Fair Oaks Nursing & Rehab Llc

F-F565

Resident R3, Resident R14, Resident R20, Resident R30

During a resident council meeting on 2/11/25 at 11:01 a.m., Resident R3, Resident R14, Resident R20, and Resident R30 voiced wait time for staff to answer a call light was at least one and half hours at times. The residents further stated staff may come and turn off the call light and say they would return however, do not come back.

During an interview on 2/12/25 at 1:56 p.m., licensed practical nurse (LPN)-A stated the facility worked short staffed every weekend and at least twice a week Monday through Friday. LPN-A further stated the facility would have staff float (work in a different area) than originally assigned due to staff call-ins or an open shift resulting in resident cares taking longer to complete or longer to answer call lights. LPN-A verified the facility utilized agency staff at times and rarely mandated staff to work. LPN-A confirmed it was exhausting to work short staffed and tough on the residents.

During an interview on 2/12/25 at 3:38 p.m., scheduler stated staffing levels were determined on resident acuity and census. Scheduler further stated staff would float to other areas of need within the facility if there was a call-in or scheduled short staff instead of mandating staff to cover the open shift. Scheduler verified

the facility utilized supplemental nursing agency staff at times. Scheduler confirmed the facility had 61 call-ins in the past 30 days and even though 61 call-ins sounded like a lot, that was an average number of call-ins for the facility. Scheduler verified the following model was used when scheduling staff:

Memory Care first floor;

-Day shift two nursing assistants (NA), one nurse.

-Evening shift two NA's and one nurse.

-Night shift one NA and one nurse.

Second floor;

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 22 245581 Department of Health & Human Services Printed: 09/08/2025 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 245581 B. Wing 02/12/2025

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

Fair Oaks Nursing & Rehab LLC 201 Shady Lane Drive Wadena, MN 56482

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 -Day shift three NA's and two nurses.

Level of Harm - Minimal harm or -Evening shift three NA's an two nurses. potential for actual harm -Night shift two NA's and one nurse. Residents Affected - Many Scheduler further verified the current staffing hours;

-Day shift 6:00 a.m., to 2:30 p.m.

-Evening shift 2:00 p.m., to 10:30 p.m.

-Night shift 10:00 p.m., to 6:30 a.m.

Review of the facility master schedule identified on a weekly basis less than the facility recommended staffing levels:

Memory Care first floor;

-Five out of seven days on 1/12/25 through 1/18/25.

-Seven out of seven days on 1/19/25 through 1/25/25.

-Five out of seven days on 1/26/25 through 2/1/25.

-Six out of seven days on 2/2/25 through 2/8/25.

-Six out of seven days on 2/9/25 through 2/15/25.

Second floor;

-Seven out of seven days on 1/12/25 through 1/18/25.

-Seven out of seven days on 1/19/25 through 1/25/25.

-Six out of seven days on 1/26/25 through 2/1/25.

-Six out of seven days on 2/2/25 through 2/8/25.

-Seven out of seven days on 2/9/25 through 2/15/25.

Review of the facility call light alarm response report 1/28/25 through 2/11/25, identified the following:

-fifteen and twenty minutes: 135 times.

-twenty and thirty minutes: 136 times.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 22 245581 Department of Health & Human Services Printed: 09/08/2025 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 245581 B. Wing 02/12/2025

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

Fair Oaks Nursing & Rehab LLC 201 Shady Lane Drive Wadena, MN 56482

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 -thirty and forty minutes: 62 times.

Level of Harm - Minimal harm or -forty and fifty minutes: 24 times. potential for actual harm -fifty minutes and one hour: 11 times. Residents Affected - Many -one hour and one and a half hours: 17 times.

-one and a half hours and two hours: four times.

-over two hours: two. A resident call light was on for two hours and forty seven minutes and another call light was on for two hours and twenty five minutes.

37905

Resident R3

Resident R3's quarterly MDS dated [DATE REDACTED], identified Resident R3 was cognitively intact and had diagnoses which included heart failure, peripheral vascular disease (restricted blood flow to limbs) and depression. Resident R3's MDS also identified Resident R3 was dependent on staff for dressing, bathing, and toileting and personal hygiene.

Resident R3's CAA dated 9/19/24, identified Resident R3 was dependent for toileting hygiene, to shower/bathe self, upper and lower body dressing, and required substantial/maximal assistance with personal hygiene. Staff would review and update care plan as needed.

Resident R3's care plan revised 12/16/24, identified Resident R3 had an activities of daily living (ADL) self-care performance deficit related to immobility and related to amputation of one lower extremity. Resident R3 required assistance of one for toilet use, personal hygiene, dressing and bathing.

During interview on 2/10/25 at 2:13 p.m., Resident R3 indicated she had concerns with sufficient staffing and stated last week in the afternoon, staff assisted her onto a bed pan. Resident R3 stated she had put her light on to be removed from the bed pan, but they did not answer her call light for four hours.

Review of the facility call light alarm response report dated 1/28/25 through 2/11/25, identified the following:

-2/2/25 at 5:23 p.m., Resident R3's rooms call light on for two hours and forty seven minutes.

-call lights for Resident R3's room were not answered for longer than fifteen minutes multiple times.

Refer to

F-F584

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 22 245581 Department of Health & Human Services Printed: 09/08/2025 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 245581 B. Wing 02/12/2025

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

Fair Oaks Nursing & Rehab LLC 201 Shady Lane Drive Wadena, MN 56482

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 an interview on 2/12/25 at 9:48 a.m., nursing assistant (NA)-H stated she felt they were not able to get all cares done due to staffing. NA-H indicated they tried their best to get all residents repositioned, and Level of Harm - Minimal harm or checked on, but felt they did not have time to get everything done, including do the cares the way the would potential for actual harm like to do them, or straighten up the rooms. NA-H stated their call lights were heavy and if NA-H was unable to answer the light, she would ask for help. NA-H stated she had noticed a call-light had been going off Residents Affected - Many earlier for a half an hour, so she let the resident know they were on their way. NA-H indicated some staff would never answer a call light, and the floor nurses usually did not answer call lights. NA-H stated some nurses were good to assist the nursing assistants with cares such as transfers however, others would not. NA-H gave an example, a nurse came to tell them while they were providing cares to a resident, that another resident wanted a drink of water, instead of getting them a drink of water themselves, which she felt was frustrating.

48583

Refer to

F-F679

Resident R37

During a telephone interview on 2/10/25 at 4:27 p.m., family member (FM)-A stated Resident R37 spent a lot of time in Resident R37's room throughout the day and FM-A did not feel the facility had the staffing to meet each residents needs on the memory care unit.

During a telephone interview on 2/10/25 at 4:59 p.m., FM-B stated FM-B on a few occasions over the past couple months, had came to see Resident R41 and had to assist Resident R41 in the bathroom. FM-B further stated Resident R41 had been left in the bathroom at times due to not having enough staff to assist Resident R41 while Resident R41 was using the restroom. FM-B indicated Resident R41 was a high fall risk and FM-B felt Resident R41 was going to have another fall because

the unit was understaffed. Resident R41 was to be monitored at all times due to several previous falls.

During an interview on 2/12/25 at 8:23 a.m., nursing assistant (NA)-E indicated activities aids were responsible for completing activities on the memory care unit but at times activities did not get completed. NA-E further indicated nursing staff had been told they were responsible to complete activities but stated nursing staff did not have the time or staff to complete activities. NA-E stated nursing staff did not have the staff to meet the needs of the residents in the memory care unit. NA-E further stated nursing staff were not able to complete all their required tasks because the unit was usually short staffed. NA-E indicated there were times when the memory care unit had one NA and one nurse because the second NA had been pulled to another floor. NA-E there were times when the facility only had three NAs on staff at one time. NA-E stated nursing staff had to ask for help but it usually did not change anything. NA-E further stated nursing staff did not have enough staff to answer call lights in a timely manner. NA-E indicated residents had long wait times due to short staffing. NA-E stated nursing staff did not have time to complete exercises with residents and often did not have time to walk residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 22 245581 Department of Health & Human Services Printed: 09/08/2025 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 245581 B. Wing 02/12/2025

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

Fair Oaks Nursing & Rehab LLC 201 Shady Lane Drive Wadena, MN 56482

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 an interview on 2/12/25 at 8:30 a.m., NA-I stated there were many times when NA-I was the only NA

on the floor to care for all the residents. NA-I further stated if other floors were short staffed or there was a Level of Harm - Minimal harm or call in, a NA would be pulled from the memory care unit to help on that floor. NA-I indicated the weekends potential for actual harm were worse for staffing. NA-I stated nursing staff were not able to get their tasks completed because nursing was constantly working short staffed. NA-I indicated nursing staff were not able to complete the interventions Residents Affected - Many for residents because of working short staffed. NA-I stated if activities aids did not complete activities, nursing staff were responsible to complete them. NA-I stated nursing staff did not have the time to complete activities especially when one staff had been pulled to another until. NA-I further stated residents did not have exercises and were not walked because of being short staffed.

During an interview on 2/12/25 at 2:42 PM activity director (AD) indicated AD was trying to ensure activities were being completed on the memory care unit but AD did not have enough staff at all times. AD further indicated AD was working on getting more staff so activities could be done consistently on the memory care unit.

During an interview on 2/12/25 at 1:18 p.m., director of nursing (DON) stated they would like call lights to be answered within 10 minutes. DON stated an hour on a bed pan could feel like four hours, and Resident R3 was lucky

she did not have skin breakdown if was left on the bed pan that long. DON stated it was the facility's expectation that everybody answer call lights, and indicated all staff could not do the cares needed, but all staff could answer the call lights.

During a follow-up interview on 2/12/25 at 5:06 p.m., DON stated the facility would float staff from a scheduled area to a different area of need within the facility resulting in staffing shortages. DON stated the expectation would be the schedule would be complete rather than float staff to other areas of need and the expectation would be to mandate staff to work until the facility could get someone else to cover the shift instead of working short staffed. Review of the facility Call Light Use and Response policy, revised 7/18/23, DON verified the expectation that call lights were to be answered promptly within ten minutes. DON confirmed that it was important to have sufficient staff to answer call lights promptly to ensure resident care was completed timely and safely.

During an interview on 2/12/25 at 5:35 p.m., administrator verified the facility assessment updated 9/5/24, had a contingency staffing plan to utilize contract/agency staff and all nursing staff including nursing management would be the back-up to work the floor due to inclement weather or other incidents.

A facility policy titled Sufficient Staffing, revised 10/19/23, identified the facility would have sufficient qualified nursing staff available at all times to provide nursing and related service to meet the residents' needs safely and in a manner that promoted each resident's rights, physical, mental and psychosocial well-being. The policy further identified daily reviews of staffing patterns would be completed by the scheduler, human resources, administrator, and director of nursing. Nursing direct care staffing ratios would be recalculated based on census and level of care needs.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 22 245581 Department of Health & Human Services Printed: 09/08/2025 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 245581 B. Wing 02/12/2025

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

Fair Oaks Nursing & Rehab LLC 201 Shady Lane Drive Wadena, MN 56482

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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45844 potential for actual harm Based on observation, interview and document review, the facility failed to maintain sanitary conditions for Residents Affected - Some mechanical lifts for 2 of 2 residents (Resident R20, Resident R31) observed who used a mechanical lift. In addition, the facility failed to implement hand hygiene for 3 of 3 residents (Resident R1, Resident R3, Resident R20) observed during cares. In addition, the facility failed to ensure safe delivery of beverages during dining observation. In addition, the facility failed to ensure proper signage for 1 of 3 residents (Resident R25) observed for enhanced barrier precautions (EBP) (an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities).

Findings include:

LIFTS AND HAND HYGIENE

Resident R20, Resident R31

During an observation on 2/10/25 at 1:12 p.m., nursing assistant (NA)-A took the mechanical lift without sanitizing it before into Resident R20's room. NA-A and NA-B Resident R20 hooked Resident R20's lift pad to the lift and lifted Resident R20 out of

the wheelchair and placed Resident R20 into her recliner and unhooked Resident R20's lift sheet from the mechanical lift.

During the transfer, Resident R20 touched the mechanical lift. NA-A took the mechanical lift into Resident R31's room. NA-A and NA-B did not sanitize their hands or the mechanical lift

During an observation on 2/10/25 at 1:18 p.m., NA-A and NA-B assisted R 31 to roll onto her side while touching Resident R31's back. NA-B placed the hoyer sheet under Resident R31. NA-A and NA-B hooked the hoyer sheet to

the mechanical lift and lifted Resident R31 into her wheelchair. During the transfer,r both Resident R31's arms came into contact with the lift. NA-A and NA-B unhooked the hoyer sheet from the mechanical lift. NA-A took the mechanical lift into the hallway and walked to Resident R1's room with the mechanical lift. NA-A and NA-B did not sanitize their hands or the mechanical lift.

During a joint interview on 2/10/25 at 1:28 p.m., NA-A and NA-B verified they had not sanitized their hands or

the mechanical lift after assisting Resident R20 and Resident R31. NA-A and NA-B both stated they should have sanitized their hands and the lift to prevent the spread of infection. NA-A stated she would sanitize the lift prior to using it for Resident R1.

37905

Resident R3

Resident R3's quarterly Minimum Data Set (MDS) dated [DATE REDACTED], identified Resident R3 was cognitively intact and had diagnoses which included heart failure, peripheral vascular disease (restricted blood flow to limbs) and depression. Resident R3's MDS also identified Resident R3 was dependent on staff for dressing, bathing, and toileting and personal hygiene.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 22 245581 Department of Health & Human Services Printed: 09/08/2025 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 245581 B. Wing 02/12/2025

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

Fair Oaks Nursing & Rehab LLC 201 Shady Lane Drive Wadena, MN 56482

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 0880 Resident R3's Functional Abilities Care Area Assessment (CAA) dated 9/19/24, identified Resident R3 was dependent for toileting hygiene, to shower/bathe self, upper and lower body dressing, and required substantial/maximal Level of Harm - Minimal harm or assistance with personal hygiene. Staff would review and update care plan as needed. potential for actual harm Resident R3's care plan revised 12/16/24, identified Resident R3 had an activities of daily living (ADL) self-care performance Residents Affected - Some deficit related to immobility and related to amputation of one lower extremity. Resident R3 required assistance of one for toilet use, personal hygiene, dressing and bathing.

During observation on 2/12/25 at 7:37 a.m. nursing assistant (NA)-F, wearing a gown and gloves, was assisting Resident R3 while in bed with morning cares. NA-F had a basin of water on bedside stand next to Resident R3's bed, rinsed it out with water, then offered the washcloth to Resident R3 to wash her face and offered her a towel to dry. NA-F proceeded to remove Resident R3's shirt, washed Resident R3's chest and underarms with soap and water and used a washcloth to dry the areas. NA-F assisted Resident R3 to apply a sweater top and asked Resident R3 if she wanted lotion on her leg, which Resident R3 said yes. NA-F applied lotion with her gloved hands to Resident R3's foot and leg and asked her if

she wanted any on her hands. NA-F did not sanitize hands or apply new gloves and NA-F applied lotion to Resident R3's hands. NA-F assisted Resident R3 to roll to her side, after unfastening Resident R3's brief tabs. NA-F proceeded to use

the soap and water from basin on the washcloth, and proceeded to wash Resident R3's perineal area. NA-F then proceeded with same washcloth used on perineal area, to wipe buttocks, wiped incision scar area and wiped away the ointment from that area. NA-F did not sanitize hands or change gloves after washing Resident R3's perineal area, or change washcloth. NA-F called for a nurse to come to room using her walkie talkie, while she wore

the same gloves. At 7:47 a.m. registered nurse (RN)-A entered the room wearing gown and gloves and applied powder to Resident R3's skin folds. RN-A removed gloves, washed hands, applied new gloves, then applied

an ointment to Resident R3's incision scar. NA-F continued to wear same gloves, applied a new brief to Resident R3, pulled up Resident R3's pants and placed a mechanical lift sling under Resident R3. NA-F called for assistance to come to the room for transfer assistance using her walkie talkie. NA-F took Resident R3's basin to the bathroom, and put Resident R3's soiled linen in

a bag. At this point, NA-F removed her gloves and sanitized her hands. NA-F informed Resident R3 she was going to leave to get the mechanical lift. At 7:58 a.m. NA-F returned to room with the mechanical lift after applying a gown and gloves. NA-F assisted Resident R3 to put in her dentures, removed her gloves and applied new gloves. NA-F did not sanitize her hands between glove use. At 8:09 a.m. NA-H entered the room wearing a gown and gloves and NA-F and NA-H assisted Resident R3 from her bed to her wheelchair using a mechanical lift.

During a phone interview on 2/12/24 at 3:54 p.m., NA-F indicated her usual practice was to change her gloves after assisting residents after washing, before brushing their teeth, or if they had to apply a cream. NA-F indicated it was a habit to just leave on the gloves during resident cares. NA-F confirmed she left the same gloves on while assisting Resident R3 with bathing, lotion application, perineal cares, and dressing. NA-F also verified she had washed Resident R3's perineal area and washed Resident R3's incision area with same gloves and washcloth. NA-F stated she had not received any education on how to wash using clean to dirty, verses dirty to clean areas. NA-F indicated not sanitizing hands or changing gloves when needed could be a problem, because

the gloves and hands could be considered soiled.

48583

EPB:

According to the Centers for Disease Control and Prevention (CDC) dated 4/2/24, EBP are required for residents who receive wound care: any skin opening requiring a dressing.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 22 245581 Department of Health & Human Services Printed: 09/08/2025 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 245581 B. Wing 02/12/2025

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

Fair Oaks Nursing & Rehab LLC 201 Shady Lane Drive Wadena, MN 56482

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 0880 Resident R25

Level of Harm - Minimal harm or Resident R25's quarterly MDS dated [DATE REDACTED], identified Resident R25 had moderate cognitive impairment and diagnoses which potential for actual harm included diabetes mellitus (DM), dementia and a pressure ulcer of the right heel. Identified Resident R34 required moderate assistance with ADL's which included toileting, transfer, and dressing Residents Affected - Some Resident R25's care plan revised 2/1/25, indicated Resident R25 had an alteration in skin integrity related to pressure. Care plan directed staff to administer treatments and assess/monitor skin integrity weekly. Resident R25's care plan lacked documentation related to Resident R25 being on EBP.

Resident R25's comprehensive CAA dated 9/27/24, indicated Resident R25 had an unhealed pressure ulcer on the right heal.

The CAA further indicated Resident R25 required moderate assistance with bed mobility, transfers, toileting.

Resident R25's wound assessment dated [DATE REDACTED], identified Resident R25 had a pressure ulcer that measured 1.5 centimeters (cm) by 1.9 cm by 1.4 cm. The wound assessment further indicated Resident R25's pressure ulcer had moderated exudate (fluid released from the wound) and it was unknown how Resident R25 obtained the pressure ulcer.

During an observation on 2/10/25 at 12:19 p.m., there was no PPE located near Resident R25's room for staff to wear while providing care for Resident R25 (who was on EBP). Further, there was no sign to identify Resident R25 was on EBP.

During an observation on 2/10/25 at 7:01 p.m., a three drawer bin containing PPE was located outside Resident R25's door for staff to wear while providing cares for Resident R25 (who was on EBP). Further, there was a sign attached to Resident R25's door that identified Resident R25 was on EBP and provided guidance on what PPE staff were required to wear while providing cares for Resident R25.

During an interview on 12:20 p.m., NA-D stated Resident R25 had a wound on her right heel and Resident R25 was on EBP.

49620

DINING OBSERVATION

During an observation on 2/10/25 at 4:40 p.m., dietary aide (DA)-A and (DA)-B delivered two food carts to

the memory care unit and placed them near the kitchenette area. The food carts were setup with a tray for each resident labeled with the resident name, food preferences, silverware and meal. DA-B removed two clear plastic drink glasses from the kitchenette area, filled the glasses with juice, milk or water and carried

the glasses holding the top rim with his bare hands back to the tray on the cart. DA-B removed a coffee cup from the kitchen, filled the coffee cup with coffee and carried the cup holding the top rim with his bare hands back to the tray on the cart. DA-B filled a glass with milk, handed the glass to DA-A who proceeded to carry

the glass holding the top rim with her bare hands back to the tray on the cart. DA-B filled another glass with juice, handed the glass to DA-A who proceeded to carry the glass holding the top rim with her bare hands back to the tray on the cart.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 22 245581 Department of Health & Human Services Printed: 09/08/2025 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 245581 B. Wing 02/12/2025

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

Fair Oaks Nursing & Rehab LLC 201 Shady Lane Drive Wadena, MN 56482

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 0880 During an interview on 2/10/25 at 4:56 p.m., DA-A and DA-B confirmed they both touched the top rim of the glasses with their bare hands and DA-B confirmed he touched the top rim of the coffee cup with his bare Level of Harm - Minimal harm or hands. DA-A and DA-B stated this practice could spread bacteria to the residents and cause illness. potential for actual harm

During an interview on 2/10/25 at 5:04 p.m., dietary manager (DM) confirmed the expectation of staff was to Residents Affected - Some hold onto the handle of a coffee cup and to not touch the rim of the glasses or coffee cup with bare hands. DM verified that was important not to touch the top rim of glasses to prevent cross contamination and the spread of germs.

Review of facility policy titled Hospitality and Dining Services effective 1/1/20, indicated the facility would provide safe and sanitary storage, handling and consumption of all foods. The policy indicated servers would handle eating utensils and plates, utilizing sanitary precautions; glasses handled by base, flatware by handles, plates kept away from clothing or aprons when serving.

During an interview on 2/11/25 at 2:38 p.m., infection preventionist (IP) verified Resident R25 should have been on enhanced barrier precautions. IP stated her expectation was that proper signage was posted for all residents

on transmission based precautions(TBP), lifts were sanitized between residents, hand hygiene to be performed when appropriate and staff not to touch the top of glasses during meal service to prevent the spread of infection.

During an interview on 2/12/25 at 8:31 a.m., director of nursing (DON) verified mechanical lifts were to be sanitized between residents. Further verified staff were to sanitize hands when appropriate. DON stated her expectation was that lifts were sanitized between residents and hand hygiene was performed to prevent the spread of infection.

During a follow-up interview on 2/12/25 at 4:43 p.m., DON stated her expectation was that staff washed their hands before and after glove use. DON also stated she would expect gloves to be changed after going from

a dirty task, such as changing a brief. DON stated residents should always be washed from clean to dirty, and to use different gloves and wash cloths for infection control purposes.

During a follow-up interview on 2/12/25 at 5:01 p.m., DON indicated she was unaware Resident R25 did not have an EBP sign on the door and no PPE near Resident R25's room prior to 2/10/25 at 7:01 p.m. DON indicated Resident R25 was to be on EBP due to the open wound.

Review of a facility policy titled Disinfection of Resident Care Equipment revised 5/8/24, identified Reusable equipment will be cleaned and disinfected after use of one resident and before use of another resident

Review of a facility policy titled Hand Hygiene revised 5/8/24, identified Staff will perform hand hygiene by washing hands for at least twenty (20) seconds with antimicrobial soap and water should be performed after providing direct resident care.

Review of a facility policy titled Personal Cleanliness and Hygienic Practices revised 11/28/22, identified all plates, utensils and drinking cups would be handled in a way to avoid touching eating surfaces.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 22 245581