Divine Providence Community Home

would ask about GDR in their medication reviews and was unsure if GDR's were discussed or Level of Harm - Minimal harm mentioned at that time. or potential for actual harm

Interview on 415/26 at 2:50 p.m., with the administrator identified she was unaware GDR were not Residents Affected - Few being performed and/or documented for Resident R3 or Resident R8, only mediation reviews were being requested to either continue or discontinue the medication. The administrator agreed GDR must be requested and attempted as required. If the request from the physician was denied, a rational for the denial was required and must be documented.

Review of the December 2022, Pharmaceutical Services, Psychotropic Drugs policy identified residents who use psychotropic drugs were to receive GDR's unless contraindicated in an effort to discontinue the drug.

Review of the undated, Psychotropic Medication policy, identified a psychotropic drug review would be completed by the consulting pharmacist with a collaborated goal of reduction or discontinuation of psychotropic medication. The purpose of the gradual dose reduction was to find an optimal dose or to determine if the continued use of the medication was beneficial to the residents. Accepted standards of practice for GDR were within the first year of a resident admission on a psychotropic medication or

after the start of a psychotropic medication the facility must attempt a GDR in two separate quarters with at least one month between the attempts, unless clinically contraindicated. After the first year a GDR must be attempted annually, unless clinically contraindicated.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete 245599 Page 7 of 1 2 Department of Health & Human Services Printed: 06/12/2026 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 245599 04/15/2026 B. Wing NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Divine Providence Community Home 700 Third Avenue Northwest Sleepy Eye, MN 56085 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)

actions that can be measured.

Level of Harm - Minimal harm or potential for actual harm Based on interview and document review, the facility failed to ensure care plans were appropriately developed for 1 of 5 sampled residents (Resident R3) who received anticoagulant therapy.Findings include: Residents Affected - Few Resident R3's comprehensive MDS assessment, accepted on 9/11/25 identified she was admitted to the facility in August 2025. Resident R3 had moderate cognitive impairment, with diagnoses of heart disease, cardiovascular and coagulation treatment, atrial fibrillation (heart's inability to appropriately contract, causing potential blood clots), and a history of heart attack. Resident R3 required staff assistance with Activities of Daily Living (ADL) such as bathing, dressing and toileting. Resident R3 used a walker, wheelchair, and cane or crutch for mobility and had a physical impairment on one side of her body. Resident R3's current Medication Administration Record (MAR) indicated Resident R3 received Xarelto, 15 milligrams (mg) daily related to their diagnosis of atrial fibrillation. Resident R3's current, undated care plan identified Resident R3 was at risk for falls as she was weaker and was known to be more fatigued than normal and may not remember to call staff for assistance. Resident R3 had dementia and was known to be confused. Resident R3 had muscle weakness and unsteadiness. Resident R3's goal was to stay safe while out or moving about, transferring, and to avoid injury. There was no mention on the care plan Resident R3 was at increased risk of bleeding and there were no bleeding precautions noted. Interview and care plan review on 4/15/26 at 12:18 p.m., with registered nurse (RN)-A identified she agreed there were no bleeding precautions listed on the care plan to alert staff what to monitor for since Resident R3 was on an anti-coagulant. We probably haven't thought of that. RN-A agreed residents on anticoagulants should have increased monitoring related to increased risk of bleeding. Interview on 4/15/26 at 2:50 p.m. with the administrator identified she was unaware Resident R3's care plan did not have any bleeding precautions. The administrator was unaware if any residents on anti-coagulants had interventions as they were at high risk for bleeding. The administrator agreed care plans needed to be developed as appropriate. Review of the current, undated Xaralto (anti-coagulant) patient safety information, located at: https://www.xarelto-us.com/what-is-xarelto/?utm_source=bing&utm_medium=cpc&utm_campaign=EG-DTCB-BR-NA-Xarelto-JJ-Priority/Top-Phrase-NA&utm_content=Core+Branded-TXT-National-NA-1-PH&utm_term=xarelto&gclid=8931e1615f0a13ed37da8886d53418dc&gclsrc=3p.ds&msclkid=8931e1615f0a13ed37da8886d53418dc, identified Xarelto was a blood thinner that treats and helps prevent blood clots that are related to certain conditions involving the heart and blood vessels. Anticoagulants lower your blood's ability to clot by stopping specific proteins and enzymes, also known as clotting factors, from doing their job to help blood clots form. Side effects of Xarelto included increased risk of bleeding. Patients were likely to bruise more easily, and it may take longer for bleeding to stop which can be serious and may lead to death. Patients were to notify a physician or receive medical attention if a patient developed signs or symptoms of bleeding such as:Unexpected bleeding or bleeding that lasts a long time, such as:Nosebleeds that happen often.Unusual bleeding from gums.Menstrual bleeding that is heavier than normal, or vaginal bleeding.Bleeding that is severe or you cannot control.Red, pink, or brown urine.Bright red or black stools (looks like tar).Cough up blood or blood clots.Vomit blood or your vomit looks like coffee grounds.Headaches, feeling dizzy or weak.Pain, swelling, or new drainage at wound sites.Left upper belly (abdominal) pain, pain below the left rib cage or at the tip of your left shoulder or diffuse abdominal discomfort (these may be symptoms of the rupture of the spleen). Review of the National Library of Medicine (NLM) article located at: https://pmc.ncbi.nlm.nih.gov/articles/PMC12284669/, To anti-coagulate or not to anti-coagulate-that is the question in patients with fall risks, identified falls were associated with an increased risk of traumatic bleeding events and death. Another NLM article located at: https://pmc.ncbi.nlm.nih.gov/articles/PMC11242576/, Traumatic Brain Injury in Patients under Anticoagulant Therapy: Review of Management in Emergency Department identified the National Institute for Health Care Excellence (NICE) suggested considering conducting a head CT scan for people who have sustained a traumatic brain injury (TBI) [ex: hitting their head from a fall] and have no other indications for a head CT scan, except being on anticoagulant therapy. There was no policy related to anti-coagulation monitoring provided by the end of survey.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete 245599 Page 8 of 1 2 Department of Health & Human Services Printed: 06/12/2026 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 245599 04/15/2026 B. Wing NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Divine Providence Community Home 700 Third Avenue Northwest Sleepy Eye, MN 56085 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)

reviewed, and revised by a team of health professionals.

Level of Harm - Minimal harm or potential for actual harm Based on interview and document review, the facility failed to revise the care plan for 1 of 1 sampled resident (Resident R4) reviewed for falls.Findings include: Resident R4's 4/2/26, accepted admission Minimum Data Set Residents Affected - Few (MDS) assessment identified Resident R4's cognition was severely impaired. Resident R4 required substantial assistance from staff for activities of daily living (ADL's) and was incontinent of bowel and bladder. Resident R4 had a history of falls prior to admission, had 2 falls since admission (1 with minor injury and 1 with major injury). Resident R4 was identified to have delirium, inattention, disorganized thinking, and altered mental status that fluctuated. Resident R4 took scheduled pain, antipsychotic, antianxiety, antidepressant, diuretic, and opioid medication. She was also noted during the assessment period to take an antibiotic. Resident R4 was receiving occupational and physical therapy. Resident R4's diagnoses list identified dementia with psychotic disturbance, anxiety, cardia arrhythmia, high blood pressure, depression, osteoporosis, weakness and malnutrition. Resident R4's fall reports identified on:2/17/26, Resident R4 had an unwitnessed fall in her room, and was found next to the chair. Resident R4 was assessed and assisted in her chair and then toileted. She reported she thought she bumped her head when she tried to walk. The call light was not on at time of fall. The Corrective action/solution was to place alarm on her bed, chair, and wheelchair.2/22/26, Resident R4 had an unwitnessed fall in the facility living room and was found next to a recliner leaning on her right side.

Her glasses were broken, and she had a laceration (cut) near her left eye. Prior to her fall Resident R4 had been sitting on a chair near the window in the living room. At time of fall there were no staff in the area due to residents finishing up lunch and transporting residents out of the dining room. Resident R4 had tried to walk and fell. The Corrective action/solution was to make sure she was sitting on her chair alarm, to not take her out of dining room until staff were around the living room area and have a staff member be in dining area when she was in dining area. Review of 3/10/26, interdisciplinary team (IDT) meeting note identified the IDT did a review of Resident R4's 2/22/26 fall on 2/24/26 with a new identified intervention of having Resident R4 in the living room area for supervision as much as able, and to continue with her therapy treatments. Resident R4's current, undated care plan, identified Resident R4 required 2 staff to assist with transfers and toileting. Resident R4 did not understand instructions and was not able express her needs. Resident R4 had a wander guard on her wheelchair. Resident R4 could not safely transfer without assistance and had a bed and chair sensor alarm in place that connected to and turned on the call light and/or pager. The care plan lacked identification that Resident R4 should remain in the dining room until staff were around the living room area and to ensure staff were in the dining room area while Resident R4 was there or that Resident R4 should be in the living room area as much as possible for supervision. Interview and care plan review on 4/15/26 at 2:17 p.m., with registered nurse (RN)-A identified Resident R4 had been admitted to the facility for failure to thrive and dementia. Resident R4 had 2 falls since admission in February 2026. RN-A identified the only intervention on her care plan was to have a bed and chair alarm. RN-A confirmed the interventions that had been identified on the 2/22/26, fall report had not been added to the care plan following Resident R4's second fall that resulted in a fractured of her pelvis. RN-A identified when a fall occurred, that the charge nurse would complete a fall report and that person was to update the care plan with the new interventions. Then the IDT meets weekly and reviews any falls and would review interventions. The IDT also should update the care plan if the intervention was changed after review. RN-A stated the care plan should be updated any time care needs change for a resident. Interview on 4/15/26 at 4:14 p.m., with the administrator identified she would expect that Resident R4's care plan would reflect her current care needs including identified fall interventions. Any time a new intervention or care need was identified to care for a resident that the care plan would be updated. Review of undated Fall and Post-Fall Assessment identified that following a fall the nurse would assess the resident and provide necessary medical attention. The environment would be evaluated for possible causes and necessary action would be taken to correct as needed. The family and medical doctor would be updated and notified of new interventions. Interventions would be added to the care plan and communicated to the staff.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete 245599 Page 9 of 1 2 Department of Health & Human Services Printed: 06/12/2026 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 245599 04/15/2026 B. Wing NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Divine Providence Community Home 700 Third Avenue Northwest Sleepy Eye, MN 56085 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)

dressings were applied.3/16/26, Resident R5's Allevyn dressing was identified as intact on Resident R5's right Level of Harm - Minimal harm buttock.3/23/26, R5s right buttock was as opened and cleaned with an Allevyn dressing or potential for actual harm applied.3/30/26, Resident R5's right buttock was not open however, an Allevyn dressing was applied4/5/26, Resident R5's right buttock was opened and cleaned with an Allevyn dressing applied 4/6/26, Resident R5's Allevyn Residents Affected - Few dressing was intact on Resident R5's right buttock 4/13/26, Resident R5's Allevyn dressing was identified as intact on Resident R5's right buttock 4/14/26, Resident R5's right buttock had a stage 2 pressure ulcer with the wound tissue being pink and surrounding tissue identified as dark discolored. The right buttock wound measured 1 cm x 0.7 cm, the area was cleaned, and an Allevyn dressing was applied.Prior to the surveyor's

observation of the wound and treatment with the RN-A on 4/14/26, there was no evidence to support

the nurse appropriately assessed and measured Resident R5's wound weekly to monitor for worsening, remaining the same, or if they showed improvement. Interview on 4/14/26 at 12:21 p.m., with RN-B confirmed the nurse should be following the treatment orders to assess and measure Resident R5's wound weekly. She was unsure why this was not being completed. Interview on 4/15/26 at 4:14 p.m., with administrator identified she would expect the licensed nurses would follow the facility policy on wound monitoring and measuring. Review of April 2017, Pressure Ulcer Assessment policy identified pressure ulcers would be evaluated, measured and characteristics of the wound would be documented weekly to determine worsening or improvement.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete 245599 Page 1 1 of 1 2 Department of Health & Human Services Printed: 06/12/2026 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 245599 04/15/2026 B. Wing NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Divine Providence Community Home 700 Third Avenue Northwest Sleepy Eye, MN 56085 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)

was completed and was similar to the above UTI section.VA (vulnerable adult) reports: staff noted Level of Harm - Minimal harm they had no submissions for the previous quarter.Falls were notes as discussed. 38 for last quarter (9 or potential for actual harm with minor injuries and 0 major injuries). The interdisciplinary team (IDT) was noted to review falls weekly and discussed interventions and strategies. However, in the QAPI review, no residents were Residents Affected - Many specifically discussed to ensure IDT was doing analysis of data behind falls. It was also not clear if

this is a continued concern, th numbers were better or worse, what goals were, or if there was any analysis of data by QAPI to ensure IDT was reviewing their data appropriately.Resident infections were discussed in numbers but no there was no data documented as being reviewed, there were no benchmarks or goals, and no analysis identified. There was also no mention employee surveillance having been discussed. 6. Medication errors were noted as reviewed. 4 errors occurred. There was no documentation to support what the errors were, what the facility's benchmarks and goals were, or analysis of data. The QAPI committee notes documented There were no pharmacy trends to review at

this time. There was no evidence to suggest the facility addressed and included all systems of care, such as dietary or maintenance, actual and/or potential staffing issues, or that other areas that would impact resident care were reviewed. There was also no evidence of a thorough review of data if the area was not part of a performance improvement project (PIP). Interview and document review on 4/15/26 at 3:45 p.m., with the administrator identified she was in charge of PIP and the director of nursing (DON) was in charge of the rest of discussion and documentation of QAPI. The administrator noted that whatever the DON documented in the QAPI meeting minutes was all they had. In review of

the QAPI minutes provided, it was discussed with the administrator there was no evidence of oversight of analysis evident as only data brought forward with a brief overview of areas that weren't

a PIP project. The administrator agreed there was a need for all data to have benchmarks, goals, actions, interventions and analysis of how well the plans worked and to ensure oversight was provided. The administrator agreed the QAPI committee needed more information to show those topics discussed were monitored appropriately to identify compliance or the need for further monitoring. Survey findings were discussed, specifically that one resident (Resident R4) who was reviewed for falls failed to have their care plan revised after new interventions were identified to be implemented and would have been identified had the QAPI committee reviewed specifics around IDT review for falls and appropriate oversight would have occurred. The administrator agreed with that discussion and understood need for documenting the oversight. Review of the February 2026, Quality Assurance/Assessment and Performance Improvement Plan identified QAPI would make quality improvement decisions based on data analysis with input from residents, families, staff and the community. QAPI was to set goals for performance and measures progress toward those goals. The committee was to include representatives from all departments including nursing, food and nutrition, laundry, housekeeping, maintenance, health information technology, therapeutic recreation, therapy, business office and administration.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete 245599 Page 3 of 1 2 Department of Health & Human Services Printed: 06/12/2026 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 245599 04/15/2026 B. Wing NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Divine Providence Community Home 700 Third Avenue Northwest Sleepy Eye, MN 56085 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)

quarterly Level of Harm - Minimal harm or potential for actual harm Based on interview, and document review, the Quality Assurance (QA) committee failed to ensure

they received reports from the infection preventionist relating to employee surveillance for 4 of 4 Residents Affected - Few quarters reviewed. Refer to F-F865 and F880Findings include: Review of the QAPI meeting minutes submitted for review identified for review of the past 4 Quarters of QAPI meeting minutes identified

review of each quarter is as follows: Quarter 1 (April 2025): Attendees included the medical director, DON, RN staff development coordinator (RN-A), the pharmacist, dietary manager, facility director, vice president, maintenance supervisor, the administrator, and social services attended. Data submitted included:Infections: 18. 15 were urinary tract infections (UTI), and 3 were skin. The DON reviewed infection statistics. QAPI noted the IDT team would continue to review falls weekly and interventions, however there was no indication of a comprehensive review by QAPI occurred of any benchmarks, goals or analysis of IDT data. There was also no indication employee surveillance was being reviewed or discussed. Quarter 2 (July 2025): Attendees included the medical director, DON, RN staff development coordinator (RN-A), the pharmacist, facility director, the administrator, the vice president, and social services attended. Those areas included:Resident infection data was documented as reviewed. There were 18 total infections, with 9being UTI, 3 skin infections, and 6 respiratory infections. Staff were encouraged to utilize McGeer's criteria and follow antibiotic stewardship, however no benchmarks or goals were discussed, and no analysis of data was documented to have occurred to identify trends, or if tracking was occurring appropriately, if transmission-based precautions were needed or implemented timely etc. There was also no employee surveillance reviewed. Quarter 3 (October 2025): Attendees included the medical director, DON, RN staff development coordinator (RN-A), the pharmacist, facility director, the vice president, the administrator and social services attended. Those areas included:Resident infection data was reviewed. 13 in total with 7 UTI, 4 were skin, and 2 respiratory. Again, no employee surveillance was included. Quarter 4 (January 2026): Attendees included the medical director, director of nursing (DON), social services, the administrator, the Minimum Data Set (MDS) nurse, and pharmacist. No other departments were noted to have attended. Topics discussed were:Resident infections were discussed in numbers but no there was no data documented as being reviewed, there were no benchmarks or goals, and no analysis identified. There was also no mention employee surveillance having been discussed. Interview and document review on 4/15/26 at 3:45 p.m., with the administrator identified she was in charge of PIP and the director of nursing (DON) was in charge of

the rest of discussion and documentation of QAPI. There was no evidence to support the IP had brought employee surveillance to QAPI for oversight. The administrator agreed with that discussion and understood need for documenting the oversight. Review of the February 2026, Quality Assurance/Assessment and Performance Improvement Plan identified QAPI would make quality improvement decisions based on data analysis with input from residents, families, staff and the community. QAPI was to set goals for performance and measures progress toward those goals. The committee was to include representatives from all departments including nursing, food and nutrition, laundry, housekeeping, maintenance, health information technology, therapeutic recreation, therapy, business office and administration. There was no specific mention to the IP bringing all surveillance data to QAPI for review. Review of the January 2026, Infection Control Coordinator policy, identified

the infection control coordinator was to report information related to compliance to Administrator and Quality Assurance and Assessment Committee. The IP was to collect, analyze, and investigate data and trends to nursing staff and health practitioners; maintain infection logs for staff and residents; consult on strategies for infection prevention; and implement evidence-based control practices.

Infection logs -summaries of infections.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete 245599 Page 1 2 of 1 2

Level of Harm - Minimal harm Based on interview and document review, the facility failed to have a system for employee or potential for actual harm surveillance based on national standards or identify specific criteria used in determining staff return to work (RTW) for 3 of 5 sampled staff (nurse aide (NA)-A, NA-B, and trained medication aide Residents Affected - Many (TMA)-A).Findings include: Interview, employee surveillance review, and staff timecard punch review

on 4/15/26 at 12:18 p.m., with registered nurse (RN)-A identified she is the interim infection preventionist (IP) while the IP was on vacation. When staff called in sick, facility process only dictated a return to work that was 3 days or longer required a physician Return to Work (RTW) note.

They used no criteria to identify when staff would be able to safely RTW using national and State guidelines to ensure the safety of all residents and other staff in transmission prevention of potentially infectious disease. With the 3 sampled staff:Nurse aide (NA)-B called in ill on 2/8/26, 2/9/26, 2/13/26, 2/23/26 and 2/26/26. RN-A was allowed to return to work as soon as the next day.

It was later discovered after 2/26/26 NA-B was pregnant and that was the cause of her vomiting, however it was unknown at the time of illness. NA-A called in on 3/31/26 with a sore throat and runny nose. It was not documented with a presence or absence of fever. NA-A RTW on 4/1/26. NA-A was known to call-in multiple times for illness. RN-A was unaware if NA-A had tested for COVID and was not cleared for potential respiratory infectious disease following CDC guidance of symptoms improving and fever free for at least 24 hours prior to RTW. Trained medication aide (TMA)-A left her shift on 4/2/26. TMA-A was seen by a physician and had a RTW clearance date of 4/6/26. The documented reason was RSV. On 4/6/26, TMA-A called in with continued symptoms of RSV.

Timecards identified she had RTW on 4/7/26. There was no evidence that staff had ensured TMA-A was fever free or had improved symptoms for 24 hours before her return.RN-A stated she agreed there should be a system to vet staff prior to returning based off national guidelines and was unaware staff with unknown gastro-intestinal (GI) illness were to be kept off work for 48 hours after cessation of all symptoms per CDC and minimum 72 hours per State standards of the MDH to prevent highly potentially contagious GI illness such as Norovirus. Interview on 4/15/26 at 2:50 p.m. with the administrator identified the lack of employee surveillance was discussed. The administrator was unaware of staff needing to be vetted prior to returning to work to show national and/or state standards were followed, and employees were deemed appropriate to RTW as not to potentially expose other residents and/or staff to infectious disease. The documentation above showed no evidence of that occurring. Although she thought the DON may have screened employees prior to RTW, she agreed there was no evidence appropriate employee surveillance that had occurred. The administrator agreed with the findings and on the need to improve the surveillance and RTW vetting process and ensure documentation occurred. The administrator was unaware employee surveillance was not being discussed in QAPI. Review of the January 2026, Staff with Signs and Symptoms of Infectious Disease policy identified staff assessment protocols were to have been established in order for the facility to be notified if a staff member had symptoms of an infectious disease and must stay out of the facility. The goal was to prevent residents from contracting communicable disease and prevent an outbreak. Staff exhibiting any of the symptoms below need to call into DPCH and report

the symptoms they are having. The staff member receiving the call were to document the employee's signs and symptoms such as: VomitingDiarrheaGeneralized body achesCoughRunny and or stuffy noseHeadachesChillsFatigueTemperature Sore Throat Once a staff's temperature had been normal for 24 hours without taking fever reducing drugs and other symptoms were absent, the employee was allowed to return to work, depending on the infection (testing may be requested). There was no indication the policy followed national standards of practice and/ or State guidelines, depending upon

the symptoms. There was also no mention of how the process was to occur or that staff who were taking the call-ins had been appropriately trained per national and state standards for vetting employees in order to safely RTW. The policy did note staff were to be trained upon hire and annually

on signs and symptoms of infectious disease.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete 245599 Page 4 of 1 2 Department of Health & Human Services Printed: 06/12/2026 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 245599 04/15/2026 B. Wing NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Divine Providence Community Home 700 Third Avenue Northwest Sleepy Eye, MN 56085 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)