices at the facility. The resident resided in an assisted living memory care unit with diagnoses including Parkinson's disease (a chronic neurodegenerative disorder that impairs movement and motor control) and dementia. The resident’s assessment indicated the resident was cognitively impaired and required assistance with activities of daily living (ADL’s) including dressing, grooming and incontinence care in the morning, with evening care, and as needed. The assessment indicated the resident alerted staff to toileting needs. The assessment indicated the resident received medication management and administration services. The resident had a history of falls, which at times resulted in bruising. A concern arose when the facility did not administer the resident’s Sinemet as ordered for four days. Additionally, concerns arose regarding incontinence cares and personal hygiene. Regarding the resident’s personal hygiene and incontinence cares, the resident’s service delivery record indicated the resident received cares and services as indicated in his plan of care with no concerns of neglect with ADL’s. Additionally, during onsite observation, the resident appeared clean and well-groomed with no indication of neglect with ADL’s. Medication Error The resident’s plan of care indicated the facility provided medication administration by trained medication passers. The plan of care indicated staff would report all late medications, out of stock medications, or declined medications to the nurse. The plan of care indicated staff members, and the nurse would monitor supplies and reorder as needed. The resident’s medication administration record (MAR) indicated the resident was prescribed Sinemet 50/200 mg tablets for Parkinson’s disease, with instructions to take 2 tablets 4 times daily at 6:00 a.m., 11:00 a.m., 4:00 p.m., and 10:00 p.m. A review of the MAR indicated there were four consecutive days the facility did not administer the resident’s Sinemet as ordered. Day One The MAR notes indicated the resident’s supply was down to one tablet, when two were prescribed. The progress notes indicated the unlicensed caregiver passing the medications contacted a nurse, who instructed her to give the half dose and document any missed doses as not given and the medication as not in the facility. The same document indicated the unlicensed caregiver had reordered the Sinemet. Day Two The MAR continued to reflect that the facility did not have the resident’s Sinemet on hand to administer. While the morning doses were circled in red indicating the medications were not given, by the afternoon the MAR was grayed out [indicating the medication was held]. A review of the medical provider’s orders identified there was no order for the medication to be held. The progress notes indicated the facility re-ordered all of the resident’s active medications. A fax indicated the facility notified the provider they were out of the resident’s Sinemet, then re-ordered it. Day Three The MAR indicated the facility did not administer Sinemet for the resident as ordered. Day Four The MAR indicated the facility did not administer Sinemet for the resident as ordered. At 10:16 a.m., a progress note indicated the night shift had reported the resident had knocked over his lamp overnight. The same note indicated an unwitnessed fall may have occurred as the resident had a long bruise on the back of the resident’s legs. Additionally, the resident “did not seem himself” and could be related to missed medications. The nurse directed a set of vital signs and neuro checks completed, which were within normal limits. At 1:06 p.m., a progress note indicated the unlicensed caregivers continued to report the resident was not himself and was tearful. After a discussion with the power of attorney, the resident was sent to the ED. A review of the MAR indicated the resident missed a total of 11.5 doses of Sinemet over these four days. The resident’s ED record following the incident indicated the resident had gone without his Sinemet for three days because the facility had run out of the medication. The ED record indicated one dose of Sinemet was given to the resident and then he was discharged back to the facility. The record indicated the resident’s change in mental status and disorientation was due to the resident not receiving the Sinemet for several days. The facility investigation documentation into the resident’s Sinemet medication incident including staff interviews, findings, and actions taken to prevent recurrence including staff re-education on the medication re-ordering process and use of local pharmacy to fill critical medications in an emergency was requested, none was provided. During an interview, facility leadership stated the resident’s provider and pharmacy required 10-14 days to obtain a refill by mail. Leadership indicated staff had not notified nursing a refill was needed until the resident’s medication had run out, then the medication was reordered. Leadership indicated critical medication like the resident’s Sinemet should have been obtained from the local emergency pharmacy sooner. Leadership indicated staff should complete cart audits to look for medications that need refills and staff should notify nursing if the medication supply was getting low. When asked why the medication was not obtained through the emergency pharmacy sooner, leadership stated either staff did not understand what they should do, or they did not think of it. One nurse stated prior to the incident staff looked for medications needing refills and observed the resident had half a bottle of Sinemet available but did not account for the fact the resident took 2 tablets 4 times per day and would run out. The nurse indicated the resident’s refills required 14 days to obtain a refill from the pharmacy via mail and staff had not notified the nurse until the resident was out of the medication. The nurse indicated staff did not count the resident’s Sinemet to identify a refill was needed and ensure he had enough medication available for staff to administer. The nurse verified there was no providers order to hold the resident’s Sinemet and explained the medication was put on hold so staff would not call the on call nurse with each scheduled dose missed to report the medication was unavailable. Another nurse stated staff should notify the nurse 10-14 days before a refill was needed for medications received via mail. The nurse indicated if a critical medication runs out, the medication should be obtained through the local emergency pharmacy, so the resident does not go without. The nurse stated the facility should have processes in place to ensure medications are re-ordered timely. Unlicensed staff interviewed stated they would notify the nurse if a resident had 7 days of medication left and indicated there was no difference in the process for the resident’s medications which had to be mailed. When interviewed the resident’s family member denied having concerns with the facility providing assistance with ADL needs and denied any concerns with bruising or abuse. The family member stated the resident ran out of Sinemet and went without for days which was unacceptable. The family stated the facility should have taken action to ensure the medication was available to administer and indicated missing the Sinemet as ordered caused the resident to suffer a decline in cognition, increased weakness, fatigue, restlessness, and confusion requiring evaluation and treatment in the ED. In conclusion, the Minnesota Department of Health determined neglect was substantiated. Substantiated: Minnesota Statutes, section 626.5572, Subdivision 19.
2025-03-05Annual Compliance VisitNo findings
Plain-language summary
A routine inspection of Maplewood Manor LLC on March 5, 2025, found a violation of Minnesota's background studies requirement under state statute 144G.60, Subdivision 1. The facility was issued a correction order and assessed a $3,000 fine for this violation. The facility must document the actions it took to correct the noncompliance and may request reconsideration or a hearing within the specified timeframe.
Full inspector notes
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 . . ." IMPOSITION OF FINES In accordance with Minn. Stat. § 144G.31, Subd. 4, fines and enforcement actions may be imposed based on the level and scope of the violations and may be imposed immediately with no opportunity to correct the violation first as follows: Level 1: no fines or enforcement. Level 2: a fine of $500 per violation, in addition to any enforcement mechanism authorized in § 144G.20 for widespread violations; Level 3: a fine of $3,000 per violation per incident, in addition to any enforcement mechanism authorized in § 144G.20. Level 4: a fine of $5,000 per incident, in addition to any enforcement mechanism authorized in § 144G.20. Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, the following fines are assessed pursuant to this survey: St - 0 - 1290 - 144g.60 Subdivision 1 - Background Studies Required - $3,000.00 An equal opportunity employer. Letter ID: IS7N REVISED 09/13/2021 Maplewood Manor LLC April 3, 2025 Page 2 Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, t he total amount you are assessed is $3,000.00. You will be invoiced approximately 30 days after receipt of this notice, subject to appeal. 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 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 REQUESTING A HEARING Alternatively, in accordance with Minn. Stat. § 144G.31, Subd. 5(d), an assisted living provider that has been assessed a fine under this subdivision has a right to a reconsideration or a hearing under this section and chapter 14. Pursuant to Minn. Stat. § 144G.20, Subd. 14 and Subd. 18, a request for a hearing must be in writing and received by the Department of Health within 15 business days of the correction order receipt date. The request must contain a brief and plain statement describing each matter or issue contested and any new information you believe constitutes a defense or mitigating factor. To submit a hearing request, please visit: https://forms.web.health.state.mn.us/form/HRDAppealsForm To appeal fines via reconsideration, please follow the procedure outlined above. P lease note that you may request a reconsideration o r a hearing, but not both. If you wish to contest tags without fines in a reconsideration and tags with the fines at a hearing, please submit two separate appeals forms at the website listed above. Maplewood Manor LLC April 3, 2025 Page 3 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: 04/03/2025 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 _____________________________ 36368 03/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1010 1ST STREET NE MAPLEWOOD MANOR LLC ELBOW LAKE, MN 56531 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 SL36368016-0 Time Period for Correction. On March 3, 2025, through March 5, 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 13 residents; 13 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 1290: An immediate correction order was issued SUBMIT A PLAN OF CORRECTION FOR on March 4, 2025, at a level 3/Widespread (I). VIOLATIONS OF MINNESOTA STATE The licensee took immediate action to mitigate STATUTES. the risk; however, scope and level remains at I. 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. 0 580 144G.42 Subd. 2 Quality management 0 580 SS=F The facility shall engage in quality management LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 VO2H11 If continuation sheet 1 of 14 PRINTED: 04/03/2025 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 _____________________________ 36368 03/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1010 1ST STREET NE MAPLEWOOD MANOR LLC ELBOW LAKE, MN 56531 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) 0 580 Continued From page 1 0 580 appropriate to the size of the facility and relevant to the type of services provided. "Quality management activity" means evaluating the quality of care by periodically reviewing resident services, complaints made, and other issues that have occurred and determining whether changes in services, staffing, or other procedures need to be made in order to ensure safe and competent services to residents. Documentation about quality management activity must be available for two years. Information about quality management must be available to the commissioner at the time of the survey, investigation, or renewal.
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