Inspection Reports for Brookdale Plymouth
15855 22nd Avenue North,Plymouth, MN, MN
Back to Facility ProfileDeficiencies per Year
12
9
6
3
0
Severe
High
Inspection Report
Routine
Census: 39
Deficiencies: 12
Jan 9, 2025
Visit Reason
The Minnesota Department of Health conducted a survey to evaluate and assess compliance with state licensing statutes for an assisted living facility with dementia care license.
Findings
The licensee was found in substantial compliance but had several deficiencies including failure to ensure food service compliance with Minnesota Food Code, ineffective infection control practices, missing emergency number postings, incomplete employee records and orientation, missing background study affiliations, incomplete resident reassessments, expired medications not discarded, and failure to maintain dignified dining experience for a resident.
Severity Breakdown
Level 1: 1
Level 2: 11
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to ensure food was prepared and served according to Minnesota Food Code. | Level 2 |
| Failed to establish and maintain an effective infection control program related to gloving and hand hygiene. | Level 2 |
| Failed to post the 911 emergency number in common areas and near telephones. | Level 2 |
| Employee records lacked annual reviews identifying areas of improvement and training needs for two employees. | Level 2 |
| Failed to comply with State Fire Code: fire door altered without approval and emergency lights not functioning. | Level 2 |
| Assisted living contract included language waiving facility liability for resident health, safety, or personal property. | Level 1 |
| Failed to submit background study and receive clearance affiliated with licensee's HFID for two employees. | Level 2 |
| Failed to complete orientation including all required content for three employees. | Level 2 |
| Failed to provide all required annual training topics for two employees. | Level 2 |
| Failed to complete 14-day reassessment for two residents within required timeframe. | Level 2 |
| Failed to discard expired medications for three residents. | Level 2 |
| Failed to maintain a dignified dining experience for one resident who waited 19 minutes before receiving feeding assistance. | Level 2 |
Report Facts
Residents present: 39
Expired medications: 9
Days late for reassessment: 5
Temperature: 40
Surface sanitizer concentration: 704
Hot water temperature: 166
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| ULP-A | Unlicensed Personnel | Named in infection control and orientation training deficiencies |
| ULP-B | Unlicensed Personnel | Named in infection control, orientation, annual training, and medication administration deficiencies |
| LPN-C | Licensed Practical Nurse | Named in orientation and annual training deficiencies |
| DOM-K | Director of Maintenance | Named in background study affiliation deficiency |
| LALD-D | Licensed Assisted Living Director | Interviewed regarding multiple deficiencies |
| LPN-J | Licensed Practical Nurse | Interviewed regarding medication and infection control deficiencies |
| CNS-I | Clinical Nurse Supervisor | Interviewed regarding resident reassessment deficiency |
| Spencer | Culinary Director | Named in food service inspection report |
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