Brainerd Carefree Living

Summary: MDH found the licensee failed to support protection and safety by not posting the 911 emergency number in common areas and near telephones provided by the facility as required.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to support protection and safety by not posting the 911 emergency number in common areas and near telephones provided by the facility as required. This had the potential to affect all residents, staff, and visitors. [...]”

Rule cited: “The facility shall support protection and safety through access to the state's systems for reporting suspected criminal activity and suspected vulnerable adult maltreatment by: (1) posting the 911 emergency number in common areas and near telephones provided [...]”

Summary: MDH found the licensee failed to ensure the employee record contained the required content for three of four employees (clinical nurse supervisor/CNS-A, unlicensed personnel/ULP-C, ULP-O).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the employee record contained the required content for three of four employees (clinical nurse supervisor/CNS-A, unlicensed personnel/ULP-C, ULP-O). [...]”

Rule cited: “(a) The facility must maintain current records of each paid staff member, each regularly scheduled volunteer providing services, and each individual contractor providing services. [...]”

Summary: MDH found the licensee failed to establish and maintain a tuberculosis (TB) prevention program, based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC), which included completion of a two-step TST (tuberculin skin test) or other evidence of TB screening such as a blood test for one of four employees (unlicensed personnel/ULP-C), and TB screening for two of four employees (ULP-C, registered nurse/RN-I).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to establish and maintain a tuberculosis (TB) prevention program, based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC), which included completion of a two-step TST (tuberculin skin test) or other evidence of TB screening such as a blood test for one of four employees (unlicensed personnel/ULP-C), and TB screening for two of four employees (ULP-C, registered nurse/RN-I). [...]”

Rule cited: “(a) The facility must establish and maintain a comprehensive tuberculosis infection control program according to the most current tuberculosis infection control guidelines issued by the United States Centers for Disease Control and Prevention (CDC), Division [...]”

Summary: MDH found the licensee failed to develop a written

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to develop a written emergency preparedness plan (EPP) with all the required content defined in Appendix Z. This had the potential to affect residents receiving services under the assisted living license, staff, and visitors. [...]”

Rule cited: “(a) The facility must meet the following requirements: (1) have a written emergency disaster plan that contains a plan for evacuation, addresses elements of sheltering in place, identifies temporary relocation sites, and details staff assignments in the event [...]”

Summary: MDH found the licensee failed to ensure the physical environment of the facility was maintained in compliance with the requirements of Minnesota Statute 144G.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the physical environment of the facility was maintained in compliance with the requirements of Minnesota Statute 144G. [...]”

Rule cited: “Each assisted living facility must comply with the State Fire Code in Minnesota Rules, chapter 7511, and:”

Summary: MDH found the licensee failed to ensure the physical environment of the facility was maintained in compliance with the requirements of Minnesota Statute 144G.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the physical environment of the facility was maintained in compliance with the requirements of Minnesota Statute 144G. [...]”

Rule cited: “(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 [...]”

Summary: MDH found the licensee failed to ensure the physical environment of the facility was maintained in compliance with the requirements of Minnesota Statute 144G.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the physical environment of the facility was maintained in compliance with the requirements of Minnesota Statute 144G. [...]”

Rule cited: “(b) Each assisted living facility shall develop and maintain fire safety and evacuation plans. [...]”

Summary: MDH found the licensee failed to execute a written contract prior to providing assisted living services for 24 of 42 residents (R1, R2, R7, R9, R11, R12, R14, R15, R16, R17, R18, R19, R24, R25, R26, R27, R28, R29, R30, R31, R33, R34, R35, R36).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to execute a written contract prior to providing assisted living services for 24 of 42 residents (R1, R2, R7, R9, R11, R12, R14, R15, R16, R17, R18, R19, R24, R25, R26, R27, R28, R29, R30, R31, R33, R34, R35, R36). In addition, the licensee failed to provide a copy of the revised complaint procedure to all residents. This had the potential to effect all residents. [...]”

Rule cited: “(a) An assisted living facility may not offer or provide housing or assisted living services to any individual unless it has executed a written contract with the resident. [...]”

Summary: MDH found the licensee failed to provide a written notice with the required content for an emergency relocation to the resident, legal representative, and designated representative for one of one resident (R3) who was hospitalized.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide a written notice with the required content for an emergency relocation to the resident, legal representative, and designated representative for one of one resident (R3) who was hospitalized. [...]”

Rule cited: “(a) A facility may remove a resident from the facility in an emergency if necessary due to a resident's urgent medical needs or an imminent risk the resident poses to the health or safety of another facility resident or facility staff member. [...]”

Summary: MDH found the licensee failed to ensure current employee records contained all the required content to include a current background study (BGS) clearance letter for six of seven employees (unlicensed personnel (ULP)-F, ULP-G, ULP-H, ULP-I, ULP-J, cook (C)-K).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure current employee records contained all the required content to include a current background study (BGS) clearance letter for six of seven employees (unlicensed personnel (ULP)-F, ULP-G, ULP-H, ULP-I, ULP-J, cook (C)-K). [...]”

Rule cited: “(a) Employees, contractors, and regularly scheduled volunteers of the facility are subject to the background study required by section 144.057 and may be disqualified under chapter 245C. [...]”

Summary: MDH found the licensee failed to ensure training and competency evaluations were completed as required prior to providing direct care services for one of one unlicensed personnel (ULP-C).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure training and competency evaluations were completed as required prior to providing direct care services for one of one unlicensed personnel (ULP-C). [...]”

Rule cited: “(a) Training and competency evaluations for all unlicensed personnel must include the following: (1) documentation requirements for all services provided; (2) reports of changes in the resident's condition to the supervisor designated by the facility; (3) [...]”

Summary: MDH found the licensee failed to ensure training and competency evaluations were completed as required prior to providing direct care services for one of one unlicensed personnel (ULP-C).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure training and competency evaluations were completed as required prior to providing direct care services for one of one unlicensed personnel (ULP-C). [...]”

Rule cited: “(b) In addition to paragraph (a), training and competency evaluation for unlicensed personnel providing assisted living services must include: (1) observing, reporting, and documenting resident status; (2) basic knowledge of body functioning and changes in [...]”

Summary: MDH found the licensee failed to ensure employees received orientation to assisted living requirements and regulations prior to providing services for three of three employees (clinical nurse supervisor/CNS-A, unlicensed personnel/ULP-C, registered nurse/RN-N).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure employees received orientation to assisted living requirements and regulations prior to providing services for three of three employees (clinical nurse supervisor/CNS-A, unlicensed personnel/ULP-C, registered nurse/RN-N). [...]”

Rule cited: “(a) The orientation must contain the following topics: (1) an overview of this chapter; (2) an introduction and review of the facility's policies and procedures related to the provision of assisted living services by the individual staff person; (3) handling [...]”

Summary: MDH found the licensee failed to ensure annual training included all required topics for each 12 months of employment for one of one employee (unlicensed personnel/ULP-O).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure annual training included all required topics for each 12 months of employment for one of one employee (unlicensed personnel/ULP-O). [...]”

Rule cited: “(a) All staff that perform direct services must complete at least eight hours of annual training for each 12 months of employment. [...]”

Summary: MDH found the licensee failed to ensure two of three employees (clinical nurse supervisor/CNS-A, registered nurse/RN-N) received the required amount of mental illness and de-escalation training within the required time frame.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure two of three employees (clinical nurse supervisor/CNS-A, registered nurse/RN-N) received the required amount of mental illness and de-escalation training within the required time frame. In addition, the licensee failed to ensure two of four employees (CNS-A, RN-N) received the required amount of dementia care training in the required time frame. [...]”

Rule cited: “(a) All assisted living facilities must meet the following dementia care, mental illness, and de-escalation training requirements: (1) supervisors of direct-care staff must have at least eight hours of initial training on dementia topics specified under [...]”

Summary: MDH found the licensee failed to ensure the service plan included the required content for one of three residents (R2).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the service plan included the required content for one of three residents (R2). 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 [...]”

Rule cited: “(f) The service plan must include: (1) a description of the services to be provided, the fees for services, and the frequency of each service, according to the resident's current assessment and resident preferences; (2) the identification of staff or [...]”

Summary: MDH found the licensee failed to develop and maintain current written medication management policies and procedures under the supervision and direction of a registered nurse (RN).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop and maintain current written medication management policies and procedures under the supervision and direction of a registered nurse (RN). [...]”

Rule cited: “(a) This section applies only to assisted living facilities that provide medication management services. [...]”

Summary: MDH found the licensee failed to ensure the registered nurse (RN) conducted an individualized medication assessment to determine what medication management services would be provided and how the services would be provided, for one of three residents (R2).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure the registered nurse (RN) conducted an individualized medication assessment to determine what medication management services would be provided and how the services would be provided, for one of three residents (R2). [...]”

Rule cited: “(a) For each resident who requests medication management services, the facility shall, prior to providing medication management services, have a registered nurse, licensed health professional, or authorized prescriber under section 151.37 conduct an [...]”

Summary: MDH found the licensee failed to ensure insulin was administered per manufacturer instructions for one of one resident (R26), and failed to administer medications as ordered for one of one resident (R1).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure insulin was administered per manufacturer instructions for one of one resident (R26), and failed to administer medications as ordered for one of one resident (R1). [...]”

Rule cited: “Each medication administered by the assisted living facility staff must be documented in the resident's record. The documentation must include the signature and title of the person who administered the medication. [...]”

Summary: MDH found the licensee failed to implement policies and procedures for giving accurate and current medications for those residents who received medication management services during planned times away from home.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to implement policies and procedures for giving accurate and current medications for those residents who received medication management services during planned times away from home. This has the potential to affect all forty-two (42) residents. [...]”

Rule cited: “(a) An assisted living facility that is providing medication management services to the resident must develop and implement policies and procedures for giving accurate and current medications to residents for planned or unplanned times away from home [...]”

Summary: MDH found the licensee failed to ensure the registered nurse (RN) developed written procedures for the unlicensed personnel (ULP) providing medications for residents having unplanned time away when the licensed nurse was not available; and failed to provide complete documentation of medications sent with one of one resident (R32) who had an unplanned time away.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the registered nurse (RN) developed written procedures for the unlicensed personnel (ULP) providing medications for residents having unplanned time away when the licensed nurse was not available; and failed to provide complete documentation of medications sent with one of one resident (R32) who had an unplanned time away. [...]”

Rule cited: “(2) for unplanned time away, when the pharmacy is not able to provide the medications, a licensed nurse or unlicensed personnel shall provide medications in amounts and dosages needed for the length of the anticipated absence, not to exceed seven calendar [...]”

Summary: MDH found the licensee failed to ensure one of two medication refrigerators (south) maintained an acceptable temperature to ensure medications were stored according to manufacturer's recommendations.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure one of two medication refrigerators (south) maintained an acceptable temperature to ensure medications were stored according to manufacturer's recommendations. [...]”

Rule cited: “An assisted living facility must store all prescription medications in securely locked and substantially constructed compartments according to the manufacturer's directions and permit only authorized personnel to have access.”

Summary: MDH found the licensee failed to document in the resident's record the disposition of the medications as required for one of one resident (R4) upon discharge.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to document in the resident's record the disposition of the medications as required for one of one resident (R4) upon discharge. [...]”

Rule cited: “(a) Any current medications being managed by the assisted living facility must be provided to the resident when the resident's service plan ends or medication management services are no longer part of the service plan. [...]”

Summary: MDH found the licensee failed to develop and

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to develop and implement procedures for loss and spillage of all controlled substances defined in Minnesota Rules part 6800.4220. [...]”

Rule cited: “(a) Assisted living facilities providing medication management must develop and implement procedures for loss or spillage of all controlled substances defined in Minnesota Rules, part 6800.4220. [...]”

Summary: MDH found the licensee failed to develop and maintain current written treatment management policies and procedures under the supervision and direction of a registered nurse (RN).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop and maintain current written treatment management policies and procedures under the supervision and direction of a registered nurse (RN). [...]”

Rule cited: “(a) An assisted living facility that provides treatment and therapy management services must develop, implement, and maintain up-to-date written treatment or therapy management policies and procedures. [...]”

Summary: MDH found the licensee failed to provide written notice to the residents, legal representative, or designated representative of a change of ownership within seven calendar days.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide written notice to the residents, legal representative, or designated representative of a change of ownership within seven calendar days. [...]”

Rule cited: “(a) A facility must provide written notice to the resident, legal representative, or designated representative of a change of ownership within seven calendar days after the facility receives a new license. [...]”

MDH’s finding, as written: “This immediate correction order was amended to include information for R1 and R2 on December 9, 2025. Based on observation, interview, and record review, the licensee failed to ensure the care and services were provided according to acceptable health care and medical, or nursing standards for four of four (R6, R7, R8, R9) with urinary tract infection symptoms, and for one of one resident (R1) with a consumer bed rail and one of one resident (R2) with hospital-style bed rails. [...]”

Rule cited: “(a) Residents have the right to care and assisted living services that are appropriate based on the resident's needs and according to an up-to-date service plan subject to accepted health care standards.”

Summary: MDH found the licensee failed to allow the resident to actively participate in the planning, modification, and evaluation of their care and denied the resident the right to be told in advance of, and take part in decisions regarding recommended changes for eight of forty-two resident (R3, R37, R17, R9, R38, R31, R15, R39).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to allow the resident to actively participate in the planning, modification, and evaluation of their care and denied the resident the right to be told in advance of, and take part in decisions regarding recommended changes for eight of forty-two resident (R3, R37, R17, R9, R38, R31, R15, R39). This had the potential to affect all residents. [...]”

Rule cited: “Residents have the right to actively participate in the planning, modification, and evaluation of their care and services. [...]”

Summary: MDH found the licensee failed to protect resident's rights to have access to a telephone to make and receive calls.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to protect resident's rights to have access to a telephone to make and receive calls. This practice resulted in a level three violation (a violation that harmed a resident's health or safety, or a violation that had the potential to cause more than minimal harm to the resident), and was issued at a widespread scope (when problems are pervasive or represent a systemic failure that has affected or has potential to affect a [...]”

Rule cited: “(a) Residents have the right to communicate privately with persons of their choice. (b) If an assisted living facility is sending or receiving mail on behalf of residents, the assisted living facility must do so without interference. [...]”