Staff at a Holdingford assisted living facility gave a resident at least 16 shots of liquor and a beer before a scheduled doctor’s appointment, leaving the man too intoxicated to participate and sending them to the emergency room, according to a Minnesota Department of Health investigation.

Hospital testing found the resident had a blood alcohol concentration of 0.23 — nearly three times Minnesota’s legal driving limit.

State investigators concluded Covered Bridge Assisted Living neglected the resident by purchasing, storing and administering alcohol without a physician’s order or medical oversight. The July investigation is the latest in a series of state actions involving the Holdingford facility, which has faced multiple licensing investigations over the past two years.

Covered Bridge disputes the findings and said it is appealing the maltreatment determination.

In a Tuesday email to St. Cloud LIVE, the Stearns County facility said it serves residents with complex medical, behavioral and substance use histories who often cannot find placement elsewhere. It said its mission is to provide “a safe, supportive environment while respecting each resident’s legal rights and individual choices.”

Alcohol before appointment

According to the investigation, the resident had substance-use disorder, anxiety and a history of daily alcohol use. While the resident’s care plan authorized medication administration and behavioral management services, investigators found no physician’s order allowing staff to purchase, store or administer alcohol.

Records showed staff gave the resident six shots of liquor the evening before a scheduled telehealth appointment. The following morning, staff documented giving him one beer and 10 more shots. By the time the appointment began, staff told investigators he was “dead to the world.”

The resident’s primary care provider, who knew the man consumed alcohol but did not know the facility was purchasing or administering it — and never authorized its use, instructed staff to send him to the emergency room. The resident declined admission for alcohol withdrawal treatment, telling providers they preferred to return home and continue drinking.

Facility created its own plan

Investigators found the facility developed its own “Alcohol Plan” documents despite the absence of a physician’s order.

One version directed staff to provide two shots of liquor every hour upon request. A later version increased that amount to two to three shots an hour because medications were providing little relief from auditory hallucinations.

The facility’s registered nurse told investigators she routinely collected residents’ money and purchased alcohol. Although she acknowledged Covered Bridge was not licensed to provide harm-reduction services, she said alcohol was kept locked and dispensed according to agreements with residents.

According to Covered Bridge, competent adults have the legal right to consume alcohol and staff may purchase personal items, including alcohol, through a shopping assistance program. The facility said it assesses risks, educates residents, develops individualized care plans and documents purchases in accordance with state regulations. It said its care planning and documentation demonstrate compliance with Minnesota assisted living requirements.

Broader concerns

Investigators determined the alcohol practices extended beyond a single resident. Records showed six others were tracked on alcohol logs, including one who requested alcohol 14 times in a single day.

MDH also found Covered Bridge improperly delegated alcohol administration and monitoring to unlicensed staff. During the inspection, investigators found the facility housed 18 residents despite being licensed for 15.

Covered Bridge said “one isolated incident should not define the quality of care or the mission of our organization.” The facility said many residents had previously been turned away by other assisted living providers because of their complex medical, behavioral and social needs. It also said it supports residents who choose to reduce or stop drinking and has helped some achieve sobriety.

Earlier this year, owner and former director Trista Barstow voluntarily and permanently surrendered her permit under a consent order with the Minnesota Board of Executives for Long-Term Services and Supports. The agreement followed multiple MDH investigations that documented failures to respond to correction orders, obtain required physician documentation, properly train staff and promptly report suspected maltreatment.

In March, investigators issued multiple correction orders involving licensing requirements, fire safety and the separation between licensed and unlicensed portions of the building.

A follow-up inspection in July found the facility had operated for months without a licensed assisted living director after Barstow’s departure, a violation investigators said had the potential to affect all residents.

Covered Bridge said it respectfully disagrees with the state’s findings and is exercising its right to appeal. The facility said it remains committed to improving the quality of care it provides while serving residents “with dignity, respect and compassion.”