Majestic Pines.
Majestic Pines is Grade C−, ranked in the bottom 47% of Minnesota memory care with 1 MDH citation on record; last inspected Apr 2025.
A large home, reviewed on public record.
Ranked against 138 Minnesota facilities.
ALF memory care · 36-month window. Higher percentile = better. Source: Minnesota Dept. of Health · Health Regulation Division.
FACILITY WATCH · BETA
Majestic Pines 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)
Every MDH visit, verbatim.
3 inspections in the public record, most recent first. Click any row to expand — cited rows open automatically.
2025-04-03Annual Compliance VisitNo findings
Plain-language summary
A routine inspection of Majestic Pines Senior Living on April 3, 2025 found a violation of fire protection and physical environment requirements under Minnesota Statutes chapter 144G. The facility was assessed a $500 fine for this violation and must document the corrective actions taken.
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 - 0775 - 144g.45 Subd. 2. (a) - Fire Protection And Physical Environment - $500.00 An equal opportunity employer. Letter ID: IS7N REVISED 09/13/2021 Majestic Pines Senior Living April 30, 2025 Page 2 Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, t he total amount you are assessed is $500.00. 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. Majestic Pines Senior Living April 30, 2025 Page 3 INFORMAL CONFERENCE In accordance with Minn. Stat. § 144A.475, Subd. 8 OR Minn. Stat. § 144G.20, Subd. 20, the Commissioner of Health is authorized to hold a conference to exchange information, clarify issues, or resolve issues. The Department of Health staff would like to schedule a conference call with Majestic Pines Senior Living. Please contact Jessie Chenze at 218-332-5175 on or before Monday, May 5, 2025, to schedule the conference call. 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: 04/30/2025 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 _____________________________ 30986 04/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1614 GOLF COURSE ROAD MAJESTIC PINES SENIOR LIVING GRAND RAPIDS, MN 55744 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 SL3098016 Time Period for Correction. On March 31, 2025, through April 3, 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 94 residents: 90 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. 0 100 144G.10 Subdivision 1 License required 0 100 SS=F (a)(1)Beginning August 1, 2021, no assisted living LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 VY3011 If continuation sheet 1 of 56 PRINTED: 04/30/2025 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 _____________________________ 30986 04/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1614 GOLF COURSE ROAD MAJESTIC PINES SENIOR LIVING GRAND RAPIDS, MN 55744 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) 0 100 Continued From page 1 0 100 facility may operate in Minnesota unless it is licensed under this chapter. (2) No facility or building on a campus may provide assisted living services until obtaining the required license under paragraphs (c) to (e). (b)The licensee is legally responsible for the management, control, and operation of the facility, regardless of the existence of a management agreement or subcontract.
2024-10-01Complaint InvestigationNo findings
Plain-language summary
A complaint investigation was conducted at Majestic Pines on October 1, 2024, and concluded on October 15, 2024. No correction orders were issued as a result of the investigation.
Full inspector notes
STATE LICENSING COMPLIANCE REPORT Report #: HL309865581C Date Concluded: October 15, 2024 Name, Address, and County of Facility Investigated: Majestic Pines 1614 Golf Course Road Grand Rapids, MN 55744 Itasca County Facility Type: Assisted Living Facility (ALF) Evaluator’s Name: Holly German, RN Special Investigator The Minnesota Department of Health conducted a complaint investigation to determine compliance with state laws and rules governing the provision of care under Minnesota Statutes, Chapter 144G. The purpose of this complaint investigation was to review if facility policies and practices comply with applicable laws and rules. No maltreatment under Minnesota Statutes, Chapter 626 was alleged. To view a copy of the correction orders, if any, please visit: https://www.health.state.mn.us/facilities/regulation/directory/provcompselect.html, or call website, please see the attached state form. PRINTED: 10/17/2024 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 _____________________________ 30986 10/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1614 GOLF COURSE ROAD MAJESTIC PINES SENIOR LIVING GRAND RAPIDS, MN 55744 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 On October 1, 2024, the Minnesota Department of Health initiated an investigation of complaint #H309865581C. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 SNC611 If continuation sheet 1 of 1
2023-10-26Complaint Investigation1 · Substantiated Finding
Plain-language summary
The Minnesota Department of Health substantiated a complaint that the facility neglected three residents by failing to supervise those with wandering and aggressive behaviors. One resident wandered into another resident's room and was struck in the head with a wheelchair pedal, resulting in multiple lacerations requiring seven staples; nine days later the same resident wandered into a third resident's room and sustained bruising injuries to his lip and face during an altercation. The facility had documented knowledge of wandering and aggressive behaviors in its care plans but failed to implement adequate supervision or safety interventions to prevent these incidents.
“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 three residents (R1, R2, and R3) when they failed to supervise residents with wandering and physically aggressive behaviors. R2 wandered into R3’s room and was struck in the head by R3 with his wheelchair foot pedal causing multiple head lacerations and a hematoma. R2 received seven staples for treatment of his injuries. Nine days later R2 wandered into R1’s room and had a verbal and physical altercation resulting in bruising injury to R1’s lip and face. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was substantiated. The facility was responsible for the maltreatment. The facility identified R3 had physically and verbally aggressive behaviors but failed to implement identified interventions to prevent residents from wandering into R3’s room. Following the incident with R2 and R3, the facility was aware R2 An equal opportunity employer. wandered into other resident rooms frequently but failed to implement interventions to ensure R2 was supervised by staff when wandering. R2 wandered into R1’s room and had a physical and verbal altercation resulting in a bruising injury to R1’s lip and face. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted law enforcement, and the resident’s family members. The investigation included review of resident records including, incident reports, progress notes, care plans, assessments, service agreements, service delivery of care records, behavior plans, behavior documentation, facility investigation documentation, policies and procedures, surveillance videos, police reports, outside medical and emergency department records. Also, the investigator observed residents and staff in the facility. R2 resided in an assisted living facility secure memory care unit with diagnoses including vascular dementia with behavioral disturbance, and Alzheimer’s Disease with depression. R2’s assessment prior to the incidents indicated he had moderately impaired cognition and was sometimes able to make his needs known. The assessment identified R2 wandered and had a history of threatening physical violence towards both staff and residents. R2’s care plan and individual abuse prevention plan (IAPP) prior to the incidents also identified R2 had verbally abusive behaviors towards residents. The care plan and IAPP failed to identify R2 wandered and went into other resident rooms frequently. The care plan and IAPP lacked staff supervision or interventions for R2’s wandering to ensure safety other than routine safety checks every two hours. R3 resided in an assisted living facility secure memory care unit with diagnoses including Wernicke-Korsakoff syndrome (a neurologic disorder caused by alcoholism), emotional liability, behavioral disturbance, aggressive behavior, stroke, and traumatic brain injury. R3’s progress notes prior to the incident included documentation of verbally and physically aggressive behaviors toward other residents including grabbing another resident’s arm and threatening to put resident’s and family members “down in a military way”. A progress note 86 days prior to the incident indicated due to R3’s paranoid delusions his apartment door would be locked to prevent other residents from entering. However, the resident record indicated the intervention was not implemented. R3’s assessment prior to the incident indicated he had moderately impaired cognition but failed to identify R3 was physically aggressive toward other residents. R3’s care plan prior to the incident identified R3 was physically aggressive towards staff and verbally aggressive towards staff and residents. The care plan and IAPP failed to identify R3 had physically aggressive behaviors toward other residents and had no specific interventions in place to ensure safety other than routine every two-hour safety checks . A facility incident report indicated one day R2 wandered into R3’s room to look out the window, and R3 struck R2 in the head with his wheelchair pedal causing multiple head lacerations. R2 was transferred to the emergency department (ED)for treatment of his head injury and received seven staples. The incident report indicated the facility was aware R2 wandered into other resident rooms frequently. However, at the time of the incident R2 and R3’s care plan and IAPP, did not address behaviors with wandering or aggression, and failed to direct staff on interventions to ensure the residents safety. During a review of the facility provided recorded security footage an agitated male voice using profane language was heard while R2 wandered in the common area near R3’s room. R3’s door was open, and R2 was observed looking out the window in the common area. The next video R2 is not seen, but mumbled incoherent speech is heard. Staff then enters the room stated, “Is everybody,” as she entered the room indicating she knew R3 was not alone in his room. Then, staff was heard telling R3, “let go, let go, OH MY GOD, you did not!” R3 responded “this is my room!” Staff stated, “I cannot believe you did that!” R3 responded “he was stealing my shit!”. Staff was observed removing R2 from R3’s room then called for assistance. The following day a care conference summary indicated R2 and R3’s family members and facility leadership determined R1 and R2 should not engage each other, and staff would keep them away from each other when not supervised. However, the facility failed to implement the intervention on either resident’s care plan or IAPP, so staff were aware of the intervention. 11 days later a facility investigation included an action plan which indicated R3’s apartment door would always be locked. In addition, R3’s wheelchair pedals were removed. However, R3’s IAPP and care plan failed to include the intervention to ensure R3’s door was locked until 60 days after the incident occurred and lacked directions to remove R3’s pedals after transporting him with his wheelchair. R3’s service delivery record failed to include interventions to ensure R3’s door was locked by staff, safety checks were completed, and wheelchair pedals were removed after transporting the resident. Following the incident R3’s progress notes included documentation of ongoing physically aggressive behavior toward other residents including punching a resident in the genitals and kicking other residents with no new interventions added to ensure the safety of other residents. R2 was treated in the ED for his head injury, however the facility failed to re-assess R2’s wandering behaviors after the incident occurred to prevent recurrence or implement actions to ensure safety following the incident with R3. Nine days later a facility incident report indicated R1 had an unwitnessed incident which resulted in a swollen left upper lip. The incident report indicated the resident was not a reliable reporter of the event and reported several different versions of what happened to staff at the time of the incident. The incident report indicated the nurse assessed R1’s injuries, applied ice, her room door was locked, and the family was notified the following morning. R1 resided in an assisted living facility secure memory care unit with diagnoses including memory loss. R1’s assessment prior to the incident indicated she had cognitive impairment, poor safety awareness, and was unable to problem solve. R1’s care plan and IAPP indicated R1 needed staff guidance, queuing, and direction in an emergency due to cognitive impairment. The care plan and IAPP identified R1 was at risk to be abused by other residents that may have behaviors but failed to include specific interventions to ensure R1’s safety other than routine every two-hour safety checks. Two days following the incident a resident assessment included interventions for staff to lock R1’s door and ensure the door was locked on safety rounds. However, the intervention was not implemented on the resident’s IAPP until 12 days later and was not implemented on the resident’s care plan until 41 days after the incident occurred. R1’s after visit summary indicated she was seen the following day in the ED for evaluation of a soft tissue lip contusion with no indication of any concerns of a head injury following the incident. A police report following the incident indicated R1 was observed to have a dark purple bruise on the left side of her upper lip. The report indicated R1 provided vague details of the incident, but reported a male resident entered her apartment and punched her.
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