Maplewood Assisted Living.
Maplewood Assisted Living is Grade C−, ranked in the bottom 46% of Minnesota memory care with 1 MDH citation on record; last inspected Oct 2024.
A large home, reviewed on public record.
Ranked against 142 Minnesota facilities.
ALF memory care · 36-month window. Higher percentile = better. Source: Minnesota Dept. of Health · Health Regulation Division.
FACILITY WATCH · BETA
Maplewood Assisted Living 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 Maplewood Assisted Living's record and state requirements.
The Minnesota Department of Health roster shows this community holds an Assisted Living Facility with Dementia Care license under Minn. Stat. ch. 144G — can you walk us through the written dementia care program and show how it differs from the general assisted living services for the other residents?
Ask the operator on tour. Take notes and compare answers across facilities you visit.
MDH conducted an inspection on October 23, 2024, and recorded zero deficiencies — can you provide a copy of that survey report and explain how the facility prepares for unannounced inspections?
Ask the operator on tour. Take notes and compare answers across facilities you visit.
Two complaints were filed with the Minnesota Department of Health during the period on file — can you describe the nature of those complaints and share any written corrective action plans or internal review documentation the facility produced in response?
Ask the operator on tour. Take notes and compare answers across facilities you visit.
Every MDH visit, verbatim.
4 inspections in the public record, most recent first. Click any row to expand — cited rows open automatically.
2025-06-05Complaint InvestigationNo findings
Plain-language summary
On May 6, 2025, a complaint investigation found that the facility failed to maintain the physical environment in good repair and safety, with an ongoing mouse and ant infestation throughout the building, particularly severe on the memory care unit, where staff observed dead mice on resident beds, ants in food bowls, stained carpeting, and odors of spoiled food. The infestation affected the health and safety of residents, staff, visitors, and volunteers, though no resident harm was documented. A correction order was issued for this violation.
Full inspector notes
findings which When a Minnesota Statute contains several are in violation of the state requirement items, failure to comply with any of the items will after the statement, "This Minnesota be considered lack of compliance. requirement is not met as evidenced by." Following the evaluators ' findings is the INITIAL COMMENTS: Time Period for Correction. HL207126258C/HL207128722M PLEASE DISREGARD THE HEADING OF HL207125546C/HL207128503M THE FOURTH COLUMN WHICH HL207124112C STATES,"PROVIDER'S PLAN OF CORRECTION." THIS APPLIES TO On May 6, 2025, the Minnesota Department of FEDERAL DEFICIENCIES ONLY. THIS Health conducted a complaint investigation at the WILL APPEAR ON EACH PAGE. above provider, and the following correction orders are issued. At the time of the complaint THERE IS NO REQUIREMENT TO investigation, there were 51 residents receiving SUBMIT A PLAN OF CORRECTION FOR services under the provider's Assisted Living with VIOLATIONS OF MINNESOTA STATE Dementia Care license. STATUTES. The following correction order is issued for THE LETTER IN THE LEFT COLUMN IS HL207125546C/HL207128503M, tag USED FOR TRACKING PURPOSES AND identification 2360. REFLECTS THE SCOPE AND LEVEL ISSUED PURSUANT TO 144G.31 The following correction order is issued for SUBDIVISION 1-3. HL207124112C, tag identification 880. No correction orders are issued for HL20712258C/HL207128722M. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 XB9M11 If continuation sheet 1 of 8 PRINTED: 06/05/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ C B. WING _____________________________ 20712 05/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1890 SHERREN AVENUE EAST MAPLEWOOD ASSISTED LIVING MAPLEWOOD, MN 55109 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) 0 800 144G.45 Subd. 2 (a) (4) Fire protection and 0 800 SS=F physical environment (4) keep the physical environment, including walls, floors, ceiling, all furnishings, grounds, systems, and equipment in a continuous state of good repair and operation with regard to the health, safety, comfort, and well-being of the residents in accordance with a maintenance and repair program. This MN Requirement is not met as evidenced by: Based on record review, observation and interviews, the licensee failed to keep the physical environment in a continuous state of good repair and operation with regard to the health, safety, comfort and well-being of the residents. The facility had an on-going mouse and ant infestation in the building; the third floor memory care unit was particularly active. The memory care unit was dirty with debris, staining and odor. This had the potential to affect all residents, staff members, visitors and volunteers. 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 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, staff members and visitors. The findings include: STATE FORM 6899 XB9M11 If continuation sheet 2 of 8 PRINTED: 06/05/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ C B. WING _____________________________ 20712 05/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1890 SHERREN AVENUE EAST MAPLEWOOD ASSISTED LIVING MAPLEWOOD, MN 55109 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) 0 800 Continued From page 2 0 800 PEST CONTROL During a building tour on May 6, 2025 at 10:20 a.m., the investigator observed renovation construction on the first floor. Licensed assistant living director LALD-A, said the first and second floors were undergoing renovation first and the third floor memory care would be last. The decor and flooring were about 15 years old and showing its age, especially in memory care. On the memory care unit, the investigator observed areas of stained carpet in the TV gathering space. There was also the smell of garbage or spoilt food in the same area. Several residents and a staff member were watching TV. During an interview on May 6, 2025, at 11:25 a.m., unlicensed personnel (ULP)-C said the building had a mouse and ant infestation when she was hired back in January 2025. The infestation was especially bad in memory care where she was regularly scheduled. She found a dead mouse on a resident's bed recently and an "army" ant, the large black ants, in a resident's food bowl during a meal. ULP-C said a visiting hospice nurse reported she saw a mouse running along one memory care hallway recently. During an interview on May 6, 2025, at 1:00 p.m., ULP-D said there was only one housekeeping staff for the entire building. An activities staff person helped clean common areas a few days each week. She said the mice and ants were all over the building but worst on the third floor memory care unit. She was not sure how often pest control came to treat the building. ULP-D said the ongoing construction added to the mouse problem. Maintenance staff did not do any pest control. ULP-D said "The mice access the third floor from the registers. Everyone knows it's a problem." ULP-D stated the red stained areas STATE FORM 6899 XB9M11 If continuation sheet 3 of 8 PRINTED: 06/05/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ C B. WING _____________________________ 20712 05/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1890 SHERREN AVENUE EAST MAPLEWOOD ASSISTED LIVING MAPLEWOOD, MN 55109 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) 0 800 Continued From page 3 0 800 in the unit tried to be cleaned but were permanent. ULP-D said the ULP's are supposed to clean the dining room after meals but do not or clean very little. During an observation on May 6, 2025, at 1:00 p.m., the investigator observed on the third floor memory care unit the following: TV Room -AC (air conditioner)/heating register screens encrusted with dirt and food debris. -Red liquid stained on top of an AC/heating register and was splashed along the wall, baseboards and carpet. -Underneath the AC/heating register there was one rodent bait station, a plastic spoon and food debris. -Another register in the TV area also had food debris and dirt clogged screens. Dining Room -Odor, strongly smelled of garbage or spoilt food. -The floor was stained and sticky; the investigator's and ULP-D's shoes stuck to the floor. -Observed a dozen large black ants on the floor and walls in the dining room. -There was a dead black ant on the counter by the stove and a live black ant crawled the counter. -A mouse run behind the countertop toaster next to the stove, and then run behind the stove. -There was food debris and mouse feces behind the toaster. -Several empty drawers and cupboards contained mouse feces, food debris and dried stains. -One drawer stocked with paper placemats and napkins had mouse feces. During an interview on May 6, 2025, at 3:20 p.m., LALD-A said the facility used a pest control STATE FORM 6899 XB9M11 If continuation sheet 4 of 8 PRINTED: 06/05/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ C B.
2025-06-04Complaint Investigation1 · Substantiated Finding
Plain-language summary
A complaint investigation found that a staff member financially exploited a resident by using the resident's debit card without permission to purchase over 170 Uber rides to and from work, plus food and retail items, totaling approximately $9,900 over multiple dates in 2023 and 2024. The staff member, who acknowledged knowing the unauthorized purchases were wrong, is no longer employed at the facility, and the resident's family was notified and the debit card was closed. The resident, who has mild cognitive impairment and schizoaffective disorder and requires assistance with finances, did not authorize these purchases.
“MDH substantiated maltreatment or licensing violation finding”
Full inspector notes
Finding: Substantiated, individual 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 AP financially exploited the resident when she used the resident’s debit card to purchase Uber rides for herself. Investigative Findings and Conclusion: The Minnesota Department of Health determined financial exploitation was substantiated. The AP was responsible for the maltreatment. The AP found and used the resident’s debit card information to purchase various goods and services for herself on multiple dates. The approximate total of purchases was $9,900.00. The investigator conducted interviews with facility staff members, including administrative staff and unlicensed staff. The investigator contacted law enforcement and the resident’s family member. The investigation included review of the resident records, facility internal investigation, facility incident reports, personnel file, staff schedules, law enforcement report, related facility policy and procedures. Also, the investigator observed the resident interacting with staff members. The resident lived on the memory care floor of the facility. The resident’s diagnoses included mild cognitive impairment and schizoaffective disorder. The resident’s service plan included assistance with dressing, toileting, bathing, reassurance checks, medication administration and transfers. The resident was her own decision maker and had a trust that paid some of her bills. She also had a family member who was available to assist with finances as needed. The nurse assessed the resident as forgetful. She could follow through with simple tasks but not complex tasks. The resident did not have the reasoning or initiative for self-care, including finances, personal care and obtaining personal supplies. She needed daily reminders for routines. According to law enforcement records, the facility staff contacted police the summer of 2024 with a concern of fraudulent purchases made with the resident’s debit card. The resident received a bank statement and a staff member reviewed it with her to reconcile purchases. There were a number of purchases made with the resident’s debit card for food delivery, Uber ride services and store purchases. The resident did not make those purchases. She had personal care staff from another company who took her out for coffee and to shop at a store, but those items and services were authorized purchases and not in question, according to law enforcement records. Law enforcement records indicated the AP purchased Uber ride services with the resident’s debit card. The AP purchased over 170 rides; most from her home to the facility and back to her home when she was done working. The cost was $2,600. Law enforcement records indicated there were numerous purchases made on food delivery service during 2023 to 2024. Some of the larger purchases ranged from $200 to $1,900 dollars from an online store. About $2,800 were purchases from a store that started in 2023. The amounts of unauthorized purchases provided by law enforcement total about $9,900. The resident initially agreed to do an interview but then declined. She said she knew some of her money was gone and she probably would not get it back. During an interview, the administrator said there had been a previous concern of possible financial exploitation of the resident involving a debit card and different staff member who no longer worked at the facility. After that incident, all staff, including the AP, were re-educated on vulnerable adults and financial exploitation. The administrator was surprised when law enforcement called her several months ago with new information on the resident’s case that involved the AP and fraudulent purchases. The administrator started an internal investigation which included determining if the AP received rides to work from a ride service. Staff members she interviewed said someone drove the AP to and from work, but they did not know details. The administrator and law enforcement asked the AP to meet with them, but the AP did not show up for the meeting and did not return their calls. The AP is no longer employed at the facility. The administrator said she notified the resident’s family member about the financial exploitation and the debit card was stopped. During an interview, the AP said she worked at the facility about one year and was a direct care provider for the resident. One day she found a card on the floor outside the resident’s apartment door. She called it a credit card but was not sure and said it could have been a debit card. The AP copied the card information to purchase groceries and clothes at a store and various items online. She purchased Uber rides to and from work. She did not recall when she started using the card. She said she knew what she was doing was wrong when she used the resident’s debit card, but she needed food and had house expenses. The AP said she was sorry. The AP said she did not meet with the administrator and law enforcement about the debit card because she was “busy” that day. Review of the AP’s personnel file included her job description, which included promoting the resident’s right to be free from abuse, mistreatment, neglect or misappropriation of resident property. The AP would also maintain care and security of resident’s personal possessions. During an interview, the family member said the resident had a trust to pay for some of her monthly expenses. He was a financial representative for the resident, but did not have access to all her finances and account information so he was not aware of the financial exploitation until law enforcement and the facility staff called him with concerns. The debit card account was closed, and the fraudulent purchases have stopped. He now helped order items for the resident. The family member said overall the facility has been good communicating concerns to him. The complainant did not return calls for an interview. In conclusion, the Minnesota Department of Health determined financial exploitation 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. Financial exploitation: Minnesota Statutes, section 626.5572, subdivision 9 "Financial exploitation" means: (1) engages in unauthorized expenditure of funds entrusted to the actor by the vulnerable adult which results or is likely to result in detriment to the vulnerable adult; or (2) fails to use the financial resources of the vulnerable adult to provide food, clothing, shelter, health care, therapeutic conduct or supervision for the vulnerable adult, and the failure results or is likely to result in detriment to the vulnerable adult. (b) In the absence of legal authority a person: (1) willfully uses, withholds, or disposes of funds or property of a vulnerable adult; (2) obtains for the actor or another the performance of services by a third person for the wrongful profit or advantage of the actor or another to the detriment of the vulnerable adult; Mitigating Factors considered, Minnesota Statutes, section 626.557, Subd. 9c(f): (1) The AP did not follow an erroneous order, direction or care plan with awareness and failure to take action. The facility did not direct an erroneous order, direction, or care plan. (2) The facility was in compliance with regulatory standards. The facility provided proper training and/or supervision of staff. The facility provided adequate staffing levels. (3) The AP failed to follow the facility directive and/or policies and procedures. The AP failed to follow professional standards and/or exercise professional judgement. The AP failed to act in good faith interest of the vulnerable adult. The maltreatment was not a sudden or foreseen event. Vulnerable Adult interviewed: Declined. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Yes. Action taken by facility: The facility completed an internal investigation and the AP is no longer employed by facility. Action taken by the Minnesota Department of Health: The facility was issued a correction order regarding the vulnerable adult’s right to be free from maltreatment. You may also call 651-201-4200 to receive a copy via mail or email The responsible party will be notified of their right to appeal the maltreatment finding.
2024-10-23Annual Compliance VisitNo findings
Plain-language summary
A standard inspection of Maplewood Assisted Living took place from October 21–23, 2024, and found violations of Minnesota state statutes for assisted living facilities with dementia care. The facility received correction orders requiring documented actions to address the areas of noncompliance within specified timeframes, and no immediate fines were assessed. The facility may challenge the correction orders within 15 calendar days of receipt.
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: An equal opportunity employer. Letter ID: IS7N REVISED 09/13/2021 Maplewood Assisted Living November 26, 2024 Page 2 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 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, Jess Schoenecker, Supervisor State Evaluation Team Email: jess.schoenecker@state.mn.us Telephone: 651-201-3789 Fax: 1 -866-890-9290 JMD PRINTED: 11/26/2024 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 20712 10/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1890 SHERREN AVENUE EAST MAPLEWOOD ASSISTED LIVING MAPLEWOOD, MN 55109 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 SL20712016-0 Time Period for Correction. On October 21, 2024, through October 23, 2024, PLEASE DISREGARD THE HEADING OF the Minnesota Department of Health conducted a THE FOURTH COLUMN WHICH full survey at the above provider. At the time of STATES,"PROVIDER'S PLAN OF the survey, there were 52 residents; 43 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. 0 480 144G.41 Subd 1 (13) (i) (B) Minimum 0 480 SS=F requirements LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 P4RK11 If continuation sheet 1 of 11 PRINTED: 11/26/2024 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 20712 10/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1890 SHERREN AVENUE EAST MAPLEWOOD ASSISTED LIVING MAPLEWOOD, MN 55109 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) 0 480 Continued From page 1 0 480 (13) offer to provide or make available at least the following services to residents: (B) food must be prepared and served according to the Minnesota Food Code, Minnesota Rules, chapter 4626; and This MN Requirement is not met as evidenced by: 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) 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 the residents). The findings include: Please refer to the document titled, Food and Beverage Establishment Inspection Report (FBEIR) dated October 21, 2024, for the specific Minnesota Food Code violations. The Inspection Report was provided to the licensee within 24 hours of the inspection. TIME PERIOD FOR CORRECTION: Please refer to the FBEIR for any compliance dates. 01440 144G.62 Subd. 4 Supervision of staff providing 01440 SS=F delegated nurs (a) Staff who perform delegated nursing or therapy tasks must be supervised by an STATE FORM 6899 P4RK11 If continuation sheet 2 of 11 PRINTED: 11/26/2024 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 20712 10/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1890 SHERREN AVENUE EAST MAPLEWOOD ASSISTED LIVING MAPLEWOOD, MN 55109 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) 01440 Continued From page 2 01440 appropriate licensed health professional or a registered nurse according to the assisted living facility's policy where the services are being provided to verify that the work is being performed competently and to identify problems and solutions related to the staff person's ability to perform the tasks. Supervision of staff performing medication or treatment administration shall be provided by a registered nurse or appropriate licensed health professional and must include observation of the staff administering the medication or treatment and the interaction with the resident.
2024-10-14Complaint InvestigationNo findings
Plain-language summary
Minnesota Department of Health investigated a complaint that facility staff linked a resident's debit card to the staff member's personal Amazon account and made unauthorized purchases; the investigation found it inconclusive whether financial exploitation occurred because while the staff member did manage the resident's finances and possess the debit card for seven months, the investigator could not definitively determine if questionable charges on the bank statement were made without authorization, particularly since some purchases occurred after the staff member left the facility. The resident, who had mild cognitive impairment and dementia and could not manage finances independently, did not recall the details of the arrangement and could not monitor her account activity. A police investigation into the questionable charges was ongoing at the time of this determination.
Full inspector notes
Finding: Inconclusive 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 alleged perpetrator (AP), facility staff, financially exploited the resident when she linked the resident’s debit card and credit card to the AP’s personal online Amazon account. Investigative Findings and Conclusion: The Minnesota Department of Health determined financial exploitation was inconclusive. The AP managed the resident’s finances and assisted the resident with obtaining supplies. However, it could not be determined if unauthorized charges were made by the AP using the resident finances. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted law enforcement and family. The investigation included review of the resident record, the facility internal investigation, facility incident reports, personnel files, financial records, and related facility policy and procedures. Also, the investigator observed resident interactions with staff. The resident resided in an assisted living memory care unit. The resident’s diagnoses included mild cognitive impairment and schizoaffective disorder. The resident’s assessment indicated the resident struggled with mild to moderate dementia and did not have the reasoning to manage finances. The facility internal investigation indicated the AP had possession of two of the resident’s debit cards for approximately seven months. One debit card was used by an external homecare agency’s staff when they took the resident on outings. The AP believed this card was eventually lost during an outing. The other card was kept in the AP’s office and used by the AP to order the resident’s supplies. The AP linked the debit card to her own online Amazon account after the resident was unable to access her own account. The AP managed the resident’s finances without notifying facility leadership or making a significant attempt to obtain an appropriate representative payee for the resident. The resident said she gave her debit card to the AP as part of the AP’s job duties. The resident expressed confusion about how many cards she had and whether they were debit or credit cards. The resident also said she had no way to monitor her debit card activity of if purchases were made without her knowledge. The resident said she simply received whatever came in the mail. The resident’s bank statement indicated two Amazon purchases were made while the AP was still employed with the facility. One Amazon Prime purchase was made after the AP’s employment was terminated, as well as numerous Uber and Walmart purchases. A police report was requested but not received, as the police investigation was open and ongoing. However, when consulted, a police officer involved with the case said the department was currently investigating the questionable charges found on the resident’s bank statement. When interviewed, a supervisor said the arrangement with the resident’s debit card was discovered when the AP trained in a new staff member and informed her that managing the resident’s debit card was one of their duties. The new staff member was uncomfortable with this and reported it to management. Staff assessed the resident and determined, due to her cognitive status, she was unable to knowingly enter such an arrangement with a staff member to manage her finances. The AP never provided the Amazon records to enable leadership to reconcile the Amazon records with the resident’s bank records. The AP never provided leadership or the resident with receipts for any purchases, and she maintained she had done nothing wrong. When interviewed, a supervisor said the AP admitted to taking possession of the resident’s debit card to make purchases on her behalf. The AP did not provide receipts, so leadership was unable to verify if the purchases noted on the resident’s bank statement were legitimate. The supervisor stated it appeared there were many fraudulent purchases made with the resident’s debit card. However, many of the purchases were made after the AP no longer worked for the facility. There was concern about caregivers from the resident’s home care agency misusing her debit card, and facility leadership notified the home care agency to have them follow-up with their staff. When interviewed, the AP said the resident began to have more trouble managing her finances and asked for help. The AP said she helped the resident cancel some ongoing subscriptions, and then began to place orders on behalf of the resident. The AP kept the resident’s debit card locked in her office and placed orders as requested. The AP said she linked the resident’s debit card to the AP’s Amazon account because the resident lost access to her own Amazon account, and eventually lost her phone as well. The AP said the resident had also ordered an expensive engagement ring and the AP returned it for her. The AP said in hindsight she would have provided receipts to the resident for the purchases the AP made with the resident’s debit card. When interviewed, the resident said she had a debit card that she gave to a staff member to buy her groceries. The resident did not remember who the staff member was or what her role was at the facility. The resident did not recall purchasing a ring. When consulted, a family member said he was pleased with how the facility managed the situation and had no concerns about the quality of care the resident received there. In conclusion, the Minnesota Department of Health determined financial exploitation was inconclusive. Inconclusive: Minnesota Statutes, section 626.5572, Subdivision 11. "Inconclusive" means there is less than a preponderance of evidence to show that maltreatment did or did not occur. Financial exploitation: Minnesota Statutes, section 626.5572, subdivision 9 "Financial exploitation" means: (a) In breach of a fiduciary obligation recognized elsewhere in law, including pertinent regulations, contractual obligations, documented consent by a competent person, or the obligations of a responsible party under section 144.6501, a person: (1) engages in unauthorized expenditure of funds entrusted to the actor by the vulnerable adult which results or is likely to result in detriment to the vulnerable adult; or (2) fails to use the financial resources of the vulnerable adult to provide food, clothing, shelter, health care, therapeutic conduct or supervision for the vulnerable adult, and the failure results or is likely to result in detriment to the vulnerable adult. (b) In the absence of legal authority a person: (1) willfully uses, withholds, or disposes of funds or property of a vulnerable adult; (2) obtains for the actor or another the performance of services by a third person for the wrongful profit or advantage of the actor or another to the detriment of the vulnerable adult; (3) acquires possession or control of, or an interest in, funds or property of a vulnerable adult through the use of undue influence, harassment, duress, deception, or fraud; or (4) forces, compels, coerces, or entices a vulnerable adult against the vulnerable adult's will to perform services for the profit or advantage of another. Vulnerable Adult interviewed: Yes. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Yes. the Action taken by facility: The facility completed an internal investigation and retrained staff regarding resident rights and finances. The AP is no longer employed by the facility. Action taken by the Minnesota Department of Health: 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 Maplewood Police Department PRINTED: 10/15/2024 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.
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