Wabasso Restorative Care Center: Abuse Report Delay - MN
Federal inspectors cited Wabasso Restorative Care Center following a complaint investigation completed September 2, 2025, finding the facility failed to report an allegation of resident abuse to the Minnesota State Agency within the required timeframe. The incident had occurred at approximately 8:00 a.m. on August 21, 2025. The state was not notified until 11:35 a.m. on August 22, approximately 25 and a half hours later.
The facility's own policy, last revised just four months earlier in April 2025, required reporting within two hours.
The resident at the center of the incident, identified in inspection records as Resident 1, had severe cognitive impairment and relied on a wheelchair for mobility. She needed substantial staff assistance with dressing, transferring, moving in bed, and personal hygiene. Her care plan flagged her as having a potential for abuse precisely because of those vulnerabilities — her dependence on others for daily care and her impaired cognition. She carried diagnoses including major depressive disorder, alcohol dependence, and a repaired fracture of the femur and pelvis.
When inspectors interviewed her on September 2, she was clear about what had happened. At around 8:00 that morning in the facility's outdoor smoking area, another resident, Resident 2, hit her in the back of the head, pulled her hair, and pushed her wheelchair into the fence. "I immediately got a headache and got a Tylenol," she told inspectors. She said she reported it to several nursing staff right away but couldn't remember exactly who she had spoken to.
She didn't wait to see what the facility would do. The next day, August 22, Resident 2 threatened her again. She called a family member to come get her, discharged herself, and told inspectors she was not going back.
Nursing assistant NA-A confirmed the timeline. She told inspectors she was working the morning of August 21 when Resident 1 reported the incident. Resident 1 came to her at approximately 8:00 a.m. and described being hair-pulled and punched while outside. NA-A said she immediately told the assistant director of nursing and the charge nurse. The facility's response was to place both residents on 15-minute checks.
Nobody called the state.
By 7:21 that evening, Resident 1's family had called the sheriff's office to request a welfare check. A deputy responded 13 minutes later. Resident 1 told the deputy the same thing she had told staff that morning: Resident 2 had pulled her hair, struck her in the back of the head, and pushed her wheelchair. The deputy informed facility staff of the situation. Staff told the deputy they would keep the two residents separated.
The sheriff's office had now documented the assault. The family had now called law enforcement. The deputy had now stood in the facility and spoken to staff about it. Still, nobody called the state. That call wouldn't come for another 16 hours.
The administrator, when interviewed by inspectors on September 2, said she had been notified of an incident on August 21 but did not know about Resident 2 hitting Resident 1 until August 22. She confirmed the facility-reported incident was submitted late to the state agency and that she filed it once she became aware of the hitting.
What that account leaves unexplained is the gap between what the nursing assistant knew at 8:00 a.m. on August 21 and what the administrator says she knew. NA-A told inspectors she reported the allegation immediately to the assistant director of nursing and the charge nurse. The inspection report does not document any explanation from those two individuals about what they did with that information or why it did not reach the administrator in a form that prompted a report to the state.
Resident 2, the resident accused of the assault, had intact cognition according to his most recent quarterly assessment. He had full use of his upper extremities and was independent in operating his manual wheelchair. His diagnoses included paraplegia, alcohol dependence, and adjustment disorder with mixed anxiety and depressed mood. The inspection report does not indicate he faced any documented consequence described in the records reviewed.
The two-hour reporting requirement exists for a specific reason. When a cognitively impaired resident who cannot fully advocate for herself reports being physically assaulted, the state agency is supposed to know about it fast enough to intervene, investigate, and protect her. At Wabasso, by the time the state was notified, Resident 1 had already been threatened a second time, had already called her family, and had already decided to leave.
The inspection report rated the level of harm as minimal harm or potential for actual harm. That rating reflects the regulatory classification of the reporting violation itself, not a finding that Resident 1 was unharmed. She reported an immediate headache after being struck in the back of the head. She received Tylenol. There is no indication in the inspection records that she received any medical evaluation beyond that.
The facility's abuse, neglect, and exploitation policy, revised in April 2025, spelled out the obligation precisely: report all alleged violations involving abuse or serious bodily injury to the administrator, the state agency, adult protective services, and other required authorities, immediately but no later than two hours after the allegation was made. The policy was current. The training, presumably, had happened. The allegation was reported to supervisors within minutes of the incident.
And then, for more than a day, nothing moved up the chain in a way that reached the state.
Resident 1 told inspectors she reported what happened to her immediately. She told staff. She told the deputy. She told her family. She did everything a person is supposed to do. She left the facility the next day because, after being threatened a second time and watching a day pass without any visible consequence, she had decided she was not safe there.
She was 25 and a half hours right.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Wabasso Restorative Care Center from 2025-09-02 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
WABASSO RESTORATIVE CARE CENTER in WABASSO, MN was cited for abuse-related violations during a health inspection on September 2, 2025.
The incident had occurred at approximately 8:00 a.m.
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.