Zumbrota Care Center

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents whose Medicare Part A services were ending, but who remained in the facility, received the required Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) (Form CMS-10055) prior to the termination of services to advise them of potential costs and options. This affected 2 of 3 residents (R4 and R31) reviewed for Medicare Part A coverage termination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident possessed the clinical knowledge and skills required to monitor and manage an indwelling medical device independently, and failed to clinically assess the resident's competency to self-manage the device. This affected 1 of 1 resident (R12) reviewed for an indwelling biliary drain.

Inspectors wroteBased on interview and document review, the facility failed to identify triggers or attempt to identify triggers to avoid potential re-traumatization and failed to develop a care plan to include individualized trauma-informed approaches for 1 of 1 resident (R29) who had a history of trauma.

Inspectors wroteBased on interview and document review, the facility failed to ensure 3 of 5 residents (R2, R29, R31) reviewed for immunizations were offered and/or provided the pneumococcal conjugate vaccine (PCV)20 as recommended by the Centers for Disease Control (CDC) to help reduce the risk of associated infections. Findings Include: A review of the CDC Shared Clinical Decision-Making document titled PCV20 or PCV21 Vaccination for Adults 65 years or older dated 9/11/24 indicated that adults [AGE] years of age or older have the option to receive supplemental PCV20 or PCV21 if they previously completed the pneumococcal vaccine series with both PCV13 and PPSV23. [...]

Inspectors wroteBased on observation, interview and document review the facility failed to comprehensively assess sling/harness sizes according to manufacturer's instructions to ensure safe transfers for 2 of 2 residents (R1 and R4) who utilized mechanical lifts sit to stand lift and full body mechanical lifts for transfers.

Inspectors wroteBased on observation, interview, and document review the facility failed to comprehensively assess each fall to identify and analyze causal factors for potential root cause in order to determine individualized interventions to prevent or decrease the risk for future falls for 1 of 3 residents (R2) reviewed for falls.

Inspectors wroteBased on observation, interview and document review the facility failed to develop an individualized toileting program to maintain or improve bowel/bladder continence for 1 of 3 residents (R2) reviewed for falls.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure food stored in the refrigerators were labeled and dated appropriately. This deficient practice had the potential to affect 35 residents who received food from the refrigerators.

Inspectors wroteBased on interview and document review, the facility failed to provide completed Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN CMS 1005) to 1 of 3 residents (R6) reviewed whose Medicare Part A coverage ended and then remained in the facility.

Inspectors wroteBased on interview and document review, the facility failed to notify the Ombudsman of transfers and discharges. During the survey documentation review and preparation process, the designated ombudsman was notified of the upcoming facility survey. Per electronic communication on 8/1/2025 at 10:38 a.m., ombudsman stated she had not received any notifications from the facility about transfers and discharges. During interview on 8/7/25 at 8:57 a.m., social worker (SW) stated she does keep track of admissions, discharges, and transfer. SW stated she was unaware she needed to send the admissions, discharges, and transfer notifications to the ombudsman. SW confirmed she had not sent the admissions, discharges, and transfer to the ombudsman. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to maintain a functioning Wanderguard system and failed to comprehensively assess risk for elopement and appropriate interventions, resulting in elopement for 2 of 7 residents (R1, R2). R1's elopement occurred due to the failure of the Wanderguard system, which did not sound an alarm when R1 exited the building. R2's elopements occurred due to R2's risk of elopement was not accurately comprehensively assessed leading to insufficient supervision and lack of intervention, followed by a failure of the Wanderguard system. The facility's failures resulted in an immediate jeopardy (IJ). [...]

Inspectors wroteBased on interview and document review, the facility failed to be in compliance with the supplemental nursing service agency (SNSA) requirements when the facility obtained nursing services from Swenswen Staffing, LLC (an SNSA) which was not registered with the commissioner as required. This had the potential to affect all 34 residents of the facility who received services from the supplemental staff.

Inspectors wroteBased on interview and document review, the facility failed to review and update the facility assessment to identify the facility's staffing plan for number of staff needed to ensure sufficient qualified staff were available to meet residents' needs.

Inspectors wroteBased on interview and document review, the facility failed to report an elopement immediately to the administrator and to the State Agency within 2 hours for 1 of 1 resident (R1) who had eloped from the facility.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure the Minimum Data Set (MDS) was accurately coded to reflect wander/elopement alarm use for 1 of 2 residents (R1) reviewed for MDS accuracy.

Inspectors wroteBased on interview and document review, the facility failed to post accurate data reflecting the total number and actual hours worked per shift by nursing staff directly responsible for resident care on a daily basis. This had the potential to affect all 34 residents residing in the facility and their visitors who may wish to review the information.

Inspectors wroteBased on interview and document review the facility failed to submit accurate and/or complete data for staffing information based on payroll and other verifiable and auditable data during 1 of 1 quarter (Quarter 2) reviewed, to the Centers for Medicare and Medicaid Services (CMS), according to specifications established by CMS. This had the potential to affect all 34 residents of the facility who received services from the supplemental staff.

Inspectors wroteBased on interview and document review, the facility failed to ensure that in the absence of a full-time registered dietician (RD), the dietary manager (DM) was certified to oversee nutrition and food services. This had potential to affect all 32 residents who resided in the facility.

Inspectors wroteBased on interview and document review, the facility failed to submit accurate and/or complete data for staffing information, including information for licensed nursing staff, based on payroll and other verifiable and auditable data during 1 of 1 quarter reviewed - FY (fiscal year) Quarter 1 2024, (October 1 - December 31), to the Centers for Medicare and Medicaid Services (CMS), according to specifications established by CMS.