Above average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Zumbrota Care Center during CMS and state inspections, most recent first.
A facility failed to provide the required SNFABN to two residents whose Medicare Part A coverage ended but who stayed in the facility on private pay. Although NOMNCs were signed and indicated coverage would end, the records lacked evidence that the residents or their representatives were given the ABN explaining potential costs and options. Interviews showed confusion between SS and the HUC about who was responsible for completing the forms, and both confirmed the forms were not completed for these residents.
A resident with an indwelling biliary drain was allowed to empty and manage the drainage bag without a documented competency assessment showing he could safely self-manage the device. The resident’s bag was observed clipped high on his upper chest above the insertion site, while RN, NM, MD, and DON interviews confirmed staff performed site care but had no assessment verifying the resident’s knowledge or ability to manage the drain independently.
Failure to identify PTSD triggers and complete a trauma-informed care plan for a resident with PTSD, Parkinson’s disease, and anxiety disorder. The resident’s trauma-informed assessment identified the resident as a trauma survivor, but no triggers were documented to avoid re-traumatization, and the care plan lacked PTSD triggers or interventions. The RN, NA, and LPN all acknowledged the absence of documented triggers/interventions, and social services stated the assessment was completed but was unaware of responsibility for the care plan.
Failure to document and offer PCV20 vaccination to 3 residents. Two residents had prior PCV13 and PPSV23 immunizations, but the chart lacked evidence of shared clinical decision-making with the provider and resident/rep. A third resident’s pneumococcal history was unclear, and the IP confirmed the family was not followed up with to verify which vaccine had been received; the IP also confirmed PCV20 had not been discussed with any of the 3 residents.
The facility did not comprehensively assess or document the correct sling and harness sizes for two residents requiring mechanical lifts for transfers, resulting in staff relying on weight-based charts and informal communication rather than manufacturer-recommended measurements and documentation. This led to inconsistencies and lack of clear guidance in care plans and Kardexes regarding the appropriate equipment for safe resident transfers.
Failure to comprehensively assess falls and update individualized fall interventions. A resident with Lewy body dementia, non-Alzheimer’s dementia, gait/balance problems, incontinence, and a history of falls had repeated falls related to reaching for spilled water, trying to toilet without help, and independently transferring to a recliner. The record showed root causes were documented in some notes, but toileting needs, self-transfer risk, and other individualized fall factors were not fully assessed or reflected in the care plan.
Failure to develop an individualized toileting program for a resident with dementia, diabetes, frequent bladder incontinence, and occasional bowel incontinence. The resident required 1-person assist for transfers and toileting, stated staff did not always help him to the bathroom in time, and staff confirmed there was no toileting plan in place despite his need for assistance and history of falls.
Surveyors found that food items such as soup, potato salad, and diced ham cubes were stored in facility refrigerators without required labels or dates. Staff were unable to confirm the age of these foods, and the facility's policy mandates labeling and dating of all prepared and opened food items. This deficiency had the potential to affect 35 residents receiving food from these refrigerators.
Failure to provide a completed SNF ABN when a resident’s Medicare Part A coverage ended. The resident remained in the facility as private pay after the NOMNC was issued and signed by the responsible party, but the record lacked evidence that the SNF ABN was given to explain the estimated daily cost or the rationale for continued services. The SS director stated she provided the NOMNC and appeal rights but was unaware of the SNF ABN and had not been providing it.
The facility failed to notify the Ombudsman of resident admissions, discharges, and transfers. The SW stated she tracked these events but did not know the notifications had to be sent, and confirmed they were not sent. The administrator also confirmed the notifications had not been submitted to the designated ombudsman.
Two residents with cognitive impairment and a history of wandering successfully eloped from the facility due to a malfunctioning Wanderguard system and inadequate assessment and intervention for elopement risk. Staff failed to notify maintenance or test the system after the first incident, and care plans did not specify needed supervision or address risk factors. Testing revealed that most Wanderguard-equipped doors did not alarm as intended, leaving residents unsupervised and able to exit undetected.
The facility obtained nursing staff from an unregistered supplemental nursing service agency, Swenswen Staffing, LLC, which was not listed as approved by the state and had an expired registration certificate. Both nursing assistants and trained medication aides from this agency provided care to all residents during the review period. The administrator was unaware of the requirement to verify agency registration, and no policy on supplemental staffing was available.
The facility did not update its assessment to reflect that overnight nursing and aide staff were regularly shared with the assisted living facility, resulting in an inaccurate staffing plan that overstated the number of staff available to meet resident needs. The assessment failed to account for staff time spent outside the nursing home, and this discrepancy was confirmed by both the administrator and DON.
A resident with dementia and a history of elopement risk was found outside the facility after the Wanderguard alarm failed to activate. The incident was not reported to the administrator or state agency within the required two-hour timeframe, as outlined in facility policy, resulting in a delay in notification.
A resident identified as an elopement risk had a Wanderguard device in place and checked daily, but the MDS assessment failed to accurately document the use of this wander/elopement alarm. Staff confirmed the device was present and in use, and the MDS Coordinator acknowledged the omission.
Nurse staffing information posted by the facility did not accurately reflect the actual hours worked by nursing staff directly responsible for resident care, as staff assigned to the nursing home also provided care in the assisted living facility during their shifts. The posted forms failed to adjust for time spent away from the nursing home, resulting in inaccurate reporting of staff presence and hours worked.
The facility submitted inaccurate PBJ staffing data to CMS by failing to subtract hours that nursing staff spent assisting at an assisted living center during their scheduled shifts. Documentation and staff interviews confirmed that this practice resulted in overreported staffing hours for the facility, as the reported data did not reflect actual time spent providing care within the facility.
The facility did not ensure that the dietary manager was certified to oversee nutrition and food services in the absence of a full-time registered dietician. The DM had been employed for about a year without the necessary certification, although she had a ServSafe certificate. The RD and administrator were aware of this issue, which had the potential to affect all 32 residents.
The facility failed to submit accurate staffing data to CMS for Q1 FY2024, missing licensed nursing coverage on specific dates. Despite having scheduled and employed licensed nurses, the data submitted was incomplete due to a misunderstanding of requirements.
Missing SNFABN When Medicare Part A Ended
Penalty
Summary
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) before services terminated. Two residents, R4 and R31, were identified as affected. R31 was admitted on Medicare Part A coverage, which ended on 5/11/26, and remained in the facility on private pay the next day. Although R31 had a signed Notice of Medicare Non-coverage (NOMNC) dated 5/7/26 stating Medicare coverage would end on 5/11/26, the electronic medical record did not show that a SNFABN was provided to R31 or the representative to advise of the potential cost of staying in the facility after Medicare Part A ended and to offer the choice of receiving the services, asking Medicare to be billed, or declining the services. R4 started Medicare Part A coverage on 5/4/26 and it ended on 6/27/26; R4 remained in the facility on private pay the next day. R4’s NOMNC, signed 6/24/26, stated Medicare coverage would end on 6/27/26 and noted verbal consent from the responsible party, with the form signed by the facility social services employee. However, the record lacked evidence that a SNFABN was provided to R4 or the representative. During interviews, the social services employee stated she had not been completing the forms and was not trained on them, while the health unit secretary stated she had not completed the NOMNC or ABN forms since April 2026 and confirmed R4 and R31 did not receive them. The administrator stated the NOMNC and ABN forms should be completed in a timely manner, and the facility policy stated that if the beneficiary continues to stay in the care center, the facility would provide the NOMNC and SNF ABN demand bill portion.
Failure to Assess Competency for Self-Management of Biliary Drain
Penalty
Summary
The facility failed to ensure a resident with an indwelling biliary drain had the clinical knowledge and skills needed to independently monitor and manage the device, and failed to clinically assess the resident’s competency to self-manage it. R12’s record showed he was cognitively intact, independent with most activities of daily living, and had diagnoses including kidney disease, chronic gall bladder inflammation, stroke, aphasia, PTSD, and a history of falls. His care plan stated he emptied the drainage bag independently, while provider orders directed dressing changes to the insertion site twice daily and monitoring for signs of infection. During observation, R12 was seen with the biliary tube inserted below the right ribcage and the drainage bag clipped to his upper left chest, above the level of the insertion site, and he stated he emptied the bag himself and had been told by facility staff to hang it on his upper left chest. Staff interviews showed nursing performed site care and dressing changes, while R12 managed emptying and changing the drainage bag. RN-B stated staff did not track the amount of drainage and assessed it based on what was collecting in the tube, and she had no specific training regarding management of a biliary drain. The NM stated R12 had the drain for 5 to 6 years and staff did not have an assessment showing he was knowledgeable enough to care for the drainage bag and report concerns independently. The MD stated the drainage bag should hang below the opening for proper drainage and that placing it on the left upper chest would pose a problem if R12 was lying down because fluid would flow back into the gallbladder. The DON stated staff were responsible for emptying the bag, monitoring drainage, and providing site care unless it was determined R12 was safe to do so himself.
Failure to Identify PTSD Triggers and Complete Trauma-Informed Care Plan
Penalty
Summary
The facility failed to identify trauma triggers and failed to develop an individualized trauma-informed care plan for one resident with a history of trauma. The resident’s MDS assessment showed intact cognition with no hallucinations, delusions, behaviors, or rejection of care, and the resident’s diagnoses included PTSD, Parkinson’s disease without dyskinesia, and an anxiety disorder. A trauma-informed assessment identified the resident as a trauma survivor, but no triggers were identified to avoid potential re-traumatization. The resident’s current care plan, revised on 6/26/26, did not include any PTSD triggers or interventions. During interviews, the RN stated that residents with PTSD should be assessed for triggers and that those triggers should be documented on the care plan; after reviewing the care plan, the RN acknowledged that trauma-informed care planning was lacking. The NA stated awareness of the resident’s PTSD diagnosis but could not locate triggers or interventions on the care plan or Kardex. The LPN stated awareness of the PTSD diagnosis but was not aware of any specific triggers or interventions. Social services stated that the trauma-informed care assessment had been completed but was unaware of responsibility for completing the trauma-informed care plan.
Failure to Document and Offer PCV20 Vaccination
Penalty
Summary
Develop and implement policies and procedures for flu and pneumonia vaccinations after the facility failed to ensure 3 of 5 residents reviewed for immunizations were offered and/or provided the pneumococcal conjugate vaccine (PCV20) as recommended by the CDC. The report states that adults 65 years of age or older who previously completed the pneumococcal vaccine series with PCV13 and PPSV23 may receive PCV20 through a shared clinical decision-making process with a provider, and that this decision should be documented in the medical record. R2’s record showed she was 65 years old and had received PPSV23 and PCV13, but there was no documentation of shared decision-making with the provider and resident or responsible agent regarding PCV20. R29’s record showed she was 65 years old and had received PCV13 and PPSV23, but likewise lacked documentation of shared decision-making about PCV20. R31’s record showed she was 65 years old, the MIIC report did not show any pneumococcal vaccines, and the vaccination consent form only indicated a prior pneumococcal vaccine without identifying which one; there was no documentation of shared clinical decision-making regarding PCV20. During interview, the ADON stated the family member thought R31 had received the pneumococcal vaccine, but the IP did not follow up to determine which vaccine was received, and the IP confirmed that neither she nor the facility provider had discussed providing PCV20 to R2, R29, or R31.
Failure to Assess and Document Proper Sling/Harness Sizes for Mechanical Lift Transfers
Penalty
Summary
The facility failed to comprehensively assess and document the appropriate sling and harness sizes for residents requiring mechanical lifts for transfers, as per manufacturer instructions. For two residents with significant mobility impairments and histories of falls, the care plans, Kardexes, and therapy/nursing communication forms did not specify the required sling or harness sizes. Although assessments noted residents' heights and weights, they did not include all manufacturer-recommended measurements, such as the distance from tailbone to base of neck or torso circumference, which are necessary for proper sizing and safe transfers. Direct care staff interviews revealed that nursing assistants determined sling and harness sizes primarily based on residents' weights and reference charts, rather than comprehensive assessments. Staff reported relying on slings or harnesses found in residents' rooms or consulting with other aides if uncertain about sizing. There was inconsistency among staff regarding which size should be used for each resident, and the required measurements for proper fit were not routinely obtained or documented. The lack of clear documentation in the care plans and Kardexes meant that staff did not have immediate access to the correct sling or harness size information during transfers. The assistant director of nursing confirmed that comprehensive sling and harness assessments had not been completed for the residents in question, which resulted in the absence of this information in their care plans. Manufacturer instructions for the mechanical lifts and harnesses emphasize the need for a full patient assessment to determine the appropriate accessory size and type prior to each use. The facility was unable to provide a policy and procedure for mechanical lift equipment upon request.
Failure to comprehensively assess falls and update individualized fall interventions
Penalty
Summary
The facility failed to comprehensively assess each fall to identify and analyze causal factors for potential root cause and to determine individualized interventions to prevent or decrease the risk for future falls for one resident with repeated falls. The resident had a history of Lewy body dementia, non-Alzheimer’s dementia, anxiety, diabetes, gait and balance problems, intermittent confusion, and use of assistive devices. The resident’s records also showed incontinence, need for extensive assistance with transfers and toileting, and a history of falls including a prior hip fracture with surgical intervention. After a fall in which the resident was found face down on the floor next to the bed with wet clothing and water on the floor, the record identified that the resident had spilled water and reached forward from the wheelchair to pick it up. The post-fall documentation listed contributing factors such as spilled water and incontinence, and the fall progress note identified the root cause as the resident spilling the cup and reaching forward from the wheelchair. However, the record did not show that the resident’s incontinence and need for toileting assistance were addressed in a toileting care plan, and the last time the resident had been toileted was not identified. Following another fall in the bathroom, the resident stated he was trying to do it by himself and had attempted to go to the bathroom without assistance. The documentation identified self-transfer as the root cause, and later notes described the resident as unable to make safe decisions due to dementia, parkinsonism, and Lewy body disease. Review of the record showed no indication that a comprehensive assessment was completed to determine individualized interventions for the resident’s self-transfer risk related to needing to use the bathroom, and the care plan was not updated to reflect interventions such as a low bed or floor mat. A later fall occurred when the resident was found on the floor in his room on his knees while trying to get back into his recliner, and the record identified multiple possible contributing diagnoses, but there was no indication that an intervention was developed and implemented to address the resident independently transferring to the recliner or that the care plan was updated to include the later identified interventions.
Failure to Develop an Individualized Toileting Program
Penalty
Summary
The facility failed to develop an individualized toileting program to maintain or improve bowel and bladder continence for a resident reviewed for falls. The resident’s quarterly MDS identified intact cognition, diagnoses of Lewy body dementia, non-Alzheimer’s dementia, anxiety, and diabetes, and the resident required extensive assistance of one person for transfers, toileting, and toileting hygiene. The resident was frequently incontinent of bladder and occasionally incontinent of bowel. Review of the resident’s record showed no indication that a comprehensive bowel and bladder assessment had been completed. The care plan included general ADL support and a focus on bladder incontinence, with interventions such as monitoring and documenting possible causes of incontinence, cleaning the peri area after incontinent episodes, and using a medium pull-up brief changed daily and as needed. However, the care plan did not include an individualized toileting schedule or program. During observation and interview, the resident stated he needed help getting to the bathroom so he would not fall, but he did not always get to the bathroom in time because staff did not always offer assistance. The resident also stated he could not reliably remember to look at the sign placed on his dresser to remind him to call for help. Nursing staff and the nurse manager confirmed the resident did not have a toileting plan in place, despite needing assistance with toileting and transfers and having a history of falls. The nurse manager stated the facility did not really have a process in place for a personalized toileting plan and needed to develop one.
Failure to Label and Date Stored Food Items
Penalty
Summary
During a kitchen tour, surveyors observed that food items stored in the facility's refrigerators were not labeled or dated as required. Specifically, a large walk-in refrigerator contained an undated plastic container half full of soup, and the kitchen prep area refrigerator contained an undated three-quarters full plastic container of potato salad and an undated plastic container one-quarter full of diced ham cubes. Staff present at the time were unable to confirm how old these food items were or provide information on when they had been prepared or stored. The facility's policy on perishable food management requires all foods not in their original packaging to be labeled with a description and dates, including a use-by or discard date. The policy also states that leftover foods must be clearly labeled before refrigeration and used within three days, with disposal on the fourth day. The observed failure to label and date these food items was confirmed by the dietary manager, who stated that it is expected for all prepared foods and opened packages to be dated prior to storage. This deficiency had the potential to affect 35 residents who received food from these refrigerators.
Failure to Provide SNF ABN When Medicare Part A Coverage Ended
Penalty
Summary
The facility failed to provide a completed Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN CMS 1005) to 1 of 3 residents reviewed, R6, whose Medicare Part A coverage ended and who remained in the facility. R6’s census record showed the payer source changed to private pay on 5/23/25, and the face sheet listed private pay as the primary payer source with Medicare B as secondary. The Notice of Medicare Non-coverage (NOMNC) identified 5/22/25 as the last covered day and showed verbal consent from R6’s responsible party on 5/19/25, with the form signed on 5/22/25. R6’s medical record did not contain evidence that a SNF ABN was provided to explain the estimated daily cost or to give a rationale or explanation for the extended care services or items to be furnished, reduced, or terminated. During interview, R6’s responsible party confirmed receipt and signing of the NOMNC and stated they did not recall discussing the potential cost of continuing services or completing a SNF ABN. The social services director stated she provided the NOMNC and explained the right to appeal, but was unaware of the SNF ABN form and had not been providing them; she confirmed R6’s responsible party did not receive the SNF ABN. The administrator stated it was the expectation that the SNF ABN be provided when the NOMNC is given if the beneficiary chooses to remain at the facility.
Failure to Notify Ombudsman of Transfers and Discharges
Penalty
Summary
The facility failed to notify the Ombudsman of resident transfers and discharges. During survey documentation review and preparation, the designated ombudsman was contacted and stated she had not received any notifications from the facility about transfers and discharges. During interview, the social worker stated she keeps track of admissions, discharges, and transfers but was unaware that these notifications needed to be sent to the ombudsman, and she confirmed they had not been sent. The administrator stated the social worker is responsible for keeping a log of admissions, discharges, and transfers, but was unaware whether the notifications had been submitted to the designated ombudsman and confirmed she had not sent them.
Failure to Maintain Wanderguard System and Comprehensive Elopement Risk Assessment
Penalty
Summary
The facility failed to maintain a functioning Wanderguard system and did not comprehensively assess or implement appropriate interventions for residents at risk of elopement, resulting in two residents successfully eloping from the building. In one case, a resident with severe cognitive impairment and a history of wandering was able to exit the facility without the Wanderguard alarm sounding. Staff did not notify maintenance of the malfunction, did not test all doors or Wanderguard devices after the incident, and did not provide education to staff regarding system testing. The Director of Nursing was unaware of manufacturer recommendations for testing and did not know how the doors were being tested. Another resident, with multiple diagnoses including dementia, Parkinson's disease, and visual deficits, was not accurately assessed for elopement risk despite documented behaviors such as confusion, wandering at night, and exit-seeking. The resident exhibited multiple behaviors and verbalizations indicating risk, including calling 911, wandering the facility at night, and expressing a desire to leave. Despite these behaviors, the resident was not reassessed for elopement risk, and no interventions beyond the eventual placement of a Wanderguard were implemented. The care plan did not specify the needed level of supervision or address the management of elopement risk factors. Testing of the Wanderguard system revealed that four out of five doors did not alarm when tested with a Wanderguard bracelet, and one door did not alarm when opened with the automatic button. Staff and the Environmental Services Director were unaware of these issues, and daily testing logs were found to be incomplete. The administrator and staff relied on the Wanderguard system to alert them to elopement risks, but the system's failure left residents unsupervised and able to exit the facility undetected.
Use of Unregistered Supplemental Nursing Service Agency
Penalty
Summary
The facility failed to comply with state requirements regarding the use of supplemental nursing service agencies (SNSAs) by obtaining nursing staff from Swenswen Staffing, LLC, which was not registered with the commissioner as required. Document review confirmed that Swenswen Staffing, LLC was not listed as an approved SNSA on the Minnesota Department of Health website, and the certificate of registration provided by the agency had expired. Staffing schedules showed that Swenswen Staffing, LLC provided both nursing assistants and trained medication aides to the facility on multiple occasions within the reviewed period. During interviews, the staffing coordinator verified that Swenswen Staffing, LLC had provided staff in the past month, and the facility administrator stated she was unaware of the requirement to verify SNSA registration status prior to obtaining staff. Additionally, the facility was unable to provide a policy on supplemental staffing when requested. This deficiency had the potential to affect all 34 residents who received care from the supplemental staff during the period in question.
Failure to Accurately Assess and Document Staffing Needs Due to Shared Staff with Assisted Living
Penalty
Summary
The facility failed to review and update its facility-wide assessment to accurately identify the staffing plan necessary to meet residents' needs during both routine operations and emergencies. Documentation and interviews revealed that overnight staff assigned to the nursing home were also providing services at the assisted living facility, a practice not reflected in the facility's assessment or staffing plan. The staffing plan listed the number of licensed nurses, nursing assistants (NAs), and trained medication aides (TMAs) required for each shift but did not account for the time these staff spent working in the assisted living facility. As a result, the actual number of staff available to care for residents in the nursing home was less than what was documented in the assessment. The administrator and DON confirmed that staff had been providing care at the assisted living facility during their scheduled shifts at the nursing home, and that this practice had been ongoing for some time. The administrator acknowledged that the facility assessment was not accurate, as it included staff hours spent in the assisted living facility as part of the nursing home's staffing hours. The facility assessment policy was requested but not provided. No information was given regarding specific residents affected or their medical conditions at the time of the deficiency.
Failure to Timely Report Resident Elopement
Penalty
Summary
The facility failed to immediately report an elopement incident involving a resident with dementia, delirium, and a history of falls. The resident, who required supervision for transfers and had severe cognitive impairment, was identified as being at risk for elopement and had interventions in place, including a Wanderguard device. Despite these measures, the resident was found wandering outside the facility, and it was noted that the Wanderguard alarm did not activate when the resident exited, though it did sound upon re-entry. The incident was documented in the resident's progress notes and incident report, which indicated confusion and impaired memory as contributing factors. The nurse on duty did not report the elopement to the on-call nurse, administrator, or DON immediately after the event. The incident was not reported to the state agency until the following day, exceeding the facility's policy requirement to report such events to the administrator and state agency within two hours. Facility policies reviewed confirmed the expectation for immediate reporting of elopements and potential neglect, but these procedures were not followed in this case.
Inaccurate MDS Coding for Wander/Elopement Alarm Use
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was accurately coded to reflect the use of a wander/elopement alarm for a resident identified as being at risk for elopement. The resident's quarterly MDS assessment indicated that no wander/elopement alarm was used during the look-back period, despite documentation and care plans showing that a Wanderguard device was in place on the resident's wrist and checked daily. Observations and interviews with staff confirmed the presence and use of the Wanderguard device, and the MDS Coordinator acknowledged that the device should have been documented on the MDS but was missed. The facility's MDS assessment policy was requested but not provided.
Inaccurate Posting of Nurse Staffing Hours Due to Staff Coverage in Assisted Living
Penalty
Summary
The facility failed to accurately post daily nurse staffing information reflecting the total number and actual hours worked per shift by nursing staff directly responsible for resident care. Documentation showed that nursing assistants assigned to the nursing home were also providing care in the connected assisted living facility during their scheduled shifts. However, the posted nurse staffing forms did not account for the time these staff members spent away from the nursing home, resulting in inaccurate reporting of hours worked in the facility. For example, one nursing assistant was scheduled from 10:00 p.m. to 6:30 a.m., but records indicated that one hour of this shift was spent providing care in the assisted living facility, not the nursing home. Despite this, the posted staffing information listed the full shift as being worked in the nursing home and did not adjust the total hours accordingly. Interviews with staff, including the administrator, staffing coordinator, and DON, confirmed that it was common practice for nursing home staff to assist in the assisted living facility during overnight shifts, and that the posted staffing hours did not reflect the actual time spent in each location. The staffing coordinator acknowledged that adjustments to posted hours were not made in real time and were often updated the following day, if at all. The facility's policy on staffing was requested but not provided for review. This failure to accurately post nurse staffing information had the potential to affect all residents and visitors who relied on this information.
Inaccurate PBJ Staffing Data Submission Due to Unadjusted Staff Hours
Penalty
Summary
The facility failed to submit accurate and complete direct care staffing information to CMS for one reviewed quarter, as required by federal regulations. Payroll Based Journal (PBJ) data submitted for the quarter included total nursing staff hours for various roles, but did not account for time that facility staff spent providing services at the assisted living center during their scheduled shifts at the facility. Documentation, including the 'AL Filling in Time Book,' showed that staff regularly left the facility to assist at the assisted living center, with over 50 hours documented during the quarter. Some entries in the log were illegible or incomplete, making it difficult to determine the exact amount of time spent away from the facility. Interviews with the DON, administrator, and director of human resources confirmed that this practice had been ongoing and that the time spent by staff at the assisted living center was not subtracted from the hours reported to CMS in the PBJ submissions. The director of human resources acknowledged that the PBJ hours submitted were incorrect, as they were based solely on timecard data without adjusting for time spent away from the facility. The facility's PBJ policy was requested but not provided.
Uncertified Dietary Manager in Absence of Full-Time RD
Penalty
Summary
The facility failed to ensure that the dietary manager (DM) was certified to oversee nutrition and food services in the absence of a full-time registered dietician (RD). The DM had been employed at the facility for about a year but was not a certified dietary manager, although she had recently received her ServSafe certificate. The RD, who visited the facility every four to six weeks and worked online with staff, was aware that the DM did not meet the required credentials. The administrator was also aware of the DM's lack of certification and had been discussing the need for her to enroll in a course. This deficiency had the potential to affect all 32 residents residing in the facility.
Inaccurate Staffing Data Submission to CMS
Penalty
Summary
The facility failed to submit accurate and complete staffing data to the Centers for Medicare and Medicaid Services (CMS) for the first quarter of the fiscal year 2024. The CMS payroll-based journal (PBJ) staffing data report indicated that the facility did not have licensed nursing coverage 24 hours a day on specific dates in December 2023. However, upon review, it was found that licensed nurses were indeed scheduled and worked on those dates. The health unit coordinator, responsible for nurse staff schedules, confirmed that a licensed nurse was scheduled for each shift and verified the presence of licensed nurses on the infraction dates. The human resources representative, who entered staffing data into a spreadsheet for corporate submission to CMS, acknowledged that the data submitted was inaccurate and did not include all licensed staff who had worked. This discrepancy was attributed to a misunderstanding of the data requirements. The facility's Payroll Based Journal policy, dated April 1, 2019, outlines the process for gathering and preparing PBJ data, emphasizing the need for complete and accurate information for all care center, agency, and contract staff. Despite the policy, the facility failed to ensure the accuracy of the staffing data submitted to CMS.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Nursing homes near Zumbrota
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Edenbrook Pine Haven | 6.1 mi | ★★★★★ | 25 | 0 |
| Rochester Rehabilitation And Living Center | 17.2 mi | ★★★★★ | 16 | 0 |
| Madonna Towers Of Rochester | 18.1 mi | ★★★★★ | 5 | 0 |
| St Crispin Living Community | 18.2 mi | ★★★★★ | 15 | 1 |
| Edenbrook Rochester West | 19.2 mi | ★★★★★ | 25 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.