Warroad Care Center

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure staff completed COVID-19 self-testing per manufacturer guidelines and Centers for Disease Control (CDC) guidelines for 13 of 19 staff (DA-B, DA-C, HSKG-A, HSKG-B, LA-A, NA-J, NA-O, NA-P, LPN-B, LPN-C, RN-C, administrator) observed to complete COVID-19 testing. This had the potential to affect all residents residing in the nursing home.

Inspectors wroteBased on observation, interview and document review, the facility failed to follow Centers for Disease Control (CDC) guidelines including transmission-based precautions and documenting testing procedures 7 of 14 (R11, R16, R43, R34, R41, R20, R14) reviewed for COVID-19 procedures; and failed to ensure 26 of 50 staff (RN-A, RN-B, LPN-A, NA-A, NA-C, NA-D, NA-E, NA-F, NA-G, AA-A, LPN-A, NA-B, NA-G, NA-H, RN-D, NA-J, administrator, DON, RN-C, LPN-B, TMA-A, NA-I, NA-K, NA-L, NA-M, NA-N) were tested according to CDC broad based testing guidelines; and the facility failed to monitor and track staff illness for 2 of 2 (AA-A, AA-B) staff who called in during a COVID-19 outbreak; and the facility failed to ensure resident signs/symptoms of illness were tracked during monthly surveillance for 2 of 14 (R19, R35) residents reviewed for illness. [...]

Inspectors wroteBased on interview and document review, the facility failed to provide the most recent Centers for Disease Control (CDC) education regarding the potential risks and benefits of the pneumococcal vaccine for 4 of 5 residents (R11, R13, R32, R35) reviewed for immunizations.

Inspectors wroteBased on interview and document review, the facility failed to ensure the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN CMS10055) was provided to 2 of 3 residents (R1and R5) reviewed for beneficiary notification.

Inspectors wroteBased on observation, interview, and document review, the facility failed to obtain COVID-19 vaccination information for 1 of 2 facility employees (NA-N) reviewed for immunizations.

Inspectors wroteBased on observation, interview and document review the facility failed to implement care planned interventions to reduce the risk of abuse for 1 of 3 residents (R2) who had a history of inappropriately touching female residents.

Inspectors wroteBased on observation, interview and document review the facility failed to develop care planned interventions for 1 of 3 residents (R1) reviewed who displayed behaviors toward other residents.

Inspectors wroteBased on interview and document review the facility failed to promote resident dignity following a fall for 1 of 3 residents (R1) reviewed when R1 sustained a fall, and staff left him to sleep on the floor.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure 1 of 1 resident (R39) with a known history of sexual behaviors towards others was comprehensively assessed and interventions implemented to mitigate risk to prevent ongoing sexual abuse for 2 of 2 residents (R31, R6) who were cognitively impaired, dependent on staff for their care, and were sexually abused by R39. The immediate jeopardy (IJ) began on 9/6/24, when R39 came up behind R31 and fondled her breasts. The facility failed to comprehensively assess and develop interventions to help manage and reduce the risk of injury or assault to others. This contributed to R39 continued episodes of sexual abuse toward R31 on 9/25/24, and again on 10/14/25, and toward R6 on 10/15/24. The administrator and director of nursing (DON) were notified of the IJ on 10/30/24, at 11:43 p.m. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure staff were following care planned interventions of two staff assist when transferring residents with a ceiling lift; and failed to complete therapy/or nursing assessments to determine the appropriate sling sizes per manufacturers guidelines for 3 of 4 residents (R12, R7, R2) reviewed who were transferred via ceiling lifts. These deficient practices resulted in immediate jeopardy (IJ) for R12, R7 and R2 who were at risk of serious injury as a result of the deficient practice. The IJ began on 10/29/24, when R7 was observed to be transferred in the ceiling lift from her bed to the toilet by assist of one staff when R7 was care planned to be transferred with two staff. The administrator and director of nursing (DON) were notified of the IJ on 10/30/24 at 12:57p.m. The IJ was removed on 11/5/24, at 9:09 p.m.; [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to provide sufficient staff to transfer residents in lifts according to their care plan for 3 of 4 residents (R12, R7, R2); failed to provide appropriate supervision to mitigate resident-to-resident abuse for 2 of 2 (R31, R6) residents abused by 1 of 1 residents (R39) reviewed for abuse: failed to provide sufficient staff to complete range of motion for 4 of 4 residents (R7, R19, R22, R43) reviewed for restorative therapy. In addition, 4 of 46 residents (R7, R30, R25, R34,) 10 of 10 staff members (RN-A RN-B, NA-D, LPN-A, NA-C, NA-A, SWD, RT-A, NA-H, DON); 1 of 3 family members (FM-A) voiced concerns of lack of sufficient staffing in the facility. The lack of sufficient staffing had the potential to affect all 46 residents in the facility.

Inspectors wroteBased on interview and document review, the facility failed to update the facility assessment when changes occured to ensure an effective plan was in place to maintain the highest practicable care for residents. This had the potential to affect all 46 residents residing at the facility.

Inspectors wroteBased on interview and document review, the facility failed to develop a policy and procedure defining the responsibilities of the medical director and ensure the medical director assisted in the implementation and guidance of resident care policies, and coordination of resident medical care in the facility. This had the potential to impact all 46 residents who resided in the nursing home at the time of the survey. Findings Include: During an extended survey, on 11/6/24, a medical director (MD) policy and the MD's job description and/or contract was requested; however, these items were not provided. During a telephone interview on 10/30/24 at 2:36 p.m., MD stated he was at the facility twice per month. Once to do residents rounds and the other was for paperwork; signing orders etc. The MD attended quality meetings as well. The MD was informed of staffing concerns; [...]

Inspectors wroteBased on interview, and document review, the facility failed to develop and implement appropriate plans of action to correct quality deficiencies identified during the survey that the facility was aware of or should have been aware. This had the potential to adversely affect all 46 residents residing in the facility.

Inspectors wroteBased on interview, and document review, the facility failed to develop, monitor, and evaluate their identified performance measures. This had the potential to affect all 46 residents residing in the facility.

Inspectors wroteStandard Precautions: R99's admission MDS dated [DATE], identified R99 had moderate cognition and required intermittent catheterization. Diagnoses included neurogenic bladder, Alzheimer's disease, and dementia. R99's physician notes dated 10/17/24, identified R99 performed catheterization by himself as needed to empty his bladder. R99's care plan dated 10/22/24, failed to identify R99's catheterization plan and goals including what personal protective equipment was needed. R99's medication administration report (MAR) dated 10/1/24 through 10/31/24, identified staff were required to perform catheterization for R99 every shift or as requested by the resident due to the resident's neuromuscular dysfunction of the bladder. On 10/29/24 at 10:17 a.m., R99 was seated in a wheelchair in his room. R99 stated he used a catheter to empty his bladder due to being unable to urinate on his own. [...]

Inspectors wroteBased on interview and document review, the facility failed to assure employee infection control training and education was completed for 4 of 10 (LPN-A, LPN-B, RN-A, DON) staff reviewed for training and education. This had the potential to affect all 46 residents residing in the facility.

Inspectors wroteBased on interview and document review, the facility failed to ensure staff completed mandatory communication training for 4 of 10 staff (DON, RN-E, NA-B, NA-I) reviewed for training requirements. This had the potential to affect all 46 residents residing in the facility.

Inspectors wroteBased on interview and document review, the facility failed to ensure staff completed mandatory training for resident rights for 3 of 10 staff (DON, RN-E, NA-A) reviewed for training requirements. This had the potential to affect all 46 residents residing in the facility.

Inspectors wroteBased on interview and document review, the facility failed to provide facility specific abuse prevention training to 5 of 10 employees (DON, RN-E, LPN-C, NA-I, NA-B) reviewed for training. This had the potential to affect all 46 residents residing in the facility.

Inspectors wroteBased on interview and document review, the facility failed to provide mandatory training on the facility specific Quality Assurance and Performance Improvement (QAPI) program to include goals and various elements of the program, how the facility intends to implement the program, staff's role in the facility's QAPI program, or how to communicate concerns, problems, or opportunities for improvement to the facility's QAPI program for 5 of 10 employees (DON, RN-E, LPN-C, NA-B, NA-I) reviewed for training requirements.

Inspectors wroteBased on interview and record review the facility failed to ensure staff were educated on infection control policies and procedures for 4 of 10 staff (DON, RN-E, LPN-C,NA-B) who's training records were reviewed and 3 of 3 staff (NA-B, NA-C, LPN-A) who identified they were not educated in procedures for standard, transmission-based and enhanced barrier precautions (EBP). This had the potential to impact all 46 residents who reside in the facility.

Inspectors wroteBased on interview and document review, the facility failed to ensure 4 of 10 staff (DON, RN-E, LPN-C, NA-B) received annual training on behaviors in Alzheimer's disease or related disorders, problem solving with challenging behaviors, and communication skills. This had the potential to affect all 46 residents residing in the facility.

Inspectors wroteBased on interview and document review, the facility failed to ensure 12 hours of annual in-service training was completed for 2 of 5 nursing assistants (NA-A, NA-B) reviewed for in service requirements. This had the potential to affect all 46 residents residing in the facility.

Inspectors wroteBased on interview and document review, the facility failed to ensure 3 of 10 staff (DON, RN-E, NA-B) received annual training on behaviors in Alzheimer's disease or related disorders, problem solving with challenging behaviors, and communication skills.

Inspectors wroteBased on observation, interview and document review, the facility failed to provide range of motion (ROM) services for 4 of 4 residents (R7, R19, R22 ,R43) reviewed for range of motion.

Inspectors wroteBased on interview and document review, the facility failed to provide toileting cares in a dignified manner for 1 of 1 resident (R12) reviewed for dignity.

Inspectors wroteBased on interview and document review, the facility failed ensure a voiced grievance was acted upon; and provide a written policy for how the facility would handle grievances for 1 of 1 resident (R20) reviewed for missing property

Inspectors wroteBased on interview and document review, the facility failed to ensure allegations of potential sexual abuse were reported or timely reported to the administrator and state agency (SA) for 1 of 1 resident (R39) reviewed for abuse involving 2 of 2 residents (R6, R31) with cognitive impairment, who was observed inappropriately touching other residents' multiple times

Inspectors wroteBased on interview and document review, the facility failed to provide immediate protection and investigate allegations of resident-to-resident sexual abuse for 2 of 2 residents (R31, R6) reviewed for abuse, who were abused by R39.

Inspectors wroteBased on interview and document review the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 1 of 3 residents (R7) reviewed for catheters.

Inspectors wroteBased on interview and document review, the facility failed to develop a comprehensive care plan for 1 of 2 residents (R7, R99); and failed to involve family during the care conference and document the care conference fully for 1 of 2 residents (R7) reviewed for catheters.

Inspectors wroteBased on interview and document review the facility failed to follow provider's orders for intermittent catheterization for 1 of 1 resident (R99); and failed to ensure catheter care was provided in a manner to prevent potential urinary tract infection (UTI) for 1 of 3 residents (R7) reviewed for catheters.

Inspectors wroteBased on interview and document review, the facility failed to provide the facility agreements for contracted services which had the potential to affect all 46 residents residing in the facility reviewed during the extended survey.

Inspectors wroteBased on interview and document review, the facility failed to develop and/or have evidence of an in-effect transfer agreement with a local Medicare participating hospital entity. This had potential to affect all 46 residents in the facility who could require hospitalization on an emergent basis.

Inspectors wroteBased on interview and document review the facility failed to thoroughly investigate an injury of unknown origin for 1 of 3 residents (R1) reviewed who sustained significant unexplained bruising.

Inspectors wroteBased on observation, interview and document review the facility failed to perform assessment to determine potential causal factors of extensive bruising for 1 of 3 residents (R1) reviewed for non-pressure related skin concerns. In additional the facility failed to implement interventions to prevent further injury.

Inspectors wroteBased on observation, interview and document review the facility failed to provide the physician ordered mechanically altered diet for 1 of 3 residents (R1) reviewed who was at risk for choking and served the wrong textured diet. This resulted in an immediate jeopardy (IJ) for R1. The IJ began on 5/28/24, when R1 was served a regular diet instead of the physician ordered pureed diet which resulted in R1 choking and requiring the Heimlich Maneuver to dislodge a corn dog. The administrator was notified of the IJ on 6/12/24, at 3:21 p.m. The IJ was removed on 6/13/24, at 1:15 p.m., but noncompliance remained at the lower scope and severity level D, with no actual harm with potential for more than minimal harm that was not immediate jeopardy.

Inspectors wroteBased on interview and document review, the facility failed to report an injury of unknown origin within 24 hours of it being identified to the State Agency (SA) for 1 of 3 residents (R1) reviewed for potential abuse.

Inspectors wroteBased on interview and document review, the facility failed to thoroughly investigate an injury of unknown source to ensure resident safety and appropriate interventions were implemented for 1 of 3 residents (R1) reviewed for potential abuse.

Inspectors wroteBased on observation, interview, and document review, the facility failed to assess for dementia related behaviors and implement individualized resident centered interventions to managed the dementia symptoms for for 2 of 3 residents (R3, R1) reviewed for potential abuse.

Inspectors wroteBased on interview and document review, the facility failed to offer and provide the most recent Centers for Disease Control (CDC) education regarding the potential risks and benefits of the pneumococcal vaccine for 5 of 5 residents (R7, R25, R34, R39, R43) reviewed for immunizations. This had the potential to affect all residents who were eligible for the pneumococcal booster.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure residents did not self-administer medications as assessed for 1 of 1 residents (R39) observed to self administer medication after staff set up.

Inspectors wroteBased on interview, and document review, the facility failed to assess, monitor and implement mental health interventions for 1 of 1 resident (R28) who had identified behavior needs.

Inspectors wroteBased on observation, interview and document review, the facility failed ensure the required daily nurse staffing information was posted. This had the potential to affect all 42 residents and/or visitors who may have wished to view the information.

Inspectors wroteBased on observation, interview and document review the facility failed to assess safety for 2 of 4 residents (R1, R4) following falls from recliner chairs. This resulted in actual harm for R1 who fell from a recliner chair and sustained lacerations and a brain bleed.

Inspectors wroteBased on observation, interview and document review the facility failed to assess for and failed to ensure 1 of 2 residents (R4) was free from the use of physical restraints when placed in recliner chairs that prevented rising independently.

Inspectors wroteBased on observation, interview, and document review the facility failed to maintain resident safety when a resident with a history of exiting the facility unsupervised, eloped through the Assisted Living (AL) wing of the facility at approximately 4:15 a.m. on 8/22/23. This resulted in an immediate Jeopardy (IJ) situation for R1. In addition, the facility failed to implement a system to ensure proper functioning of their Wander Alert system resulting in 1 of 3 residents (R3) reviewed for elopement, exiting the unit unnoticed by staff during the survey. The IJ began on 8/22/23, when R1 exited the facility via the attached AL wing of the facility after staff left her unattended in the lobby for the second time during the overnight shift at 4:15 a.m. R1 was not located again until 4:45 a.m. when she was attempting to re-enter the building. [...]