The Waters of Plymouth.
The Waters of Plymouth is Grade C, ranked in the top 50% of Minnesota memory care with 1 MDH citation on record; last inspected Oct 2024.
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
The Waters of Plymouth 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 The Waters of Plymouth'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 program description on file with MDH and show us the written policies that define how staff support residents with memory loss?
Ask the operator on tour. Take notes and compare answers across facilities you visit.
MDH records show 2 complaints were filed against this facility — can you tell us whether either complaint was substantiated, and if so, provide copies of the corrective action plans or remediation documentation the facility created in response?
Ask the operator on tour. Take notes and compare answers across facilities you visit.
The most recent inspection on October 18, 2024 resulted in zero deficiencies — can you share the full inspection report and explain how the facility maintains compliance with Minnesota's dementia care staffing and program requirements under chapter 144G?
Ask the operator on tour. Take notes and compare answers across facilities you visit.
Every MDH visit, verbatim.
3 inspections in the public record, most recent first. Click any row to expand — cited rows open automatically.
2025-07-29Complaint Investigation1 · Substantiated Finding
Plain-language summary
A complaint investigation found that a housekeeper emotionally abused a resident by initiating an inappropriate conversation about her personal belongings, claiming someone had told him about a private item in her room, and later leaving a handwritten note in her nightstand drawer that suggested he could meet her sexual needs if she was lonely. The facility manager compared the note's handwriting to the housekeeper's training records and found similarities in specific letters and penmanship, and security footage did not show the woman the housekeeper claimed had told him about the resident's belongings. The Minnesota Department of Health determined the abuse was substantiated and the housekeeper was responsible.
“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 alleged perpetrator (AP) emotionally abused the resident during an interaction involving her adult massager device. Investigative Findings and Conclusion: The Minnesota Department of Health determined abuse was substantiated. The AP was responsible for the maltreatment. The AP approached the resident regarding a personal adult massager device located in a private drawer by her nightstand. The AP commented someone had said he would be willing to "help her out" because she was lonely. A handwritten note indicated the resident should use the AP for her sexual needs appeared to be similar to the AP’s handwriting compared to his training records. The investigator conducted interviews with facility staff members, including administrative staff, and unlicensed staff. The investigation included review of the resident’s records, internal investigation documentation, incident reports, personnel files, staff schedules, policies, and procedures. The resident resided in an assisted living facility. The resident’s diagnoses coronary atherosclerosis. The resident’s service plan included assist with weekly housekeeping. The resident’s individual abuse prevention plan (IAPP) indicated the resident was oriented to person, place and time and no deficits with communication. The IAPP indicated the resident was able to recognize and report abuse. A facility internal investigation indicated the AP, a housekeeper, approached the resident regarding her adult massager device located in a private drawer by her nightstand and made a comment someone was in her apartment the day prior while the resident was away. The AP said the unknown person said he would be willing to help her out because she (the resident) was lonely. The AP told the resident she was being stalked. Later that same evening at 11:30 p.m., the resident found a handwritten note inside a zippered pouch in her nightstand drawer. The note read: "Use your housekeeper instead of this tiny thing. I know your secret... He will make you feel better. He will come in every Thursday for you. I do not work here but I know you need {AP’s name]. Don't be afraid to ask him." The facility management staff changed the resident’s apartment locks for only the nurse and manager to have access. The internal investigation indicated the note compared with the AP’s handwriting on his training records appeared to match. The AP’s interview with facility management indicated he confirmed the conversation of with the resident regarding the unknown person, what was said and finding her personal adult massager device. Comparison of the handwritten note and the AP’s written training tests showed there was a unique letter “f” and “y” used in both the handwritten note and the AP’s training records. The penmanship of both appeared similar. During an interview, the resident stated the AP cleaned her apartment every Thursday. She typically remained in the room while staff cleaned but had been away at an appointment during his most recent visit. She described their interactions as generally friendly and limited to cleaning-related topics. However, during their last conversation, the AP told her he had seen a woman leaving her room who informed him the resident had an adult toy in her bedroom drawer. The resident reported feeling nervous but tried to deflect by laughing and walking away. Later that day, she recalled the conversation and checked the drawer where she kept her adult massager, stored in a zippered pouch. Upon opening it, she found the handwritten note. She reported feeling "freaked out" and stated, besides the AP, the only other person who entered her room was the nurse who administered medication at night, and she was always present during those visits. The resident said she did not know who left the note but found it alarming it referenced the AP and implied he would "take care of her" if she was lonely. During an interview, the AP said he worked as a housekeeper and cleaned the resident’s room once a week. He stated he had seen a woman with red hair, dressed in blue scrubs, sitting on a staircase. He stated he had never seen her before and did not know her name, as her name tag was covered. According to the AP, the woman told him she knew the resident and the resident possessed an item not allowed in the building. The AP stated he then approached the resident to inform her of what he had been told. He denied any knowledge of the note found in the resident’s pouch and claimed he did not write it. During an interview, the facility manager stated the resident had reported the incident to her. She placed the AP on administrative leave and initiated an internal investigation. The manager compared the handwriting on the note to the AP’s handwriting on training documents and concluded it was a match. She also confirmed no one matching the AP's description of the woman had entered the building via camera footage. During her interview with the AP, the manager reported he denied writing the note and was informed it was inappropriate to tell a resident he "knew her secret." In conclusion, the Minnesota Department of Health determined abuse 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. Abuse: Minnesota Statutes section 626.5572, subdivision 2. "Abuse" means: (a) An act against a vulnerable adult that constitutes a violation of, an attempt to violate, or aiding and abetting a violation of: (1) assault in the first through fifth degrees as defined in sections 609.221 to 609.224; (2) the use of drugs to injure or facilitate crime as defined in section 609.235; (3) the solicitation, inducement, and promotion of prostitution as defined in section 609.322; and (4) criminal sexual conduct in the first through fifth degrees as defined in sections 609.342 to 609.3451. A violation includes any action that meets the elements of the crime, regardless of whether there is a criminal proceeding or conviction. (b) Conduct which is not an accident or therapeutic conduct as defined in this section, which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to, the following: (1) hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult; (2) use of repeated or malicious oral, written, or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening; or (3) use of any aversive or deprivation procedure, unreasonable confinement, or involuntary seclusion, including the forced separation of the vulnerable adult from other persons against the will of the vulnerable adult or the legal representative of the vulnerable adult unless authorized under applicable licensing requirements or Minnesota Rules, chapter 9544. (c) Any sexual contact or penetration as defined in section 609.341, between a facility staff person or a person providing services in the facility and a resident, patient, or client of that facility. (d) The act of forcing, compelling, coercing, or enticing a vulnerable adult against the vulnerable adult's will to perform services for the advantage of another. Vulnerable Adult interviewed: Yes. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Yes. Action taken by facility: The facility did an internal investigation and the AP no longer works at the 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. 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 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. If the maltreatment is substantiated against an identified employee, this report will be submitted to the nurse aide registry for possible inclusion of the finding on the abuse registry and/or to the Minnesota Department of Human Services for possible disqualification in accordance with the provisions of the background study requirements under Minnesota 245C.
2024-10-18Annual Compliance VisitNo findings
Plain-language summary
A routine licensing survey was conducted at The Waters of Plymouth from October 14 to 18, 2024, following a change of ownership, and state correction orders were issued for violations of Minnesota statutes. No immediate fines were assessed as a result of this survey, and the facility is required to document the actions taken to correct the identified violations within specified timeframes. The facility may request reconsideration of 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 The Waters Of Plymouth 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, Casey DeVries, Supervisor State Evaluation Team Email: casey.devries@state.mn.us Telephone: 651-201-5917 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 _____________________________ 29556 10/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 11305 HIGHWAY 55 THE WATERS OF PLYMOUTH PLYMOUTH, MN 55441 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 ASSISTED LIVING PROVIDER LICENSING documenting the State Licensing CORRECTION ORDER Correction Orders using federal software. In accordance with Minnesota Statutes, section Tag numbers have been assigned to 144G.08 to 144G.95 this correction order(s) has Minnesota State Statutes for Assisted been issued pursuant to a survey. Living License Providers. The assigned Determination of whether a violation has been tag number appears in the far-left column corrected requires compliance with all entitled "ID Prefix Tag." The state Statute requirements provided at the Statute number number and the corresponding text of the indicated below. When Minnesota Statute state Statute out of compliance is listed in contains several items, failure to comply with any the "Summary Statement of Deficiencies" of the items will be considered lack of column. This column also includes the compliance. findings which are in violation of the state INITIAL COMMENTS: requirement after the statement, "This SL29556017-0 Minnesota requirement is not met as evidenced by." Following the surveyors' On October 14, 2024, through October 18, 2024, findings is the Time Period for Correction. the Minnesota Department of Health conducted a change of ownership survey at the above PLEASE DISREGARD THE HEADING OF provider. At the time of the survey, there were 91 THE FOURTH COLUMN WHICH residents; 46 receiving services under the STATES,"PROVIDER'S PLAN OF Assisted Living with Dementia Care license. As a CORRECTION." THIS APPLIES TO result of the survey, the following orders were FEDERAL DEFICIENCIES ONLY. THIS issued. 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 subd. 1, 2, and 3. 01640 144G.70 Subd. 4 (a-e) Service plan, 01640 SS=D implementation and revisions to (a) No later than 14 calendar days after the date LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 HYU611 If continuation sheet 1 of 17 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 _____________________________ 29556 10/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 11305 HIGHWAY 55 THE WATERS OF PLYMOUTH PLYMOUTH, MN 55441 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) 01640 Continued From page 1 01640 that services are first provided, an assisted living facility shall finalize a current written service plan. (b) The service plan and any revisions must include a signature or other authentication by the facility and by the resident documenting agreement on the services to be provided. The service plan must be revised, if needed, based on resident reassessment under subdivision 2. The facility must provide information to the resident about changes to the facility's fee for services and how to contact the Office of Ombudsman for Long-Term Care and the Office of Ombudsman for Mental Health and Developmental Disabilities. (c) The facility must implement and provide all services required by the current service plan. (d) The service plan and the revised service plan must be entered into the resident record, including notice of a change in a resident's fees when applicable. (e) Staff providing services must be informed of the current written service plan. This MN Requirement is not met as evidenced by: Based on observation, interview, and record review the licensee failed to implement and provide all services required by the current service plan for one of four residents (R11). 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 an isolated scope (when one or a limited number of residents are affected or one or a limited number of staff are involved or the situation has occurred only occasionally). The findings include: STATE FORM 6899 HYU611 If continuation sheet 2 of 17 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.
2024-04-24Annual Compliance VisitNo findings
Plain-language summary
A standard inspection of this facility on May 13, 2024 found a violation in the infection control program, resulting in a $500 fine assessed under Minnesota law. The facility must document the actions it took to correct this deficiency and may request reconsideration or a hearing within 15 days if it wishes to challenge the finding.
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 . . ." 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 An equal opportunity employer. Letter ID: IS7N REVISED 09/13/2021 The Waters of Plymouth May 13, 2024 Page 2 § 144G.20. In accordance with Minn. Stat. § 144G.31, Subd. 4(a)(5), MDH may impose fine amounts of either $1,000 or $5,000 to licensees who are found to be responsible for maltreatment. MDH may impose a fine of $1,000 for each substantiated maltreatment violation that consists of abuse, neglect, or financial exploitation according to Minn. Stat. § 626.5572, Subds. 2, 9, 17. MDH also may impose a fine of $5,000 for each substantiated maltreatment violation consisting of sexual assault, death, or abuse resulting in serious injury. In accordance with Minn. Stat. § 144G.31, Subd. 4(b), when a fine is assessed against a facility for substantiated maltreatment, the commissioner shall not also impose an immediate fine under this chapter for the same circumstance. Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, the following fines are assessed pursuant to this survey: St - 0 - 0510 - 144g.41 Subd. 3 - Infection Control Program - $500.00 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: The Waters of Plymouth May 13, 2024 Page 3 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. 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 ah PRINTED: 05/13/2024 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 _____________________________ 29556 04/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 11305 HIGHWAY 55 THE WATERS OF PLYMOUTH PLYMOUTH, MN 55441 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 LICENSING using federal software. Tag numbers have CORRECTION ORDER(S) 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 survey. state Statute number and the corresponding text of the state Statute out Determination of whether violations are corrected of compliance is listed in the "Summary requires compliance with all requirements Statement of Deficiencies" column. This provided at the Statute number indicated below. column also includes the findings which When Minnesota Statute contains several items, are in violation of the state requirement failure to comply with any of the items will be after the statement, "This Minnesota considered lack of compliance. requirement is not met as evidenced by." Following the evaluators ' findings is the INITIAL COMMENTS: Time Period for Correction. SL29556016 On April 22, 2024, through April 24, 2024, the PLEASE DISREGARD THE HEADING OF survey at the above provider, and the following STATES,"PROVIDER'S PLAN OF correction orders are issued. At the time of the CORRECTION." THIS APPLIES TO survey, there were 90 residents; 47 receiving FEDERAL DEFICIENCIES ONLY. THIS services under the provider's Assisted Living with WILL APPEAR ON EACH PAGE. Dementia Care license. 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 LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 9KO911 If continuation sheet 1 of 53 PRINTED: 05/13/2024 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.
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