Brookdale Eagan.
Brookdale Eagan is Grade C−, ranked in the bottom 47% of Minnesota memory care with 2 MDH citations on record; last inspected Jan 2026.
A large home, reviewed on public record.
Ranked against 187 Minnesota facilities.
ALF memory care · 36-month window. Higher percentile = better. Source: Minnesota Dept. of Health · Health Regulation Division.
FACILITY WATCH · BETA
Brookdale Eagan has 2 citations on record. Know the moment anything changes.
New findings, complaint investigations, or status changes — emailed to you free.
Citation history, plotted month by month.
2 deficiencies on record. Each bar is a month with a citation.
Finding distribution
2 total · 36 monthsScope × Severity (CMS A–L)
Every MDH visit, verbatim.
5 inspections in the public record, most recent first. Click any row to expand — cited rows open automatically.
2026-01-07Annual Compliance VisitNo findings
Plain-language summary
A standard licensing inspection was conducted on January 7, 2026, at Brookdale Eagan, which resulted in one correction order related to fire protection and physical environment under Minnesota Statute 144G.45. The facility was assessed a $500 fine for this violation and must document the actions taken to correct it.
Full inspector notes
correction orders and document the actions taken to comply in the facility's records. The Department reserves the right to return to the facility at any time should the Department receive a complaint or deem it necessary to ensure the health, safety, and welfare of residents in your care. STATE CORRECTIO NORDERS The enclosed State Form documents the state correction orders. MDH documents state licensing correction orders using federal software. Tag numbers are assigned to Minnesota state statutes for Assisted Living Facilities. The assigned tag number appears in the far left column entitled "ID Prefix Tag." The state statute number and the corresponding text of the state statute out of compliance are listed in the "Summary Statement of Deficiencies" column. This column also includes the findings that are in violation of the state statute after the statement, "This MN Requirement is not met as evidenced by . . ." IMPOSITION OF FINES In accordance with Minn. Stat. § 144G.31, Subd. 4, fines and enforcement actions may be imposed based on the level and scope of the violations and may be imposed immediately with no opportunity to correct the violation first as follows: Level 1: no fines or enforcement; Level 2: a fine of $500 per violation, in addition to any enforcement mechanism authorized in § 144G.20; Level 3: a fine of $1,000 per incident, in addition to any enforcement mechanism authorized in § 144G.20; An equal opportunity employer. Letter ID: IS7N REVISE D09/13/2021 Brookdale Eagan January 30, 2026 Page 2 Level 4: a fine of $3,000 per incident, in addition to any enforcement mechanism authorized in § 144G.20; Level 5: a fine of $5,000 per violation, in addition to any enforcement mechanism authorized in § 144G.20. Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, the following fines are assessed pursuant to this survey: St - 0 - 0775 - 144g.45 Subd. 2. (a) - Fire Protection And Physical Environment - $500.00 The refor e, in accor danc e wit h Minn. Sta t. §§ 144G.01 to 144G.999 9, the total amount you are assessed is $500.00. You will be invoiced approximately 30 days after receipt of this notice, subject to appeal . DOCUMENTATIO ONF ACTION TO COMPLY In accorda nce with Min n. Stat. § 144G.30, Sub d. 5(c), th e lic ens ee mus t docum ent ac tions taken t o comply with the correction orders within the time period outlined on the state form; however, plans of correction are not required to be submitted for approval. The correction order documentation should include the following: Identify how the area( s) of noncompliance was corrected related to the · resident( s)/ employee( s) identified in the correction order. Identify how the area( s) of noncompliance was corrected for all of the provider’s · resident( s)/ employees that may be affected by the noncompliance. Identify what changes to your systems and practices were made to ensure compliance with · the specific statute( s). CORRECTIO NORDER RECONSIDERATIO PNROCESS In accordance with Minn. Stat. § 144G.32, Subd. 2, you may challenge the correction order( s) issued, including the level and scope, and any fine assessed through the correction order reconsideration process. The request for reconsideration must be in writing and received by MDH within 15 calendar days of the correction order receipt date. To submit a reconsideration request, please visit: https: / / forms. web. health. state. mn.us/ form/ HRDAppealsForm REQUESTIN GA HEARING Alternatively, in accordance with Minn. Stat. § 144G.31, Subd. 5(d), an assisted living provider that has been assessed a fine under this subdivision has a right to a reconsideration or a hearing under this section and chapter 14. Pursuant to Minn. Stat. § 144G.20, Subd. 14 and Subd. 18, a request for a hearing must be in writing and received by the Department of Health within 15 business days of the correction order receipt date. The request must contain a brief and plain statement describing each matter or issue contested and any new information you believe constitutes a defense or mitigating Brookdale Eagan January 30, 2026 Page 3 factor. To submit a hearing request, please visit: https: / / forms. web. health. state. mn. us/ form/ HRDAppealsForm To appe al fi nes via re cons iderat ion , pl ease follow the procedu r e outl ined abo ve. Plea se no te tha t you may re que st a rec onside rati on or a hearing, bu t not bot h. If you wish to cont est ta gs with out fine s in a reconsideration and tags with the fines at a hearing, please submit two separate appeals forms at the website listed above. The MDH Health Regulation Division (HRD )values your feedback about your experience during the survey and/ or investigation process. Please fill out this anonymous provider feedback questionnaire at your conv enien ce at thi s link: https: / / forms. office.com/ g/ Bm5uQEpHVa. Your inpu t is import ant to us and will enable MDH to improve its processes and communication with providers. If you have any questions regarding the questionnaire, please contact Susan Winkelmann at susan. winkelmann@state. mn.us or call 651-201-5952. You are encouraged to retain this document for your records. It is your responsibility to share the information contained in the letter and state form with your organization’s Governing Body. If you have any questions, please contact me. Sincerely, Jodi Johnson, Supervisor State Evaluation Team Email: Jodi.Johnson@state. mn.us Telephone: 507-344-2730 Fax: 1-866-890-9290 KKM PRINTED: 01/ 30/ 2026 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/ SUPPLIER/ CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 30683 01/ 07/ 2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1365 CRESTRIDGE LANE BROOKDALE EAGAN EAGAN, MN 55123 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER' S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS- REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 000 Initial Comments 0 000 *****ATTENTION***** Minnesota Department of Health is documenting the State Correction Orders ASSISTED LIVING PROVIDER LICENSING using federal software. Tag numbers have CORRECTION ORDER( S) been assigned to Minnesota State Statutes for Assisted Living Facilities. The In accordance with Minnesota Statutes, section assigned tag number appears in the 144G. 08 to 144G. 95, these correction orders are far-left column entitled "ID Prefix Tag. " The issued pursuant to a survey. state Statute number and the corresponding text of the state Statute out Determination of whether violations are corrected of compliance is listed in the "Summary requires compliance with all requirements Statement of Deficiencies" column. This provided at the Statute number indicated below. column also includes the findings which When Minnesota Statute contains several items, are in violation of the state requirement failure to comply with any of the items will be after the statement, "This Minnesota considered lack of compliance. requirement is not met as evidenced by." Following the evaluators' findings is the INITIAL COMMENTS: Time Period for Correction. SL30683016- 0 PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On January 5, 2026, through January 7, 2026, the STATES, "PROVIDER' S PLAN OF survey at the above provider and the following FEDERAL DEFICIENCIES ONLY. THIS correction orders are issued. At the time of the WILL APPEAR ON EACH PAGE. survey, there were 41 residents; 41 receiving services under the Assisted Living Facility with THERE IS NO REQUIREMENT TO Dementia Care license. SUBMIT A PLAN OF CORRECTION FOR VIOLATIONS OF MINNESOTA STATE STATUTES. THE LETTER IN THE LEFT COLUMN IS USED FOR TRACKING PURPOSES AND REFLECTS THE SCOPE AND LEVEL ISSUED PURSUANT TO 144G. 31 SUBDIVISION 1-3. 0 580 144G. 42 Subd. 2 Quality management 0 580 SS= F The facility shall engage in quality management LABORATORY DIRECTOR' S OR PROVIDER/ SUPPLIER REPRESENTATIVE' S SIGNATURE TITLE (X6) DATE STATE FORM 6899 U4NU11 If continuation sheet 1 of 17 PRINTED: 01/ 30/ 2026 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/ SUPPLIER/ CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B.
2024-04-03Complaint Investigation1 · Substantiated Finding
Plain-language summary
A complaint investigation found that the facility failed to administer an ordered blood thinner (warfarin) for six days after the resident's admission, despite the resident having atrial fibrillation and a history of stroke and being at high risk for blood clots. The resident fell on the sixth day, developed left-sided paralysis, and was hospitalized with an acute stroke caused by subtherapeutic blood levels of the medication. The Minnesota Department of Health substantiated neglect and determined the facility was responsible for this maltreatment.
“MDH substantiated maltreatment or licensing violation finding”
Full inspector notes
Finding: Substantiated, facility responsibility Nature of Investigation: The Minnesota Department of Health investigated an allegation of maltreatment, in accordance with the Minnesota Reporting of Maltreatment of Vulnerable Adults Act, Minn. Stat. 626.557, and to evaluate compliance with applicable licensing standards for the provider type. Initial Investigation Allegation(s): The facility neglected the resident when the facility failed to administer blood thinners as ordered. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was substantiated. The facility was responsible for the maltreatment. The resident admitted to the facility with orders for warfarin (an anticoagulant to prevent blood clots) but the facility did not administer warfarin for six days. The resident fell, exhibited new left-sided paralysis, and was diagnosed with an acute stroke. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted family members. The investigation included review of the resident record, hospital records, facility internal investigation, facility incident reports, personnel files, staff schedules, related facility policy and procedures. Also, the investigator toured the facility and observed interactions between the residents and facility staff. The resident resided in an assisted living facility. The resident’s diagnoses included atrial fibrillation (an abnormal heartbeat that can lead to blood clots), history of a stroke (a loss of blood flow to an area of the brain causing damage), and Alzheimer’s dementia. The resident’s service plan included assistance with medication management. The resident’s assessment indicated the resident walked with a walker and required fall prevention interventions. The resident’s admission orders indicated an order for warfarin (also known as Coumadin or Jantoven) to be given every evening for five days, then to have the resident’s blood drawn after the fifth dose to monitor if the resident’s blood levels were at a therapeutic level to prevent blood clots as intended. The electronic medication administration record (EMAR) indicated the facility administered warfarin on the first day the resident admitted. However, the same document indicated the facility did not administer warfarin on the second through the fourth day after the resident admitted. The progress notes indicated there was an entry time-stamped for each day from the second through the fifth day reporting that the resident did not receive warfarin because it was not available. On the sixth day, the EMAR did not show an order was in place for warfarin. Also, on the sixth day the medical records indicated the resident had a blood draw to check if the warfarin was at therapeutic levels. The facility notified the medical provider regarding of the blood draw on the seventh day. On the morning of the seventh day an incident report indicated the resident was transferred to the hospital for evaluation after presenting with left-sided weakness. The hospital records indicated the resident had an acute stroke and had a subtherapeutic blood level for warfarin. During an interview, nurse #2 stated a medication error occurred regarding the resident’s warfarin. Nurse #2 stated the EMAR listed “warfarin” but in the medication cart it was packaged as “Jantoven” [Coumadin and Jantoven are trade names for the generic medication warfarin] and the unlicensed caregiver(s) who were responsible for medication passes were not familiar with that term. Nurse #2 stated she verbally instructed the unlicensed caregiver regarding the different names in EMAR and on the medication packaging, however she did not place additional instructions in the EMAR or the medication packaging. Nurse #2 stated there were progress notes in the resident’s medical record by the unlicensed caregiver indicating the medication was not given, but the progress notes were not individually reviewed. During an interview, an unlicensed caregiver stated she was assigned to the resident’s medication pass during her time at the facility. The unlicensed caregiver stated she did not initially receive training regarding the medication package showing a different drug name in the EMAR and on the medication packaging. The unlicensed caregiver stated she left notes for 2-3 days on the nurses’ desk and reported to oncoming unlicensed caregivers the warfarin was not available. She was off work for two days and then came back as scheduled when nurse #2 showed her the medication was present. During an interview, nurse #1 stated if a medication was not available the unlicensed caregivers knew they were to notify a nurse. Nurse #1 stated neither she nor nurse #2 were notified the medication was not available by the unlicensed caregiver. Nurse #1 stated she nor nurse #2 viewed the progress notes made by the unlicensed caregiver(s) which indicated the warfarin was not available to administer because there would no reason to check the resident’s progress notes unless an unlicensed caregiver had notified them the warfarin had not been given. During an interview, the medical provider stated the facility sent a message over the portal (electronic communication) that the resident had a subtherapeutic warfarin blood value and that the resident had not received warfarin as ordered upon admission. When the provider requested information as to why resident was not given medication, the provider was informed the resident was sent to hospital earlier that day. The provider stated the resident was taking warfarin for atrial fibrillation, with the goal of the warfarin to thin the resident’s blood to prevent a stroke. The provider stated the risk to the resident if not receiving warfarin as ordered was for clot formation causing a stroke. In conclusion, the Minnesota Department of Health determined neglect was substantiated. Substantiated: Minnesota Statutes, section 626.5572, Subdivision 19. “Substantiated” means a preponderance of evidence shows that an act that meets the definition of maltreatment occurred. Insert maltreatment definition here. Neglect: Minnesota Statutes, section 626.5572, subdivision 17 “Neglect” means neglect by a caregiver or self-neglect. (a) "Caregiver neglect" means the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to, food, clothing, shelter, health care, or supervision which is: (1) reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult; and (2) which is not the result of an accident or therapeutic conduct. Vulnerable Adult interviewed: No. Not able to interview due to cognitive loss. Family/Responsible Party interviewed: Yes Alleged Perpetrator interviewed: Not Applicable Action taken by facility: Resident sent to hospital for treatment. The facility provided training to other caregivers regarding critical medications and communication. Action taken by the Minnesota Department of Health: The responsible party will be notified of their right to appeal the maltreatment finding. The facility was found to be in noncompliance. To view a copy of the Statement of Deficiencies and/or correction orders, please visit: https://www.health.state.mn.us/facilities/regulation/directory/provcompselect.html If you are viewing this report on the MDH website, please see the attached Statement of Deficiencies. You may also call 651-201-4200 to receive a copy via mail or email. cc: The Office of Ombudsman for Long Term Care The Office of Ombudsman for Mental Health and Developmental Disabilities Dakota County Attorney Eagan City Attorney Eagan Police Department PRINTED: 04/04/2024 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ C B. WING _____________________________ 30683 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1365 CRESTRIDGE LANE BROOKDALE EAGAN EAGAN, MN 55123 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 000 Initial Comments 0 000 ******ATTENTION****** Minnesota Department of Health is documenting the State Correction Orders ASSISTED LIVING PROVIDER CORRECTION using federal software. Tag numbers have ORDER been assigned to Minnesota State Statutes for Assisted Living License In accordance with Minnesota Statutes, section Providers. The assigned tag number 144G.08 to 144G.95, these correction orders are appears in the far left column entitled "ID issued pursuant to a complaint investigation. Prefix Tag." The state Statute number and the corresponding text of the state Statute Determination of whether a violation is corrected out of compliance is listed in the requires compliance with all requirements "Summary Statement of Deficiencies" provided at the statute number indicated below. column.
2024-01-09Complaint InvestigationNo findings
Plain-language summary
The Minnesota Department of Health investigated a complaint that staff improperly restrained a resident by pushing them against a table and locking their wheelchair brakes, but determined the complaint was not substantiated after interviewing staff, hospice workers, and reviewing medical records and facility policies. While staff acknowledged locking the wheelchair brakes on one occasion, the investigator concluded those actions did not meet the legal definition of abuse and were taken out of concern for the resident's safety due to frequent fall risks. The facility retrained all staff on wheelchair brake use, fall interventions, and restraint policies following the incident.
Full inspector notes
Finding: Not Substantiated Nature of Visit: The Minnesota Department of Health investigated an allegation of maltreatment, in accordance with the Minnesota Reporting of Maltreatment of Vulnerable Adults Act, Minn. Stat. 626.557, and to evaluate compliance with applicable licensing standards for the provider type. Initial Investigation Allegation(s): An unlicensed personnel/alleged perpetrator (AP) abused the resident when they restrained the resident by pushing the resident up against a table, locked the wheelchair brakes and restricted the resident’s movement. Investigative Findings and Conclusion: The Minnesota Department of Health determined abuse was not substantiated. Although the unlicensed personnel/alleged perpetrator (AP) acknowledged locking the resident’s wheelchair brakes on one occasion, the actions of the AP did not rise to the level of abuse. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator also contacted hospice agency staff. The investigation included review of medical records and facility policies and procedures. At the time of the onsite visit, the investigator observed medication administration, resident cares, and staff interaction with residents. An equal opportunity employer. The resident resided in an assisted living memory care unit. The resident’s diagnoses included Alzheimer’s Disease. The resident’s service plan included assistance with dressing, bathing, toileting, medication management, and escort assistance to the dining room and activities. The resident’s assessment identified cognitive and physical deficits, a history of falls, and the resident required staff assistance and a walker for mobility. The assessment did not identify the type of wheelchair the resident utilized or if the resident could independently utilize the wheelchair brakes. The resident’s medical record indicated around the time of the incident, hospice services were initiated due to the resident’s mental and physical decline. Facility internal investigation documentation indicated a hospice staff member found the resident alone at a dining room table, in a reclining-type wheelchair. The wheelchair brakes were locked, and the resident was pushed up close to the table against the dining room wall. The resident was fidgeting and trying to push himself away from the table. The hospice staff assisted the resident away from the table to visit and later returned the resident to the dining room. Upon return, a staff member/AP told hospice staff to bring the resident back to the table and lock the wheelchair brakes. The hospice staff member only placed one of the wheelchair locks on and ensured the resident was not alone before she left the facility. Facility nursing staff interviewed could not recall what type of wheelchair the resident used at the time of the incident but indicated the resident did not use a reclining-type wheelchair due to a history of falls. Facility nursing staff stated the resident received hospice services at the time of the incident for a variety of reasons including weakness, recurrent falls, and an increase in behaviors. Nursing staff also recalled the resident’s ability to utilize his wheelchair brakes was inconsistent and varied from day to day due to his health decline. During an interview, the AP indicated the day of the incident she was concerned about the resident’s frequent self-transfer attempts, so she locked the brakes on the wheelchair to ensure the resident’s safety. The AP acknowledged she told hospice staff to bring the resident back to the table and lock the wheelchair brakes to continue to keep the resident safe but could not recall if hospice followed her request. The AP denied abusing or restraining the resident and indicated she was re-trained following the incident. Facility administrative staff interviewed indicated there was no evidence of harm to the resident and all staff were retrained on appropriate wheelchair brake use, fall interventions, and the use of restraints following the incident. In conclusion, the Minnesota Department of Health determined abuse was not substantiated. “Not Substantiated” means: An investigatory conclusion indicating the preponderance of evidence shows that an act meeting the definition of maltreatment did not occur. Abuse: Minnesota Statutes section 626.5572, subdivision 2. "Abuse" means: (a) An act against a vulnerable adult that constitutes a violation of, an attempt to violate, or aiding and abetting a violation of: (1) assault in the first through fifth degrees as defined in sections 609.221 to 609.224; (2) the use of drugs to injure or facilitate crime as defined in section 609.235; (3) the solicitation, inducement, and promotion of prostitution as defined in section 609.322; and (4) criminal sexual conduct in the first through fifth degrees as defined in sections 609.342 to 609.3451. A violation includes any action that meets the elements of the crime, regardless of whether there is a criminal proceeding or conviction. (b) Conduct which is not an accident or therapeutic conduct as defined in this section, which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to, the following: (1) hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult; (2) use of repeated or malicious oral, written, or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening; (3) use of any aversive or deprivation procedure, unreasonable confinement, or involuntary seclusion, including the forced separation of the vulnerable adult from other persons against the will of the vulnerable adult or the legal representative of the vulnerable adult; and (4) use of any aversive or deprivation procedures for persons with developmental disabilities or related conditions not authorized under section 245.825. (c) Any sexual contact or penetration as defined in section 609.341, between a facility staff person or a person providing services in the facility and a resident, patient, or client of that facility. (d) The act of forcing, compelling, coercing, or enticing a vulnerable adult against the vulnerable adult's will to perform services for the advantage of another. Vulnerable Adult interviewed: No; Deceased Family/Responsible Party interviewed: Yes Alleged Perpetrator interviewed: Yes the Action taken by facility: The facility completed an internal investigation, retrained the AP, and completed re-education with all facility staff. Action taken by the Minnesota Department of Health: The facility was found to be in noncompliance. To view a copy of the Statement of Deficiencies and/or correction orders, please visit: https://www.health.state.mn.us/facilities/regulation/directory/provcompselect.html If you are viewing this report on the MDH website, please see the attached Statement of Deficiencies. You may also call 651-201-4200 to receive a copy via mail or email cc: The Office of Ombudsman for Long Term Care The Office of Ombudsman for Mental Health and Developmental Disabilities PRINTED: 01/12/2024 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ C B. WING _____________________________ 30683 12/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1365 CRESTRIDGE LANE BROOKDALE EAGAN EAGAN, MN 55123 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 000 Initial Comments 0 000 ******ATTENTION****** Minnesota Department of Health is documenting the State Correction Orders ASSISTED LIVING PROVIDER CORRECTION using federal software. Tag numbers have ORDER been assigned to Minnesota State Statutes for Assisted Living Facilities. The In accordance with Minnesota Statutes, section assigned tag number appears in the far 144G.08 to 144G.95, these correction orders are left column entitled "ID Prefix Tag." The issued pursuant to a complaint investigation. state Statute number and the corresponding text of the state Statute out Determination of whether a violation is corrected of compliance is listed in the "Summary requires compliance with all requirements Statement of Deficiencies" column. This provided at the statute number indicated below. column also includes the findings which When a Minnesota Statute contains several are in violation of the state requirement items, failure to comply with any of the items will after the statement, "This Minnesota be considered lack of compliance. requirement is not met as evidenced by." Following the evaluators' findings is the INITIAL COMMENTS: Time Period for Correction. #HL306837036C/#HL306839366M PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On December 11, 2023, the Minnesota STATES,"PROVIDER'S PLAN OF Department of Health conducted a complaint CORRECTION." THIS APPLIES TO investigation at the above provider, and the FEDERAL DEFICIENCIES ONLY. THIS following correction order is issued. At the time of WILL APPEAR ON EACH PAGE.
2023-07-31Complaint Investigation1 · Substantiated Finding
Plain-language summary
A complaint investigation found the facility neglected a resident who fell three times in one month and sustained significant bruising and facial fractures; nursing staff failed to document injuries, monitor the resident, notify the physician, or implement fall prevention measures after the falls occurred. The resident was hospitalized with multiple facial fractures, but upon return to the facility no assessment was completed, the service plan was not updated, and no additional fall precautions were put in place. The resident subsequently fell a fourth time one month later and fractured her hip.
“MDH substantiated maltreatment or licensing violation finding”
Full inspector notes
Finding: Substantiated, facility responsibility Nature of Visit: The Minnesota Department of Health investigated an allegation of maltreatment, in accordance with the Minnesota Reporting of Maltreatment of Vulnerable Adults Act, Minn. Stat. 626.557, and to evaluate compliance with applicable licensing standards for the provider type. Initial Investigation Allegation(s): The facility neglected a resident when the resident fell three times in one month and sustained significant bruising and facial fractures. Facility staff failed to document, assess, monitor the resident for injuries, and failed to develop post-fall interventions to prevent further falls. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was substantiated. The facility was responsible for the maltreatment. Nursing staff failed to follow facility policies and procedures related to falls. Although nursing staff assessed and identified the resident had a history and risk for falls, they failed to document, assess, treat, and monitor after multiple falls occurred. In addition, interventions were not developed or implemented to prevent future falls, the resident’s physician was not notified of the fall(s) and/or injury(s), and the resident was not evaluated or assessed until another fall with injury occurred four days later. The resident was sent to the hospital and found to have significant bruising and multiple facial fractures. Upon return from the hospital, the facility failed to complete an assessment, failed to document and monitor the resident’s injuries, and failed to implement additional fall interventions to prevent further occurrence. An equal opportunity employer. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator also contacted hospice services. The investigation included review of the resident’s medical records, hospital records, hospice records, and death certificate. At the time of the onsite visit, the investigator observed medication and treatment administration and resident cares provided at the facility. The resident resided in an assisted living memory care unit. The resident’s diagnoses included Alzheimer’s Disease, atrial ventricular block (when the electrical signal that controls your heartbeat is partially or completely blocked) and major depressive disorder. The resident’s service plan identified the resident as cognitively impaired and directed staff to anticipate needs, provide cues, reminders, and redirection as needed. The service plan indicated the resident was independent with the use of a walker and required assistance of one staff member for dressing, bathing, grooming, and incontinent care. The service plan also identified the resident as at risk for falls due to a history of falls, agitation, and behaviors. Review of facility documentation and the resident’s medical record identified the resident fell three times over a one-week period. The first fall occurred in the dining room of the facility. The fall report indicated the resident was using her walker at the time of the fall and was found sitting near a chair. The incident report did not identify if the resident sustained injury(s) and no additional fall interventions were implemented. The resident fell in the dining room again the next day. The fall report indicated the resident was using her walker at the time of the fall and was found sitting near a chair. The incident report did not identify if the resident sustained injury(s) and no additional fall interventions were implemented. Four days later, progress notes identified the resident “had an unwitnessed fall with possible head laceration” and was sent to the emergency room (ER) for evaluation. No fall report was completed. According to hospital records, the resident presented to the ER with a laceration (deep cut) to the back of the left side of the head, bruising on the left hand and wrist, “racoon eyes [bruising around both eyes]” and notable bruising to the face. Documentation identified the bruising was worse on the left side and appeared to be in various stages of healing. Hospital records indicated ER staff were informed the resident fell three times over the last four days, and the bruising around the resident’s eyes was a result of a previous fall. A computed tomography (CT) scan of the head was completed and found no evidence of head injury, but identified three fractures around the resident’s left eye, one fracture on the left nasal bone, and a fracture of the maxillary (sinus) bone. The physician referred the resident for evaluation by a facial surgeon due to the fractures. The resident received treatment and discharged back to the facility. Upon return to the facility, no additional assessment was completed, no changes were made to the service plan, and no additional fall interventions were implemented. The resident’s record contained no evidence of the facial fractures identified at the hospital, no evidence of monitoring to the areas of facial bruising, and no documentation on if, or when, the bruising resolved. In addition, there was no evidence the resident’s pain was assessed at the time of the fall, following the fall, or after re-admission to the facility. 2 Three weeks later, the resident admitted to hospice services for Alzheimer’s Disease, behavior management, and fall prevention. Approximately one month after the initiation of hospice services, the resident fell a fourth time and fractured her right hip. The resident was placed on bedrest and the resident’s need for services was increased to include assistance of two staff and a mechanical lift for transfers. Following the fall, the resident’s family met with facility administration and hospice staff to discuss concerns and the facility’s management of the resident’s behaviors, pain levels, use of PRN medications, and establish better communication on updates of the resident’s condition. During investigative interviews, staff confirmed the resident’s facial bruising was a result of the resident hitting her face when she fell in the dining room the second time. However, details of the fall, the assessment of injury, how the injury occurred, pain assessments, continued monitoring of the resident’s condition, and/or any treatment provided to the resident, was not included in the resident’s record. In addition, there was no evidence of notification to the resident’s physician or family of the fall with injury. During an interview, nursing staff also acknowledged the resident’s facial injuries were a result of the second fall in the dining room. Nursing staff indicated the resident’s family was notified of the fall and injury but declined for the resident to be assessed at the hospital. However, nursing staff could not recall who contacted the resident’s family and there was no documentation available to provide evidence of this discussion with family. Nursing staff was unable to confirm if an assessment was completed following a change in resident’s condition and indicated they were not familiar with the facility’s fall policy. Administrative nursing staff interviewed did not recall the resident’s second fall, if the resident injured her face, or if an assessment was completed related to a change in the resident’s condition. When interviewed, the resident’s family indicated they were not notified of the first fall but were notified of the second fall. Facility staff informed the family that the second fall resulted in the resident hitting her face on the edge of a cupboard or counter. After this notification, the resident’s family went to the facility to visit the resident. The family observed the resident was in pain, with black and swollen eyes. The family recalled they requested for staff to bring them ice to hold against the resident’s swollen face. The family questioned facility staff at that time if the resident should be sent to the hospital but were told it was not required. When the resident fell the third time, the family was told the resident was sent to the hospital due to a laceration on the back of her head. When family arrived at the hospital, ER staff informed them an x-ray of the resident’s face needed to be completed right away and revealed multiple facial fractures. In conclusion, the Minnesota Department of Health determined neglect was substantiated. Substantiated: Minnesota Statutes, section 626.5572, Subdivision 19. “Substantiated” means a preponderance of evidence shows that an act that meets the definition of maltreatment occurred. Neglect: Minnesota Statutes, section 626.5572, subdivision 17 “Neglect” means neglect by a caregiver or self-neglect.
2023-06-09Annual Compliance VisitNo findings
Plain-language summary
A routine inspection was conducted at Brookdale Eagan on June 5–9, 2023, and the facility received correction orders for violations of Minnesota Assisted Living Facility with Dementia Care regulations. The facility was required to document how it corrected the deficiencies and implement system changes to prevent future violations, but no immediate fines were assessed. Families can contact the Minnesota Department of Health for details on the specific violations issued.
Full inspector notes
CORRECTION ORDERS The enclosed State Form documents the state correction orders. The MDH documents state licensing correction orders using federal software. Tag numbers are assigned to Minnesota state statutes for Assisted Living Facilities. The assigned tag number appears in the far left column entitled "ID Prefix Tag." The state statute number and the corresponding text of the state statute out of compliance are listed in the "Summary Statement of Deficiencies" column. This column also includes the findings that are in violation of the state statute after the statement, "This MN Requirement is not met as evidenced by . . ." In accordance with Minn. Stat. § 144G.31 Subd. 4, MDH may assess fines and enforcement actions based on the level and scope of the violations; h owever, no immediate fines are assessed for this survey of your facility. DOCUMENTATION OF ACTION TO COMPLY In accordance with Minn. Stat. § 144G.30, Subd. 5(c), the licensee must document actions taken to comply with the correction orders within the time period outlined on the state form; however, plans of correction are not required to be submitted for approval. The correction order documentation should include the following: Identify how the area(s) of noncompliance was corrected related to the resident(s)/employee(s) identified in the correction order. Identify how the area(s) of noncompliance was corrected for all of the provider’s resident(s)/employees that may be affected by the noncompliance. Identify what changes to your systems and practices were made to ensure compliance with the specific statute(s). An equal opportunity employer. Letter ID: IS7N REVISED 09/13/2021 Brookdale Eagan July 25, 2023 Page 2 CORRECTION ORDER RECONSIDERATION PROCESS In accordance with Minn. Stat. § 144G.32, Subd. 2, you may challenge the correction order(s) issued, including the level and scope, and any fine assessed through the correction order reconsideration process. The request for reconsideration must be in writing and received by the MDH within 15 calendar days of the correction order receipt date. A state correction order under Minn. Stat. § 144G.91, Subd. 8, Free from Maltreatment is associated with a maltreatment determination by the Office of Health Facility Complaints. If maltreatment is substantiated, you will receive a separate letter with the reconsideration process under Minn. Stat. § 626.557. Please email reconsideration requests to: Health.HRD.Appeals@state.mn.us. Please attach this letter as part of your reconsideration request. Please clearly indicate which tag(s) you are contesting and submit information supporting your position(s). Please address your cover letter for reconsideration requests to: Reconsideration Unit 85 East Seventh Place St. Paul, MN 55164-0970 You are encouraged to retain this document for your records. It is your responsibility to share the information contained in the letter and state form with your organization’s Governing Body. If you have any questions, please contact me. Sincerely, Jonathan Hill, Supervisor State Evaluation Team Email: jonathan.hill@state.mn.us Telephone: 651-201-3993 Fax: 6 51-281-9796 JMD PRINTED: 07/25/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 30683 06/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1365 CRESTRIDGE LANE BROOKDALE EAGAN EAGAN, MN 55123 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 000 Initial Comments 0 000 ******ATTENTION****** Minnesota Department of Health is documenting the State Correction Orders ASSISTED LIVING PROVIDER LICENSING using federal software. Tag numbers have CORRECTION ORDER(S) been assigned to Minnesota State Statutes for Assisted Living License In accordance with Minnesota Statutes, section Providers. The assigned tag number 144G.08 to 144G.95, these correction orders are appears in the far left column entitled "ID issued pursuant to a survey. Prefix Tag." The state Statute number and the corresponding text of the state Statute Determination of whether violations are corrected out of compliance is listed in the requires compliance with all requirements "Summary Statement of Deficiencies" provided at the Statute number indicated below. column. This column also includes the When Minnesota Statute contains several items, findings which are in violation of the state failure to comply with any of the items will be requirement after the statement, "This considered lack of compliance. Minnesota requirement is not met as evidenced by." Following the surveyors' INITIAL COMMENTS: findings is the Time Period for Correction. SL30683015-0 PLEASE DISREGARD THE HEADING OF On June 5 through June 9, 2023, the Minnesota THE FOURTH COLUMN WHICH Department of Health conducted a survey at the STATES,"PROVIDER'S PLAN OF above provider, and the following correction CORRECTION." THIS APPLIES TO orders are issued. At the time of the survey, there FEDERAL DEFICIENCIES ONLY. THIS were 31 active residents receiving services under WILL APPEAR ON EACH PAGE. the Assisted Living with Dementia Care license. THERE IS NO REQUIREMENT TO SUBMIT A PLAN OF CORRECTION FOR VIOLATIONS OF MINNESOTA STATE STATUTES. The letter in the left column is used for tracking purposes and reflects the scope and level issued pursuant to 144G.31 subd. 1, 2, and 3. 0 480 144G.41 Subd 1 (13) (i) (B) Minimum 0 480 SS=F requirements (13) offer to provide or make available at least the LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 WPJE11 If continuation sheet 1 of 46 PRINTED: 07/25/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 30683 06/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1365 CRESTRIDGE LANE BROOKDALE EAGAN EAGAN, MN 55123 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 480 Continued From page 1 0 480 following services to residents: (B) food must be prepared and served according to the Minnesota Food Code, Minnesota Rules, chapter 4626; and This MN Requirement is not met as evidenced by: Based on observation, interview and record review, the licensee failed to ensure food was prepared and served according to the Minnesota Food Code. This had the potential to affect all residents of the assisted living facility. 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 residents). The findings include: Please refer to the included document titled, Food and Beverage Establishment Inspection Report, dated June 6, 2023, for the specific Minnesota Food Code deficiencies. TIME PERIOD FOR CORRECTION: Twenty-one (21) days 0 510 144G.41 Subd. 3 Infection control program 0 510 SS=E (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. (b)The facility's infection control program must be STATE FORM 6899 WPJE11 If continuation sheet 2 of 46 PRINTED: 07/25/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 30683 06/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1365 CRESTRIDGE LANE BROOKDALE EAGAN EAGAN, MN 55123 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 510 Continued From page 2 0 510 consistent with current guidelines from the national Centers for Disease Control and Prevention (CDC) for infection prevention and control in long-term care facilities and, as applicable, for infection prevention and control in assisted living facilities. (c) The facility must maintain written evidence of compliance with this subdivision. This MN Requirement is not met as evidenced by: Based on observation and interview, the licensee failed to establish and maintain an effective infection control program to comply with accepted health care, medical, and nursing standards for infection control.
Other facilities in Dakota County.
Other memory care facilities in Dakota County with similar care offerings.
Family reviews
No reviews yet — be the first to share your experience
No published reviews yet. Use the button above to share your experience.
Other memory care options nearby.
More options in neighboring cities
Licensed memory care in other cities within this county region — useful when your search radius crosses city limits.