Auburn Manor

F-F550. Based on observation, interview and document review, the facility failed to ensure toileting and personal care were provided in a dignified manner for Resident R1 who was left exposed and nude on the toilet facing window to facility courtyard. The window was not closed for privacy. In addition, the facility failed to ensure dignity was maintained for 1 of 1 resident (Resident R18) who utilized an indwelling catheter.

Refer to

F-F656. Based on interview and document review, the facility failed to ensure an individualized comprehensive care plan was developed and maintained to ensure appropriate care was provided for 1 of 2 residents (Resident R42) who required staff assistance with activities of daily living (ADLs) including prevention of pressure ulcers and care needs.

Refer to

F-F677. Based on interview and document review, the facility failed to ensure routine bathing was completed in accordance with identified wishes for 1 of 4 residents (Resident R7) reviewed for activities of daily living (ADLs) and who was dependent on staff for their bathing care.

Refer to

F-F686. Based on observation, interview and document review, facility failed to provide 2 of 2 residents (Resident R5, Resident R37) with care, consistent with professional standards of practice to prevent pressure ulcers (localized damage to the skin and underlying soft tissue) who were identified as risk for pressure ulcers/pressure injuries.

Refer to

F-F689. Based on observation, interview, and document review, the facility failed to comprehensively reassess and, if needed or able, develop proactive interventions to reduce the risk of falls and injury for 2 of 2 residents (Resident R44, Resident R26) reviewed who had sustained falls at the care center.

Resident R1

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 33 245604 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245604 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Auburn Manor 501 Oak Street Chaska, MN 55318

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Resident R1's quarterly Minimum Data Set (MDS), dated [DATE REDACTED] identified Resident R1 with intact cognition, impairment of one side for upper extremities and required partial to moderate assistance with toileting and upper body dressing. Level of Harm - Minimal harm or In addition, Resident R1 medical diagnoses include spinal stenosis (narrowed space around the spinal cord causing potential for actual harm irritation and compression of the spinal cord), heart failure, and arthritis.

Residents Affected - Many Resident R4

Resident R4's admission MDS assessment, dated 1/6/25, indicated Resident R4 had moderately impaired cognition. Resident R4 required maximal staff assistance for dressing, bathing, toileting and bed mobility. Resident R4 required moderate staff assistance for transfers and personal hygiene. In addition, Resident R4's medical diagnoses include osteoporosis, seizures, muscle weakness, and history of breast cancer.

Resident R5

Resident R5's quarterly Minimum Data Set (MDS) dated [DATE REDACTED] identified Resident R5 with intact cognition, was dependent on staff for all toileting, bathing, and dressing and did not reject care. In addition, Resident R5 identified as a risk of developing a pressure ulcer/pressure injury. Resident R5's medical diagnoses include bipolar, anxiety, depression, and chronic pain.

Resident R7

Resident R7's quarterly MDS, dated [DATE REDACTED], identified Resident R7 with severe cognitive impairment, was dependent on staff for personal hygiene care and did not reject care. Resident R7's medical diagnoses include stroke, peripheral vascular disease, diabetes, arthritis, aphasia (impairment in speaking), hemiplegia (paralysis on one side of body), and depression.

Resident R14

Resident R14's quarterly MDS dated [DATE REDACTED], identified Resident R14's with intact cognition, was dependent on staff for all toileting and dressing and required substantial assistance with personal hygiene and bathing. In addition, Resident R14 did not reject cares. In addition, Resident R14 medical diagnoses include spinal cord compression, neurogenic bladder, diabetes, arthritis, paraplegia (paralysis on one side of the body), and depression.

Resident R18

Resident R18's quarterly MDS dated [DATE REDACTED] identified Resident R18 with moderate cognitive impairment, was dependent on staff for toileting hygiene and lower body dressing, and did not reject care. In addition, Resident R18 with indwelling catheter (tube to drain urine from bladder to a bag outside of the body). In addition, Resident R18 medical diagnoses include diabetes, peripheral vascular disease, arthritis, and depression.

Resident R26

Resident R26's quarterly MDS dated [DATE REDACTED], identified Resident R26 had severely impaired cognition and required assistance for nearly all ADLs. In addition, Resident R26 did not reject cares. In addition, Resident R26 medical diagnoses include dementia, heart failure, kidney disease, diabetes, aphasia (difficulty speaking), seizures, anxiety and depression.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 33 245604 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245604 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Auburn Manor 501 Oak Street Chaska, MN 55318

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Resident R33

Level of Harm - Minimal harm or Resident R33's admission MDS dated [DATE REDACTED] identified Resident R33 with intact cognition, required substantial assistance with potential for actual harm dressing, bathing, and mobility such as rolling from side to side in bed, lying to sitting, sitting to stand and transferring from bed to chair. In addition, Resident R33 did not reject cares. Resident R33's medical diagnoses include hip Residents Affected - Many fracture, and Parkinson's Disease.

Resident R37

Resident R37's quarterly MDS dated [DATE REDACTED] identified Resident R37 with significant impairment to cognition, impairment to lower extremities, was dependent on staff for all efforts of self-care. Also, Resident R37 identified as a risk of developing a pressure ulcer/pressure injury. In addition, Resident R37's medical diagnoses include Alzheimer's, dementia, depression, and bipolar and did not reject care.

Resident R42

Resident R42's Significant change in status MDS dated [DATE REDACTED] identified intact cognition, no impairment in upper and lower extremity range of movements, was dependent on staff for mobility, toileting, and lower body dressing and required assistance with personal hygiene. Resident R42's medical diagnoses include hip fracture, coronary artery disease, heart failure, urinary tract infection, and Parkinson's disease.

Resident R44

Resident R44's admission Minimum Data Set (MDS), dated [DATE REDACTED], identified Resident R44 had severe cognitive impairment, demonstrated no behavioral symptoms (i.e., physical, verbal, rejection of care) and required assistance for nearly all activities of daily living (ADLs). In addition, Resident R44's medical diagnoses include dementia, hypertension, kidney disease, anxiety and depression.

Resident and family interview:

During interview with family member (FM)-A of Resident R44 on 2/3/25 at 3:51 p.m., FM-A stated Resident R44 had sustained a few falls since she admitted to the care center from her prior assisted-living setting, and the falls led him to believe the facility did not have enough staff to provide Resident R44 with adequate supervision.

During interview with Resident R4 on 2/3/25 at 5:12 p.m., Resident R4 stated she, feels the facility [sic] understaffed and it takes

a long time and sometimes they don't come. Resident R4 expressed frustration as when she admitted to the facility

she needed more assistance from staff and wasn't receiving it.

During interview with Resident R33 on 2/3/25 at 2:22 p.m., Resident R33 stated she got very frustrated when she put her call light on for staff assistance as it just takes forever. Resident R33 stated she used her call light for staff assistance to get in and out of bed, any transfers, and to go to the bathroom. Resident R33 stated the time of day did not impact how fast the call lights were answered. Resident R33 stated it could take up to an hour for her call light to be answered. Resident R33 stated facility's lack of call light response has caused her to have an accident [incontinent of urine] and added, what if I fall and no one comes for how long?

During interview with Resident R5 on 2/3/25 at 2:44 p.m., Resident R5 stated, not enough help to answer call lights.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 33 245604 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245604 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Auburn Manor 501 Oak Street Chaska, MN 55318

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Staff interviews:

Level of Harm - Minimal harm or During interview with trained medication aide (TMA)-A on 2/4/25 at 7:31 a.m., TMA-A stated I don't feel there potential for actual harm is enough staff to meet the needs of the residents. I have twenty-five residents. If aides show up it is four to five aides per morning shift. They recently reduced staffing to 'cut costs' apparently and people have missed Residents Affected - Many showers and answering call lights has been delayed.

During interview with licensed practical nurse (LPN)-A on 2/4/25 at 7:46 a.m., LPN-A stated, I have twenty-one residents. They need help today. Normally I have more than that. Some days I don't have time to get my work done. Range of motion exercises (ROM's), sometimes I don't get to it. LPN-A stated they were not surprised if showers weren't done due to staffing.

During interview with licensed practical nurse (LPN)-B who was also the facility infection control/wound nurse, stated she was responsible to complete weekly wound assessments and document results in the resident electronic medical record (EMR). LPN-B stated an initial Weekly Wound Tool assessment had been completed for Resident R42's wound on 12/16/24, and should have been completed weekly thereafter until healed. LPN-B stated she was out sick for thirteen days in December (2024) and it fell off my radar. Furthermore, LPN-B stated, I get pulled to the floor a lot.

During interview with registered nurse (RN)-B on 2/5/25 at 12:36 p.m., RN-B stated, Staffing is always a concern here. If we have five aides working on a shift and three are agency aides, then the two facility aides have to chart on all of the residents because we don't allow the agency aides to document. It is too much. Also, RN-B stated, due to staffing, the range of motion exercises and other personal cares won't be done. RN-B stated she had seen aides in the past have a tendency to leave residents in their beds to eat meals instead of assisting them up out of bed and transporting them to the dining room.

During interview with RN-B on 2/5/25 at 10:31 a.m., (RN)-B reviewed Resident R44's fall reports dated 12/23/24, and 1/2/25, and stated, I am just going to be honest with you, and stated she was not sure if all of Resident R44's fall reports had been brought to IDT for review. RN-B reviewed Resident R44's fall on 12/23/24, and verified it lacked any new interventions being recorded or outlined. RN-B stated the lack of completion with the report could possibly be related to being pulled to the floor so much due to staff call-ins adding, Often, I don't [get them done]. RN-B stated it was a chore and a struggle to get all assigned things such as fall reports and admissions done timely, adding they felt, at times, new interventions had been done but just not been documented.

During interview with staffing coordinator (SC) on 2/5/25 at 10:09 a.m., SC stated she worked in the position for ten to eleven years. SC stated she directed staff concerns regarding low staffing to the DON. SC stated call lights should be answered within ten to fifteen minutes. No more than fifteen minutes. SC stated she was expected to follow guidance from management to staff nursing assistants with one aide per 10 residents and,

it used to be one aide per 8 residents. SC stated she recently was informed that she was responsible for staffing both the skilled nursing facility and the assisted living facility portion of the building.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 33 245604 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245604 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Auburn Manor 501 Oak Street Chaska, MN 55318

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 During interview with director of nursing (DON) on 2/5/25 at 10:45 a.m., DON stated expectation of, Call lights are to be answered as soon as the staff are able to answer them. Everybody should answer call lights. Level of Harm - Minimal harm or Not just one role. Time range acceptable ideally within half an hour to forty-five minutes. Half an hour is potential for actual harm common. Things happen and we want to answer them right away. Sometimes we cannot. It is frustrating. DON stated staffing for 2/5/25, was impacted due to a call in from a nurse so the DON had to fill in for the Residents Affected - Many empty shift and administer morning medications and treatments until a nurse from the evening shift agreed to come in early to relieve her. DON stated the facility did not have access to call light logs and did not do call light audits to determine length of time call lights were on.

Call lights:

During continuous observation and interview on 2/5/25 starting at 9:20 a.m., the call light was illuminated outside room of Resident R14.

-At 9:39 a.m., registered nurse (RN)-D stood outside of room and did not answer it. RN-D entered another resident room.

-At 9:40 a.m., RN-C walked past the room and entered another resident room.

-At 9:41 a.m., Another staff member walked past the room.

-At 9:43 a.m., RN-C walked to medication cart outside of Resident R14's room and typed into computer and walked away.

-At 9:44 a.m., RN-D obtained hand sanitizer from outside Resident R14's room and walked across the hall to another resident room.

-At 9:46 a.m., RN-D obtained surgical gloves from medication cart outside Resident R14's room and walked back across the hall to another room.

-At 9:46 a.m., a laundry staff person knocked on the door and brought in clean clothes to Resident R14 room and said, Oh I don't do that. Did you get your light on? Staff walked outside of Resident R14 room and saw the illuminated call light on above Resident R14's door. Staff walked back into the room and spoke a few words and walked down the hall toward the nursing station.

-At 9:48 a.m., laundry staff entered room again and brought in more clothes. Call light was still illuminated. At

this time an activities staff member walked past Resident R14's room.

-At 9:50 a.m., RN-D walked past Resident R14's room and entered another resident room.

-At 9:51 a.m. nursing assistant (NA)-G walked out of another resident room and obtained an EZ stand from

the hall and entered Resident R14's room. NA-G stated, Sorry I didn't know your light was on.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 33 245604 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245604 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Auburn Manor 501 Oak Street Chaska, MN 55318

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 During interview with NA-G on 2/5/25 at 10:00 a.m., NA-G stated, I don't know how long it was on. I help with answering call lights. NA-G stated Resident R14 had choir practice in activities. Since we are short staffed, I am Level of Harm - Minimal harm or working on another unit and part of this one. I have an agency aide with me so this is slowing things down potential for actual harm and we can't answer all the lights when we should. There is no one to help us. NA-G stated, I have to prioritize. That was unacceptable for her to wait that long. We are responsible for answering call lights. The Residents Affected - Many nurses can answer but don't really.

During interview with Resident R14 on 2/5/25 at 10:02 a.m., Resident R14 stated, my light was on for almost an hour. I need them [staff] to get me up. I can't do it by myself. It is frustrating for me. I am late for my activity and am mad about it. They need more help here to get us all up and ready.

During interview with NA-D on 2/5/25 at 10:04 a.m., NA-D stated, we don't have enough to help with this floor so we have to ask for help from other units which takes a long time. The call light times are very long.

Resident Council:

Review of facility's Resident Council meeting minutes for January 2025, December 2024, October 2024, August 2024 and June 2024 identified concerns were verbalized from residents about inadequate staffing.

During interview with resident council member attendees (Resident R1, Resident R13, Resident R20 and Resident R25) on 2/4/25 at 1:12 p.m., Resident R1 stated, on a lane (hall) with only one aide, [we are] bound to wait. It is like Christmas out here when the lights are going. Resident R13 stated, Mornings are bad. Facility has not been responding real well. Nothing has really changed. Resident R1 stated, facility staff[sic] their hands are tied. Management are the ones who call the shots.

Facility Assessment:

The Facility Assessment (FA) reviewed 10/29/2024, identifies the facility is licensed for 60 beds with an average census of 48. The FA identified 80% of residents are totally dependent on staff for mobility needs and receive skilled nursing level care such as range of motion exercises, transfers, ambulation, dressing, feeding, including bed mobility assistance. The staffing plan includes direct care staff ratios of:

-Day Shift: 4-6 nursing assistants with one to two RN or LPN Charge nurse

-Evening Shift: 4-6 nursing assistants with one to two RN or LPN Charge nurse

-Night shift: 3 nursing assistants with one RN or LPN Charge nurse.

No other information was provided.

49034

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 33 245604 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245604 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Auburn Manor 501 Oak Street Chaska, MN 55318

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm 49339 Residents Affected - Some Based on observation and interview and policy review, the facility failed to ensure medications were securely stored safely and under direct observation of authorized staff in areas where residents, staff and guests could access medications in 3 of 5 medication carts affecting 3 of 4 units of the facility.

Findings include:

During observation on 2/03/25 at 7:36 p.m., an unattended and unlocked medication cart was observed outside in the hallway of the unit named, Eagle Lane. The unattended and unlocked cart was in the hallway against the wall between two resident rooms. At 7:40 p.m., registered nurse (RN)-E returned to medication cart. RN-E indicated they left the medication cart unlocked and unattended. RN-E stated a resident was hollering and they went to help them. RN-E stated it unattended medication carts should always be locked so residents couldn't get into it.

During a continual observation on 2/05/25 at 11:08 a.m., an unattended and unlocked medication cart was observed in the hallway of the unit named, Bluejay Lane. The cart was placed between the doors of resident rooms. During observation, numerous residents and family members walked past the unattended and unlocked medication cart. At 11:39 a.m., licensed practical nurse (LPN)-B verified the medication cart was unlocked and unattended. LPN-B locked the medication cart. LPN-B state medication carts should be locked at all times when not in use, so resident's do not get in there and overdose and staff don't steal medications.

44656

During observation on 2/5/25 at 9:35 a.m., an unattended and unlocked medication cart was observed in the hallway of the unit named, Cardinal Lane. The unattended and unlocked cart was in the hallway against the wall between two resident rooms.

During interview with registered nurse (RN)-C on 2/5/25 at 9:37 a.m., RN-C stated, it is unlocked because I forgot to lock it when I walked away. [It is] important to be locked and we have important medications that are deadly in there and we don't want anyone to get into there and take whatever they want.

During an interview on 2/05/25 at 12:30 p.m., director of nursing (DON) stated all unattended medications carts should be kept locked at all times, to prevent people from getting into them that shouldn't as it could have ill effects.

A facility policy titled Storage and Expiration Dating of Medications and Biologicals, revision date 8/1/24, section 5.3 indicates Facility should ensure all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 33 245604 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245604 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Auburn Manor 501 Oak Street Chaska, MN 55318

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 33925 potential for actual harm Based on interview and document review, the facility failed to ensure recommended pneumococcal Residents Affected - Few vaccinations, as outlined by the Centers for Disease Control (CDC), were offered and/or provided in a timely manner to reduce the risk of severe disease for 1 of 5 residents (Resident R37) reviewed for immunizations.

Findings include:

A CDC Pneumococcal Vaccine Timing for Adults feature, dated 3/2023, identified several tables with corresponding recommendations when to receive various versions (i.e., PPSV23, PCV13, PCV20) of the pneumococcal vaccine. The graph labeled, Adults [at or older than] [AGE] years old, outlined persons with a complete series of pneumococcal vaccination (i.e., PCV13 at any age, PPSV23 at or above [AGE] years old) should have shared clinical decision-making between the resident and healthcare provider to determine if PCV20 was appropriate.

Resident R37's quarterly Minimum Data Set (MDS), dated [DATE REDACTED], identified Resident R37 admitted to the care center in August 2024, and had several medical conditions including dementia and high blood pressure.

Resident R37's electronic medical record (EMR) was reviewed which identified a section labeled, Immunizations, along with Resident R37's received immunizations or, if applicable, their refusal. This identified Resident R37 as being [AGE] years old and having had received the PCV13 in 12/2017, and the PPSV23 in 3/2019 (over five years prior). However, it lacked evidence Resident R37 had been offered or received the PCV20 as recommended by the CDC.

On 2/4/25 at 12:58 p.m., a telephone call was placed to Resident R37's family member to discuss what, if any, discussion the care center had with them about Resident R37's immunization using PCV20. A message was left, however, a return call was not received.

Resident R37's medical record was reviewed and lacked evidence Resident R37 or their representative had been offered or provided the PCV20 vaccination despite being admitted to the care center multiple months prior.

On 2/5/25 at 10:25 a.m., licensed practical nurse (LPN)-B was interviewed. LPN-B verified they were the campus' infection preventionist (IP) and had reviewed Resident R37's medical record. LPN-B stated Resident R37 had not yet received the PCV20 and expressed her family member always likes to sign the paperwork so there was not a signed consent or refusal to show. LPN-B stated they last spoke with Resident R37's family member back in December 2024 about another vaccine series (i.e., RSV), however, at that time LPN-B did not have the PCV20 form for them to sign so, as a result, it had not been done. LPN-B stated they recalled Resident R37's family member did not want Resident R37 to get the vaccine, however, acknowledged the record lacked any documentation to support that conversation had happened. LPN-B verified all listed immunizations on Resident R37's EMR were correct and current and expressed they would follow-up with Resident R37's family member soon, adding, I will make

it a point to meet up with [them]. Further, LPN-B stated part of the reason for the delay in follow-up was possibly due to themselves repeatedly being pulled to work on the floor due to call-ins and other reasons adding such was, The way it is now-a-days. However, LPN-B verified Resident R37 should have been offered the vaccination and expressed it was important as pneumonia could be a heft disease process and impair the elderly.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 33 245604 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245604 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Auburn Manor 501 Oak Street Chaska, MN 55318

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 A facility provided Pneumococcal Immunization policy, last reviewed 4/2024, identified the care center would offer pneumococcal immunizations in accordance with MDH (Minnesota Department of Health) guidelines. Level of Harm - Minimal harm or The policy added, The [immunization] will be administered per professional standards of practice and potential for actual harm standing orders for administering pneumococcal vaccines to adults, adding further, Document administration

in the resident's medical record. Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 33 245604