Burnsville Carefree Living by

Survey completed November 14, 2023: 6 correction orders

• Tag 1500: 144G.63 Subd. 5 Required annual training (re-issued) scope/level letter F
  Details

  MDH’s finding, as written: “No further action needed.”

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

• Tag 1550: 144G.64 (a) TRAINING IN DEMENTIA CARE REQUIRED (re-issued) scope/level letter F
  Details

  MDH’s finding, as written: “No further action needed.”

  Rule cited: “(4) staff who do not provide direct care, including maintenance, housekeeping, and food service staff, must have at least four hours of initial training on topics specified under paragraph (b) within 160 working hours of the employment start date, and must [...]”

• Tag 1750: 144G.71 Subd. 7 Delegation of medication administration (re-issued) scope/level letter D
  Details

  MDH’s finding, as written: “No further action needed.”

  Rule cited: “When administration of medications is delegated to unlicensed personnel, the assisted living facility must ensure that the registered nurse has: (1) instructed the unlicensed personnel in the proper methods to administer the medications, and the unlicensed [...]”

• Tag 1880: 144G.71 Subd. 19 Storage of medications (re-issued) scope/level letter E
  Details

  MDH’s finding, as written: “No further action needed.”

  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.”

• Tag 1890: 144G.71 Subd. 20 Prescription drugs (re-issued) scope/level letter D
  Details

  MDH’s finding, as written: “No further action needed.”

  Rule cited: “A prescription drug, prior to being set up for immediate or later administration, must be kept in the original container in which it was dispensed by the pharmacy bearing the original prescription label with legible information including the expiration or [...]”

• Tag 1950: 144G.72 Subd. 4 Administration of treatments (re-issued) scope/level letter F
  Details

  MDH’s finding, as written: “No further action needed.”

  Rule cited: “and therapy Ordered or prescribed treatments or therapies must be administered by a nurse, physician, or other licensed health professional authorized to perform the treatment or therapy, or may be delegated or assigned to unlicensed personnel by the licensed [...]”

Survey completed September 7, 2023: 7 correction orders

• Tag 800: 144G.45 Subd. 2 (a) (4) Fire protection and physical environment (re-issued) Level 1, widespread scope, scope/level letter C
  Details

  Summary: MDH found the licensee failed to maintain the facility's physical environment in a continuous state of good repair and operation regarding the health, safety, and well-being of the residents.

  MDH’s finding, as written: “Based on observation and interview, the licensee failed to maintain the facility's physical environment in a continuous state of good repair and operation regarding the health, safety, and well-being of the residents. This had the potential to directly affect all residents, staff, and visitors. [...]”

  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 [...]”

• Tag 1500: 144G.63 Subd. 5 Required annual training (re-issued) scope/level letter F
  Details

  MDH’s finding, as written: “No further action needed.”

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

• Tag 1550: 144G.64 (a) TRAINING IN DEMENTIA CARE REQUIRED (re-issued) scope/level letter F
  Details

  MDH’s finding, as written: “No further action needed.”

  Rule cited: “(4) staff who do not provide direct care, including maintenance, housekeeping, and food service staff, must have at least four hours of initial training on topics specified under paragraph (b) within 160 working hours of the employment start date, and must [...]”

• Tag 1750: 144G.71 Subd. 7 Delegation of medication administration (re-issued) scope/level letter D
  Details

  MDH’s finding, as written: “No further action needed.”

  Rule cited: “When administration of medications is delegated to unlicensed personnel, the assisted living facility must ensure that the registered nurse has: (1) instructed the unlicensed personnel in the proper methods to administer the medications, and the unlicensed [...]”

• Tag 1880: 144G.71 Subd. 19 Storage of medications (re-issued) scope/level letter E
  Details

  MDH’s finding, as written: “No further action needed.”

  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.”

• Tag 1890: 144G.71 Subd. 20 Prescription drugs (re-issued) scope/level letter D
  Details

  MDH’s finding, as written: “No further action needed.”

  Rule cited: “A prescription drug, prior to being set up for immediate or later administration, must be kept in the original container in which it was dispensed by the pharmacy bearing the original prescription label with legible information including the expiration or [...]”

• Tag 1950: 144G.72 Subd. 4 Administration of treatments and therapy (re-issued) scope/level letter F
  Details

  MDH’s finding, as written: “No further action needed.”

  Rule cited: “Ordered or prescribed treatments or therapies must be administered by a nurse, physician, or other licensed health professional authorized to perform the treatment or therapy, or may be delegated or assigned to unlicensed personnel by the licensed health [...]”

Survey completed June 22, 2023: 11 correction orders

• Tag 780: 144G.45 Subd. 2 (a) (1) Fire protection and physical environment Level 2, isolated scope, scope/level letter D · correction period: Seven (7) days
  Details

  Summary: MDH found the licensee failed to provide smoke alarms outside and in the immediate vicinity of sleeping rooms.

  MDH’s finding, as written: “Based on observation and interview, the licensee failed to provide smoke alarms outside and in the immediate vicinity of sleeping rooms. This deficient condition had the ability to affect a limited number of staff and residents. [...]”

  Rule cited: “(a) Each assisted living facility must comply with the State Fire Code in Minnesota Rules, chapter 7511, and: (1) for dwellings or sleeping units, as defined in the State Fire Code: (i) provide smoke alarms in each room used for sleeping purposes; (ii) [...]”

• Tag 800: 144G.45 Subd. 2 (a) (4) Fire protection and physical environment Level 2, widespread scope, scope/level letter F · correction period: Seven (7) days
  Details

  Summary: MDH found the licensee failed to maintain the facility's physical environment in a continuous state of good repair and operation regarding the health, safety, and

  MDH’s finding, as written: “Based on observation and interview, the licensee failed to maintain the facility's physical environment in a continuous state of good repair and operation regarding the health, safety, and well-being of the residents. This had the potential to directly affect all residents, staff, and visitors. [...]”

  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 [...]”

• Tag 810: 144G.45 Subd. 2 (b)-(f) Fire protection and physical environment Level 2, widespread scope, scope/level letter F · correction period: Twenty-one (21) days
  Details

  Summary: MDH found the licensee failed to maintain the facility's fire safety and evacuation plan with required elements.

  MDH’s finding, as written: “Based on record review and interview, the licensee failed to maintain the facility's fire safety and evacuation plan with required elements. This had the potential to directly affect all residents, staff, and visitors. [...]”

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

• Tag 820: 144G.45 Subd. 2 (g) Fire protection and physical environment Level 2, isolated scope, scope/level letter D · correction period: Two (2) days
  Details

  Summary: MDH found the licensee failed to provide facilities that were not a distinct hazard to life.

  MDH’s finding, as written: “Based on observation and interview, the licensee failed to provide facilities that were not a distinct hazard to life. This had the potential to affect a limited number of residents and staff. [...]”

  Rule cited: “(g) Existing construction or elements, including assisted living facilities that were registered as housing with services establishments under chapter 144D prior to August 1, 2021, shall be permitted to continue in use provided such use does not constitute a [...]”

• Tag 1500: 144G.63 Subd. 5 Required annual training Level 2, widespread scope, scope/level letter F · correction period: Twenty-One (21) days
  Details

  Summary: MDH found the licensee failed to ensure an employee received all of the required annual training content for each 12 months of employment for two of two employees (unlicensed personnel (ULP)-D, ULP-J).

  MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure an employee received all of the required annual training content for each 12 months of employment for two of two employees (unlicensed personnel (ULP)-D, ULP-J). [...]”

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

From MDH’s letter: the letter says the facility is in substantial compliance; no immediate fines.

“The Minnesota Department of Health determined abuse inconclusive.”

MDH’s conclusion, as written: “The Minnesota Department of Health determined abuse inconclusive. The AP stated he provided routine shower assistance for the resident which included cleansing around the resident's anal area to remove dried stool. However, the AP denied placing his finger in the resident's anus or yelling at the resident.”

Action taken by facility: “The facility suspended the AP during their internal investigation of the allegations and followed up with the resident and the AP. The facility provided the AP with education regarding therapeutic communication.”

Action taken by MDH: “No action taken at this time.”

Survey completed October 22, 2024: no correction orders issued.

Allegation, as written: “The facility neglected the resident when the overall poor condition of the facility resulted in the resident's fall.”

“The Minnesota Department of Health determined neglect was not substantiated.”

Summary: MDH looked into an allegation and found: neglect not substantiated.

MDH’s conclusion, as written: “The Minnesota Department of Health determined neglect was not substantiated. The resident was independent with transfers and walking and had an unwitnessed fall outside of the facility on a sidewalk. The resident was able to get himself off the ground independently. The resident did not report the fall immediately and did not seek medical attention until days later. Although the concrete sidewalk had deteriorated, there was not a preponderance of evidence that the fall occurred because of the sidewalk condition.”

Action taken by facility: “Once the facility nurse learned of the resident's fall, the nurse assessed the resident and advised him to seek evaluation at a hospital. The resident's primary care provider was updated.”

Action taken by MDH: “No further action taken at this time.”

Survey completed August 11, 2026: no correction orders issued.

Survey completed October 15, 2025: no correction orders issued.

Allegation, as written: “The facility neglected the resident when the resident missed five days of her scheduled narcotic pain medication (hydrocodone) because the facility ran out of the resident's scheduled narcotic pain medication. In addition, the facility neglected the resident when they failed to supervise and monitor the resident. The resident was found with lit candles in her room, violating the building fire code.”

“The Minnesota Department of Health determined neglect was not substantiated.”

“The Minnesota Department of Health determined neglect of supervision was not substantiated.”

Summary: MDH looked into 2 allegations and found: neglect not substantiated; neglect of supervision not substantiated.

MDH’s conclusion, as written: “The Minnesota Department of Health determined neglect was not substantiated. The resident missed days of hydrocodone due to changing providers and health insurance not due to facility neglect. The resident changed health insurance companies twice within one month and waited to establish care with a new medical provider which delayed the start of the resident's hydrocodone being refilled by her new provider. The resident's new medical provider prescribed a weeks' worth of the resident's hydrocodone until she scheduled an in-person visit. The Minnesota Department of Health determined neglect of supervision was not substantiated. The facility monitored the resident's apartment, but the resident ordered candles and lighters from an on-line shopping site without the facility's knowledge. [...]”

Action taken by facility: “Facility nursing staff tried to reorder the resident's pain medication before she ran out.”

Action taken by MDH: “No further action taken at this time.”

Survey completed May 13, 2025: 2 correction orders

• Tag 2310: 144G.91 Subd. 4 (a) Appropriate care and services Level 3, isolated scope, scope/level letter G · correction period: Seven (7) days
  Details

  Summary: MDH found the licensee failed to provide care and services according to acceptable health care, medical or nursing standards for one of one resident (R1) with record reviewed for falls.

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide care and services according to acceptable health care, medical or nursing standards for one of one resident (R1) with record reviewed for falls. R1 fell and fractured her left forearm and left lower leg bone (fibula) while attempting to toilet herself. The facility failed to provide R1 with a means to contact staff for assistance when she fell. R1 was transported to the hospital to receive treatment for her fractured arm. [...]”

  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.”

• Tag 2360: 144G.91 Subd. 8 Freedom from maltreatment
  Details

  Summary: MDH found the facility failed to ensure one of one resident(s) reviewed (R1) was free from maltreatment.

  MDH’s finding, as written: “The facility failed to ensure one of one resident(s) reviewed (R1) was free from maltreatment. Findings include: The Minnesota Department of Health (MDH) issued a determination maltreatment occurred, and the facility was responsible for the maltreatment, in connection with incidents which occurred at the facility. Please refer to the public maltreatment report for details.”

  Rule cited: “Residents have the right to be free from physical, sexual, and emotional abuse; neglect; financial exploitation; and all forms of maltreatment covered under the Vulnerable Adults Act.”

Allegation, as written: “The facility neglected the resident when staff members did not administer the resident's clozapine (an antipsychotic medication used to lower the risk of suicidal behavior in individuals with schizophrenia or schizoaffective disorder) for four days. The resident was hospitalized for a suicide attempt.”

“The Minnesota Department of Health determined neglect was not substantiated.”

Summary: MDH looked into an allegation and found: neglect not substantiated.

MDH’s conclusion, as written: “The Minnesota Department of Health determined neglect was not substantiated. The resident did not receive four doses of clozapine after the resident ran out of medication and staff failed to ensure nursing was aware to order more. Although a medication error occurred, the error was an isolated incident. The resident developed suicidal ideation, was hospitalized for psychiatric stabilization, and the resident returned to her baseline mental health condition.”

Action taken by facility: “The facility provided refresher training to staff on when to contact a nurse, and the facility updated medication oversight procedures for nursing.”

Action taken by MDH: “The facility was found to be in noncompliance.”

Survey completed April 21, 2025: 1 correction order

• Tag 1760: 144G.71 Subd. 8 Documentation of administration of medication Level 2, isolated scope, scope/level letter D · correction period: Seven (7) days
  Details

  MDH’s finding, as written: “Based on interview and document review, facility staff failed to administer clozapine (an antipsychotic medication used to lower the risk of suicidal behavior in individuals with schizophrenia or schizoaffective disorder) as prescribed for one of one resident, R1, with chart reviewed. [...]”

  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. [...]”

Allegation, as written: “The facility neglected a resident when they failed to administer the resident's medications or provide meals for five days, causing the resident to miss his dialysis treatment (a process of removing waste and excess fluid from blood that kidneys would normally remove). In addition, the facility financially exploited the resident when they stole money from his bank account causing the resident to be fearful and afraid for his life.”

“The Minnesota Department of Health determined neglect was not substantiated.”

“The Minnesota Department of Health determined financial exploitation was not substantiated.”

Summary: MDH looked into 2 allegations and found: neglect not substantiated; financial exploitation not substantiated.

MDH’s conclusion, as written: “The Minnesota Department of Health determined neglect was not substantiated. Documentation in the resident's record indicated staff administered the resident's medications and provided services during the five days prior to the resident's hospitalization. The resident was responsible for scheduling his dialysis appointments and medical transportation and frequently missed his appointments telling facility staff he did not want to go. After missing three dialysis appointments in a row the resident was hospitalized with uremic toxicity (the buildup of harmful waste products in the bloodstream due to failing kidneys). The Minnesota Department of Health determined financial exploitation was not substantiated. The discrepancy in the resident's money was reconciled by facility leadership and the resident's case manager. [...]”

Action taken by facility: “The facility called 911 to transport the resident to the hospital.”

Action taken by MDH: “No further action taken at this time.”

Survey completed April 25, 2025: no correction orders issued.