Inspection Reports for Brookdale Winona
835 East Belleview Street,Winona, MN, MN
Back to Facility ProfileDeficiencies per Year
20
15
10
5
0
Severe
High
Moderate
Inspection Report
Follow-Up
Census: 19
Deficiencies: 19
Dec 4, 2024
Visit Reason
Follow-up survey to determine if orders from the July 2, 2024 survey and October 1, 2024 follow-up survey were corrected.
Findings
The follow-up survey verified that the facility is in substantial compliance with previous correction orders. However, prior surveys identified multiple deficiencies including background study issues, food code violations, grievance procedure posting, tuberculosis risk assessment, emergency preparedness, resident record documentation, fire safety, physical environment maintenance, contract waivers, service plan and medication management deficiencies.
Severity Breakdown
Level 1: 1
Level 2: 16
Level 3: 1
Deficiencies (19)
| Description | Severity |
|---|---|
| Failed to ensure a background study was submitted and received in affiliation with the assisted living license for unlicensed personnel and employees, including incorrect health facility identification numbers. | Level 3 |
| Food was not prepared and served according to the Minnesota Food Code. | Level 2 |
| Failed to post in a conspicuous place information about the grievance procedure with required contact information. | Level 2 |
| Failed to develop and implement an individual abuse prevention plan including required content for residents. | Level 2 |
| Failed to complete a facility tuberculosis risk assessment. | Level 2 |
| Failed to post an emergency disaster plan prominently and have a written emergency preparedness plan with all required content. | Level 2 |
| Failed to provide smoke alarms in compliance with Minnesota Fire Code; smoke alarms were over 10 years old. | Level 2 |
| Failed to maintain the physical environment in a continuous state of good repair including use of extension cords, fire doors held open, unprotected wall openings, and improper dryer vent pipe installation. | Level 2 |
| Assisted living contract included a waiver of facility liability for health, safety, or personal property of a resident. | Level 1 |
| Failed to ensure ongoing nursing assessments were conducted within required timeframes for residents. | Level 2 |
| Failed to ensure service plans were signed by residents or representatives and included all services provided. | Level 2 |
| Failed to ensure service plans included all required content such as fees, monitoring schedules, contingency plans, and emergency contacts. | Level 2 |
| Failed to develop individualized medication management plans with all required content for residents receiving medication management services. | Level 2 |
| Failed to ensure unlicensed personnel administering medications were competency tested by a registered nurse. | Level 2 |
| Failed to ensure registered nurse developed training and procedures for unlicensed personnel administering medications during unplanned time away when nurse was not available. | Level 2 |
| Failed to document disposition of medications including prescription numbers and to whom medications were given for a discharged resident. | Level 2 |
| Failed to develop and implement individualized treatment or therapy management plans with all required content for residents receiving treatments or therapies. | Level 2 |
| Failed to ensure treatment or therapies were administered as prescribed or document reasons for omission for residents. | Level 2 |
| Failed to maintain up-to-date written or electronically recorded orders for treatments and therapies for residents. | Level 2 |
Report Facts
Residents present: 19
Fine amount: 3000
Smoke alarm age: 10
Sanitizer concentration: 0
Sanitizer concentration required: 500
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| ULP-C | Unlicensed Personnel | Failed background study clearance and worked independently without proper supervision |
| ULP-D | Unlicensed Personnel | Background study not affiliated with licensee HFID and lacked competency testing for medication administration |
| LALD-A | Licensed Assisted Living Director/Registered Nurse | Interviewed regarding background study issues, grievance posting, emergency preparedness, and service plans |
| CNS-B | Clinical Nurse Supervisor | Interviewed regarding service plans, medication management, and treatment plans |
| MS-E | Maintenance Supervisor | Observed physical environment deficiencies including smoke alarms and fire doors |
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