The Shores of Worthington: Infection Control Failures - MN
Nobody tracked it. Nobody analyzed the data. Nobody told the medical director it had happened.
When inspectors returned on March 4, 2025, they found a facility with 39 active infections the prior month, 20 vacant staff positions, 14 active pressure ulcers across five residents, and 16 falls in February alone. The person whose job it was to monitor disease spread across all 56 residents had been gone since February 14. The nurse the administrator said was covering for her had never been told she was covering for her.
"I was never told to assist in oversight of the IC program," RN-B told inspectors on March 3. She had no knowledge of what was being entered into the facility's infection tracking system.
The administrator, interviewed the same day, said RN-B was handling it. He was wrong about that. He was also unaware, he acknowledged, that the director of nursing and assistant director of nursing had not provided direct oversight of the infection control program while the preventionist was out. The medical director said he learned about the gap from inspectors. He had not been told the contracted infection preventionist, brought on February 17 specifically to help remediate a deficiency cited in January, had never actually been briefed on the facility's situation. The first real conversation with that consultant, the director of nursing confirmed, had happened only the week before inspectors arrived.
One resident whose situation captured what this gap meant in practice was a man identified in the report as R41, admitted to the facility in September 2024 from a sister facility that had since closed. He had multiple fractures, an artificial hip, hypothyroidism, and anxiety. In November, his physician documented an additional diagnosis: chronic Hepatitis C, a bloodborne disease transmissible through contact with infected blood. His care plan, undated and reviewed by inspectors in March, contained no mention of it. His name did not appear anywhere in the facility's infection surveillance records for February or March.
The director of nursing agreed, when inspectors raised it, that Hepatitis C was a highly infectious disease and should have been on the surveillance list. It wasn't.
The employee illness tracking told a similar story. In January 2025, three staff members had reported illnesses, including coughs, fever, and abdominal pain. The columns for whether symptoms had resolved and when each employee returned to work were left blank. When the director of nursing followed up by email on March 4, she had to check with payroll to find return dates for two of the workers. She also realized she had been listed as ill that month herself. She had forgotten to enter her own return-to-work date.
"I agreed all data needed to be inputted to ensure illnesses were tracked and staff were kept off work for the appropriate amount of time," she told inspectors.
The facility had been cited for infection control failures before. The January 2025 revisit had produced a plan of correction that included contracting with an outside infection preventionist to begin immediately upon the contract's start date of February 17. That person was supposed to conduct root cause analysis, review the program, and help develop audit tools. By March 4, none of that had happened. The DON confirmed the facility had only spoken to the consultant for the first time the previous week.
No policy governing oversight of the infection control program was provided to inspectors by the end of the survey.
The infection control failures were part of a broader pattern of a quality improvement system that had, in effect, stopped functioning. The facility's Quality Assurance and Performance Improvement committee, known as QAPI, met monthly and produced minutes. What the minutes showed, across more than a year of meetings reviewed by inspectors, was a committee that gathered numbers and then did almost nothing with them.
In February 2024 through January 2025, department heads brought data on infections, falls, incident reports, and vaccinations to the committee. No benchmarks were set for any of it. No monitoring was put in place to determine whether conditions were improving or getting worse. The administrator confirmed to inspectors on March 4 that no measurable goals had been established and that the committee would need to formalize a process for identifying improvements.
The March 2025 QAPI meeting minutes, reviewed by inspectors, showed the same problem playing out in real time across every topic on the agenda.
Fourteen active pressure ulcers were reported involving five residents. The facility's stated goal was a 5 percent pressure ulcer rate. The current rate was left blank. The action items recorded were that staff were working on care plans and turning and repositioning. There was no analysis of where on residents' bodies the wounds were located, what might be causing them, what conditions the affected residents shared, or what education or audits might be needed.
Sixteen falls in February. Two with documented minor injuries. No goal listed, no current rate listed. The notes recorded that care plans had been reviewed and that isolation and possible urinary tract infections were contributing factors. One resident, identified as R1, was still being evaluated to see whether her bed could be kept at its lowest position after she had been found on the floor. Beyond that, nothing. No analysis of time of day, no review of whether certain residents needed closer supervision, no look at whether staff were performing transfers correctly.
Thirty-nine active infections the prior month, including 22 respiratory cases involving COVID, pneumonia, and RSV. No goal. No benchmark. The action items said to continue isolation and testing. The notes mentioned the facility was working on getting the infection preventionist her training so she could run the program independently, but there was no discussion of who was overseeing the program in the meantime, or when the training would be completed.
Twenty open positions. The QAPI minutes contained no goal, no plan, and no discussion of how the vacancies were affecting care. No one in the meeting connected the staffing shortages to the pressure ulcers, the falls, the call light response times, or anything else.
A family had complained that a call light was left on for an extended period and told staff that if the situation had been serious, the resident could have suffered a poor outcome. The QAPI committee noted an audit had been run showing an average 10-minute response time. Nobody had checked whether staff were actually responding or simply turning off the lights.
A resident was continuing to receive food she had told staff she could not have. Staff had been educated and signed acknowledgments. The QAPI notes contained no suggestion that repeated failures might warrant testing whether staff had actually understood and retained the education.
Antipsychotic medications were being used in 21 percent of residents. The facility's own goal was no more than 15 percent. There was no indication in the notes that anyone had reviewed whether residents on those medications had appropriate diagnoses, or whether the pharmacist had evaluated all affected residents as part of his contracted duties.
The administrator, when interviewed, acknowledged that meaningful education had not been delivered, that staff had not been tested to see whether they understood or could apply what they had been taught, and that staff had not been educated on the facility's specific QAPI plans or its new performance improvement projects. He said the facility was planning to change how it ran QAPI. That had not happened yet.
Two registered nurses told inspectors they had never attended a QAPI meeting and were not aware of any facility-specific performance improvement projects. A licensed practical nurse said she was not aware QAPI meetings were being held. A nursing assistant said she had attended meetings in the past when her schedule allowed, but could not identify a single goal the facility was monitoring.
The director of nursing confirmed in a March 4 email that there was no formal QAPI training for employees.
The administrator said the facility had educated staff on QAPI upon hire. He said they would work toward formalizing requirements going forward. When inspectors asked for documentation of employee QAPI training, none was provided.
R41 remained in the facility, his Hepatitis C diagnosis sitting in a physician's progress note from November, unacknowledged in his care plan, absent from the surveillance system meant to track exactly that kind of risk.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Shores of Worthington from 2025-03-04 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: July 5, 2026 · Our methodology
The Shores Of Worthington in WORTHINGTON, MN was cited for violations during a health inspection on March 4, 2025.
Nobody told the medical director it had happened.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.