Wabasso Restorative Care Center

F 0577

Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

Level of Harm - Potential for minimal harm

Based on observation, interview and document review, the facility failed to ensure both recertification survey results, complaint investigations, and facility plans of correction were available for review. This had

the potential to affect all forty-three (43) residents residing in the facility, as well as family, visitors, and staff.Findings include:Resident R5's brief interview for mental status (BIMS) dated 8/11/25, indicated Resident R5 had moderately impaired cognition.On 8/27/25 at 3:50 p.m., Resident R5 indicated he would like to see the results of the surveys that the State Agency (SA) conducted however, did not know where to locate them.On 8/27/25 at 4:00 p.m., a binder titled facility survey results was located in a plastic wall file by the front entrance behind

the resident council minutes. The survey results included in the binder consisted of the recertification survey results for 4/25/24, and complaint investigation results for 5/21/24, and 5/28/25.A review of Aspen Central Office (ACO-an online computerized federal document site which contains the surveys completed for facilities, including both recertification surveys, and complaint investigation) identified recertification surveys were completed on 6/29/23, 4/25/24, and 11/18/24. Additionally, complaint investigations were completed and noted to have citations issued on the following dates: 12/28/22, 3/23/23, 7/12/23, 7/26/23, 2/28/24, 5/21/24, 9/24/24, 12/24/24, and 5/28/25.The facility survey result binder lacked the following: recertification surveys completed 6/29/23, and 11/18/24; facility's plan of correction for 4/25/24; complaint surveys completed 12/28/22, 3/23/23, 7/12/23, 7/26/23, 2/28/24, 9/24/24, and 12/24/24; facility's plan of correction for 5/21/24. During an interview on 8/28/25 at 11:54 a.m., the corporate clinical care coordinator (CCCC) indicated the survey results were public knowledge and should contain all state agency surveys with facility plan of corrections. The CCCC verified the facility survey binder did not contain all the required surveys or facility plans of correction. During an interview on 9/2/25 at 4:39 p.m., the administrator was unable to locate the facilities survey binder however, indicated the residents take them and stated, they [survey results] disappear as fast as we put them out. A facility policy was requested for posting of survey results however, was not provided.

Residents Affected - Many

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/02/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Wabasso Restorative Care Center

660 Maple Street Wabasso, MN 56293

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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

p.m., identified Resident R2 had a verbal altercation and made a threat of violence with an unidentified resident. The facility identified Resident R2 had a decrease in a medication that caused Resident R2 to have increased discomfort, and he became more short-tempered. The facility placed Resident R2 on 30-minute checks for mood monitoring from 8/17/25 to 8/22/25.During an interview on 9/2/25 at 2:08 p.m., nursing assistant (NA)-A indicated she was working on 8/21/25 when the alleged incident occurred. Further identified Resident R1 told her at approximately 8:00 a.m. that Resident R2 had pulled her hair and punched her while outside in the smoking area. NA-A identified she told the assistant director of nursing and the charge nurse about the allegation immediately after Resident R1 reported it and they placed Resident R1 and Resident R2 on 15-minute checks.During an interview on 9/2/25 at 2:02 p.m., NA-B identified Resident R1 reported that Resident R2 had pulled her hair and punched or slapped her on the head. NA-B stated they started 15-minute checks on Resident R1 and Resident R2 for safety. During an interview on 9/2/25 at 2:36 p.m., NA-C indicated she was working the medication cart on 8/21/25 and Resident R1 was acting a little weird and a little distraught. NA-C further identified at approximately 8:00 a.m., Resident R1 complained that her head hurt and she wanted some Tylenol. During an interview on 9/2/25 at 2:42 p.m., NA-D indicated she was working on 8/21/25, when Resident R1 reported that Resident R2 had hit her and pulled her hair. During an interview on 8/28/25 at 2:15 p.m., licensed practical nurse (LPN)-A, indicated she was working on 8/21/25, as a charge nurse and did not recall any incident between Resident R1 and Resident R2 that occurred that day. LPN-A stated on 8/22/25, Resident R1 was upset and reported she was leaving the facility because she was scared of Resident R2. During an interview on 9/2/25 at 3:00 p.m., the director of nursing stated she was informed of the incident between Resident R1 and Resident R2 the day after

it happened and described the incident as Resident R2 pulled or touched [Resident R1's] hair and she did not like it and was upset about it. The facility implemented 15-minute checks on Resident R1 and Resident R2. During an interview on 9/2/25 at 11:34 a.m., the administrator identified she was aware of the incident that occurred between Resident R1 and Resident R2 and the facility implemented 15-minute checks on Resident R1 and Resident R2 to assure they were not outside in the smoking area at the same time. The Sheriff's Office Incident Report dated 8/21/25 at 7:21 p.m., Resident R1's family member called to request a welfare check on Resident R1 as Resident R1 had reported Resident R2 assaulted her. The sheriff's deputy responded at 7:34 p.m. and Resident R1 reported at 8 a.m. that morning, Resident R2 pulled her hair, struck her in the back of

the head, and pushed her wheelchair. The deputy informed staff of the situation and staff stated that they would keep Resident R1 and Resident R2 separated. Review of the facility's policy titled, Abuse, Neglect, and Exploitation last revised 4/25/25, indicated it was the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of property. Abuse was defined as the willful infliction of injury with resulting physical harm, pain, or mental anguish. Physical abuse included and was not limited to hitting, slapping, punching, biting, and kicking.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/02/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Wabasso Restorative Care Center

660 Maple Street Wabasso, MN 56293

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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and document review, the facility failed to report an allegation of abuse timely to the State Agency (SA) for 1 of 1 resident (Resident R1) reviewed for allegations of abuse.Findings include: A Facility Reported Incident (FRI) submitted to the State Agency (SA) on 8/22/25 at 11:35 a.m., alleged abuse when Resident R2 tugged Resident R1's hair and hit her head while outside. The alleged abuse occurred on 8/21/25 at approximately 10:00 a.m. (Approximately 25 1/2 hours prior to reporting to the SA). Resident R1's admission Minimum Data Set (MDS) dated [DATE REDACTED], indicated Resident R1 had severe cognitive impairment and no behaviors. Identified Resident R1 used a wheelchair for mobility and required substantial staff assist with dressing, transferring, bed mobility, and personal hygiene. A follow up brief interview for mental status on 8/22/25, indicated Resident R1 had moderately impaired cognition. Resident R1's Care Plan Report identified Resident R1 had a potential for abuse due to current health condition that required assistance with activities of daily living (ADL)'s and impaired cognition. Diagnoses included alcohol dependence, tobacco dependence, major depressive disorder and repaired fracture of femur and pelvis.

During an interview with Resident R1 on 9/2/25 at 5:55 p.m., Resident R1 indicated on 8/21/25 at approximately 8:00 a.m., Resident R2 hit her in the back of the head, pulled her hair, and pushed her wheelchair into the fence in the smoking area. Resident R1 stated, I immediately got a headache and got a Tylenol. Resident R1 further identified she told several nursing staff immediately after it happened but could not remember who she had talked to. Resident R1 identified the next day (8/22/25), Resident R2 threatened her again and she called a family member to come and pick her up. Resident R2 stated she discharged from the facility and was not going back. Resident R2's quarterly MDS dated [DATE REDACTED], indicated Resident R2 had intact cognition and no behaviors. Identified Resident R2 had no upper extremity impairment, had lower extremity impairment and used a manual wheelchair. Resident R2 was independent wheeling his wheelchair.

Diagnoses included paraplegia (paralysis of the legs and lower body), alcohol dependence, and adjustment disorder with mixed anxiety and depressed mood. During an interview on 9/2/25 at 2:08 p.m., nursing assistant (NA)-A indicated she was working on 8/21/25, when the alleged incident occurred. NA-A stated at approximately 8:00 a.m., Resident R1 reported that Resident R2 had pulled her hair and punched her while outside in the smoking area. NA-A identified she told the assistant director of nursing and the charge nurse about the allegation immediately after Resident R1 reported it and they placed Resident R1 and Resident R2 on 15-minute checks. During an

interview on 9/2/25 at 11:34 a.m., the administrator indicated she was notified of the incident on 8/21/25, however, did not know about Resident R2 hitting Resident R1. The administrator verified the FRI was submitted late to the SA

on 8/22/25, when she became aware of the hitting.The Sheriff's Office Incident Report dated 8/21/25 at 7:21 p.m., Resident R1's family member called to request a welfare check on Resident R1 as Resident R1 had reported Resident R2 assaulted her. The sheriff's deputy responded at 7:34 p.m. and identified that Resident R1 reported at 8 a.m. that morning, Resident R2 pulled her hair, struck her in the back of the head, and pushed her wheelchair. The deputy informed staff of

the situation and staff stated that they would keep Resident R1 and Resident R2 separated. Approximately 16 hours prior to

the FRI was submitted to the SA.Review of facility policy titled The Abuse, Neglect, and Exploitation Policy last revised 4/25/25, indicated the facility was to report all alleged violations to the administrator, state agency, adult protective services, and all other required agencies (law enforcement when applicable) within specified timeframes: Immediately, but not later than 2 hours after the allegation was made for events that caused the allegation to involve abuse or result in serious bodily injury.

Event ID:

Facility ID:

If continuation sheet