Inspection Reports for Brookdale Eden Prairie
7513 Mitchell Road,Eden Prairie, MN, MN
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Inspection Report
Routine
Census: 31
Deficiencies: 10
Jun 13, 2023
Visit Reason
The Minnesota Department of Health conducted a survey to evaluate and assess compliance with state licensing statutes for an Assisted Living with Dementia Care facility.
Findings
The licensee was found in substantial compliance but had multiple deficiencies including food preparation not fully compliant with Minnesota Food Code, infection control program deficiencies, incomplete employee records, lack of tuberculosis prevention program, physical environment maintenance issues, incomplete resident assessments and service plans, medication labeling issues, lack of hazard vulnerability assessment, and privacy concerns during medication administration.
Severity Breakdown
Level 2: 10
Deficiencies (10)
| Description | Severity |
|---|---|
| Food was not prepared and served according to the Minnesota Food Code, affecting all 31 residents. | Level 2 |
| Failed to establish and maintain an infection control program consistent with accepted standards; observed failure of hand hygiene by unlicensed personnel during medication administration. | Level 2 |
| Employee records for one unlicensed personnel lacked current job description and annual performance review. | Level 2 |
| Failed to establish and maintain a tuberculosis prevention program including required TB screening documentation for two employees. | Level 2 |
| Failed to maintain physical environment in good repair including fire safety issues, mold on air grilles, damaged doors, missing door hardware, and tripping hazards. | Level 2 |
| Failed to conduct ongoing resident monitoring and reassessment using the uniform assessment tool for three residents. | Level 2 |
| Service plans for three residents lacked signatures or authentication documenting agreement on services to be provided. | Level 2 |
| Medications, including over-the-counter supplements, lacked original prescription labels with identifying information and directions for administration. | Level 2 |
| Failed to provide a hazard vulnerability assessment or safety risk assessment of the physical environment on and around the property. | Level 2 |
| Failed to maintain resident privacy during medication and treatment administration in a common dining area. | Level 2 |
Report Facts
Residents present: 31
Correction order time period: 21
Correction order time period: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| ULP-B | Unlicensed Personnel | Named in infection control deficiency for failure to perform hand hygiene and medication administration observations. |
| DON-A | Director of Nursing | Named in infection control and resident assessment deficiencies; acknowledged issues and provided statements regarding training and assessments. |
| LALD-C | Licensed Assisted Living Director | Interviewed regarding tuberculosis screening and hazard vulnerability assessment. |
| LALD-D | Licensed Assisted Living Director | Reviewed employee records and confirmed missing documentation. |
| Jessica Davis | Public Health Sanitarian III | Conducted Food and Beverage Establishment inspection. |
| Jonathen Lopez | Kitchen Manager | Participated in Food and Beverage Establishment inspection. |
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