Carefree Cottages of Maplewood

Survey completed February 14, 2023: 6 correction orders

• Tag 480: 144G.41 Subd 1 (13) (i) (B) Minimum (re-issued)
  Details

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

  Rule cited: “requirements (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”

• Tag 510: 144G.41 Subd. 3 Infection control program (re-issued) scope/level letter D
  Details

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

  Rule cited: “(a) All assisted living facilities must establish and maintain an infection control program that complies with accepted health care, medical, and nursing standards for infection control. [...]”

• Tag 580: 144G.42 Subd. 2 Quality management (re-issued) scope/level letter F
  Details

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

  Rule cited: “The facility shall engage in quality management appropriate to the size of the facility and relevant to the type of services provided. [...]”

• Tag 770: 144G.45 Subdivision 1 Minimum site Requirements (re-issued) Level 2, widespread scope, scope/level letter F
  Details

  Summary: MDH found the licensee failed to provide all-weather walks.

  MDH’s finding, as written: “Based on observation and interview, the licensee failed to provide all-weather walks. This deficient condition had the potential to affect all staff, residents, and visitors. [...]”

  Rule cited: “The following are required for all assisted living facilities: (1) public utilities must be available, and working or inspected and approved water and septic systems must be in place; (2) the location must be publicly accessible to fire department services [...]”

• Tag 950: 144G.50 Subd. 3 Designation of representative (re-issued) scope/level letter D
  Details

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

  Rule cited: “(a) Before or at the time of execution of an assisted living contract, an assisted living facility must offer the resident the opportunity to identify a designated representative in writing in the contract and must provide the following verbatim notice on a [...]”

• Tag 1760: 144G.71 Subd. 8 Documentation of administration of medication (re-issued) scope/level letter D
  Details

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

  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. [...]”

Survey completed December 8, 2022: 10 correction orders

• Tag 480: 144G.41 Subd 1 (13) (i) (B) Minimum Level 2, widespread scope · correction period: Twenty-one
  Details

  Summary: MDH found the licensee failed to ensure food was prepared and served according to the Minnesota Food Code.

  MDH’s finding, as written: “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 [...]”

  Rule cited: “requirements (13) offer to provide or make available at least the following services to residents: (i) at least three nutritious meals daily with snacks available seven days per week, according to the recommended dietary allowances in the United States [...]”

• Tag 510: 144G.41 Subd. 3 Infection control program Level 2, isolated scope, scope/level letter D · correction period: Twenty-one (21) days
  Details

  Summary: MDH found the licensee failed to establish and maintain an infection control program that complies with accepted health care, medical and nursing standards for infection control for one of four residents (R4).

  MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to establish and maintain an infection control program that complies with accepted health care, medical and nursing standards for infection control for one of four residents (R4). [...]”

  Rule cited: “(a) All assisted living facilities must establish and maintain an infection control program that complies with accepted health care, medical, and nursing standards for infection control. [...]”

• Tag 580: 144G.42 Subd. 2 Quality management Level 2, widespread scope, scope/level letter F · correction period: Twenty-One (21) days
  Details

  Summary: MDH found the licensee failed to implement and maintain a quality management program appropriate to the size of the facility and relevant to the type of services provided.

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to implement and maintain a quality management program appropriate to the size of the facility and relevant to the type of services provided. This had the potential to affect all current residents, staff and visitors. [...]”

  Rule cited: “The facility shall engage in quality management appropriate to the size of the facility and relevant to the type of services provided. [...]”

• Tag 770: 144G.45 Subdivision 1 Minimum site Requirements Level 2, widespread scope, scope/level letter F · correction period: Two (2) days
  Details

  Summary: MDH found the licensee failed to provide all-weather walks within the lot lines to the primary entrance.

  MDH’s finding, as written: “Based on observation and interview, the licensee failed to provide all-weather walks within the lot lines to the primary entrance. This deficient condition had the potential to affect all staff, residents, and visitors. [...]”

  Rule cited: “The following are required for all assisted living facilities: (1) public utilities must be available, and working or inspected and approved water and septic systems must be in place; (2) the location must be publicly accessible to fire department services [...]”

• Tag 780: 144G.45 Subd. 2 (a) (1) 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 provide smoke alarms in all sleeping

  MDH’s finding, as written: “Based on observation and interview, the licensee failed to provide smoke alarms in all sleeping rooms and failed to provide smoke alarms that were interconnected so that actuation of one alarm caused all alarms in the dwelling unit to actuate. This deficient condition had the potential to affect all staff, residents, and visitors. [...]”

  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) [...]”

Total fines assessed, as printed in the letter: $500.00.

Allegation, as written: “The alleged perpetrator (AP) neglected a resident when the AP was pushing the resident back to her room with the resident seated on her four wheeled walker. While seated on the walker, the resident fell off the walker backwards.”

“The Minnesota Department of Health determined neglect was inconclusive.”

Summary: MDH looked into an allegation and found: neglect inconclusive.

MDH’s conclusion, as written: “The Minnesota Department of Health determined neglect was inconclusive. Conflicting information was provided by the AP and the facility. Facility staff were aware the resident had a history of using the walker inappropriately by self-propelling seated on the walker. The AP denied pushing the resident when the resident was seated on the four wheeled walker.”

Action taken by facility: “The facility completed vital signs, called 911 and had the resident sent to the hospital. The AP was no longer employed at the facility.”

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

Survey completed November 9, 2023: no correction orders issued.

Allegation, as written: “A facility staff member/alleged perpetrator (AP) neglected the resident when the AP failed to administer the correct dose of insulin causing the resident to have an increase in blood sugar levels, pneumonia, and cellulitis.”

“The Minnesota Department of Health determined neglect was inconclusive.”

Summary: MDH looked into an allegation and found: neglect inconclusive.

MDH’s conclusion, as written: “The Minnesota Department of Health determined neglect was inconclusive. Although a transcription error and medication error occurred, it was unable to be determined if the resident's high blood glucose levels and diagnoses of pneumonia and cellulitis were a direct result of the errors.”

Action taken by facility: “The facility initiated an internal investigation into the incident.”

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

Survey completed June 27, 2023: 1 correction order

• Tag 730: 144G.43 Subd. 3 Contents of resident record Level 2, pattern scope, scope/level letter E · correction period: Twenty-one (21) days
  Details

  MDH’s finding, as written: “Based on interview and record review, the license failed to ensure documentation of an incident and actions taken to follow-up in response to an incident for one of one resident (R1) and failed to ensure R1's record contained all required content for one of six residents (R1) when there was a resident fall, report of a suspected medication error, and a discovered medication error. [...]”

  Rule cited: “Contents of a resident record include the following for each resident: (1) identifying information, including the resident's name, date of birth, address, and telephone number; (2) the name, address, and telephone number of the resident's emergency contact, [...]”

Allegation, as written: “A facility staff member/alleged perpetrator (AP) abused a resident when the AP told the resident to stop pressing the call pendant, then raised her hand as if to strike the resident and told the resident: "I ought to smack you."”

“The Minnesota Department of Health determined abuse was inconclusive.”

Summary: MDH looked into an allegation and found: abuse inconclusive.

MDH’s conclusion, as written: “The Minnesota Department of Health determined abuse was inconclusive. It is unable to be determined if abuse occurred as there was no direct witness to the incident and conflicting accounts of the incident were provided by the resident, the witness, and the AP.”

Action taken by facility: “An incident report and facility investigation were completed. The AP was removed from the schedule pending a facility investigation.”

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

Survey completed June 27, 2023: 1 correction order

• Tag 730: 144G.43 Subd. 3 Contents of resident record Level 2, pattern scope, scope/level letter E · correction period: Twenty-one (21) days
  Details

  MDH’s finding, as written: “Based on interview and record review, the license failed to ensure documentation of an incident and actions taken to follow-up in response to an incident for one of one resident (R1) and failed to ensure R1's record contained all required content for one of six residents (R1) when there was a resident fall, report of a suspected medication error, and a discovered medication error. [...]”

  Rule cited: “Contents of a resident record include the following for each resident: (1) identifying information, including the resident's name, date of birth, address, and telephone number; (2) the name, address, and telephone number of the resident's emergency contact, [...]”

Allegation, as written: “The facility neglected a resident when they failed to provide supervision. The resident eloped and law enforcement found him in the community approximately six hours later.”

“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 received minimal services and required no mobility restrictions. The resident left the facility on his own, which was not unusual for him. Hospital records indicated acute (sudden) illness caused the resident to become confused.”

Action taken by facility: “The facility implemented safety checks and re-educated staff members about policies and procedures.”

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

Survey completed February 17, 2026: no correction orders issued.