Sauer Health Care

of orthostatic blood pressure will be completed as indicated for use of Antipsychotic Medications in

Facility policy titled Psychotropic Medication Management revised 6/29/2023, identified, Monitoring

residents who are ambulatory or able to attempt to stand unassisted.

245102 01/07/2026

Sauer Health Care 1635 West Service Drive Winona, MN 55987

Assessment (SCSA) Minimum Data Set (MDS) (comprehensive assessment) was completed in a

care.

Findings include:R6's quarterly MDS assessment dated [DATE] identified R6 with severe cognitive impairment, and dependent on staff for all cares including oral hygiene, toileting, dressing, and turning side-to-side in bed.

Also, R6 with indwelling catheter (tube to drain urine from bladder to bag outside the body). R6's medical conditions include neurocognitive disorder with Lewy Bodies (progressive brain disorder leading to cognitive decline) and Non-Alzheimer's Dementia. In addition, R6 also on hospice (end of life care).R6's electronic medical record (EMR) identified an admission MDS assessment dated on 1/13/25, quarterly assessments dated 4/10/25 and 7/11/25 were completed and submitted.During interview with registered nurse (RN)-A on 1/6/26 at 10:10 a.m., RN-A stated she was R6's hospice nurse and verified R6 admitted to facility in January of 2025 and started on hospice services April of 2025.During interview with infection control preventionist (IPCP) and director of nursing (DON) on 1/7/26 at 10:01 a.m., both verified R6 was admitted to hospice services on 4/17/25 and R6's EMR lacked a MDS SCSA and should have had one completed.Facility policy on MDS timing and accuracy was requested and not received.

245102 01/07/2026

Sauer Health Care 1635 West Service Drive Winona, MN 55987

During an interview on 1/7/26 at 10:16 a.m., director of nursing (DON) stated an RCA was not done due to the resident sustaining a fall outside of the facility; did not think they needed an RCA if the fall was not at the facility. DON stated the care plan should have been updated after the MDS significant change was done on 1/16/25. DON stated the importance of updating the care plan after a fall is to ensure the resident is safe at the facility and in the community.

During an interview on 1/7/26 at 11:13 a.m., administrator confirmed the RCA was not done due to the fall not happening at the facility.

Further, a risk assessment and updated care plan after the fall was not completed.

The administrator stated a RCA, risk assessment, and updated care plan are important, so the resident is safe in the facility and the community. A policy titled Falls Prevention and Management dated 1/4/25, for any falls that may occur, (witnessed, unwitnessed, intercepted), the procedure below must be followed: Evaluation, documentation, care plan, and task list.

245102 01/07/2026

Sauer Health Care 1635 West Service Drive Winona, MN 55987

During interview on 1/6/26 at 9:26 a.m., director of nursing (DON) confirmed R45 had active orders for monthly orthostatic blood pressures. DON confirmed orthostatic blood pressures are charted in the vital signs tab or in the TAR. DON confirmed orthostatic blood pressures were missing for the months of March, April, June, July, November, and December. DON stated orthostatic blood pressure measurements for residents taking antipsychotics are important so the team can identify adverse medication side effects.

During interview on 1/7/26 at 12:11 p.m., pharmacist stated pharmacy reviews were conducted monthly per regulation.

Pharmacist stated she reviews the side effect monitoring, target behaviors, and vital signs.

Pharmacist stated if she notices orthostatic blood pressures are missing, she will recommend in the monthly pharmacy review that the orthostatic measurements be completed.

Pharmacist stated the MD had written orders for orthostatic measurements to be discontinued for some residents.

Pharmacist confirmed R45 and R5 did not have orders to stop orthostatic measurements.

Pharmacist stated orthostatic measurements are important so that the medical team could identify possible adverse reactions to medications.

During interview on 1/7/26 at 2:44 p.m., medical doctor (MD) stated orthostatic measurement are built into routine monitoring to be done at least monthly while residents are taking antipsychotic medications. MD expected pharmacy to confirm orthostatic blood pressures were being completed during the monthly pharmacy reviews; to make recommendations to complete if not being done. MD would expect to be notified by nursing or pharmacy if orthostatic measurements weren't being done or were abnormal.

A policy titled Pharmacy Services dated 12/22/2016 indicated the pharmacist review involves a thorough review of resident's records and involves reporting findings with recommendations for improvement.

The pharmacist will define general guidelines for specific monitoring related to medications, when ordered or indicated, including specific item(s) to monitor (e.g., blood pressure, pulse, blood sugar, weight).

Facility policy titled Psychotropic Medication Management, revised 6/29/2023 identified, The Pharmacy Consultant will monitor drug therapy monthly with recommendations to provider as indicated.

245102 01/07/2026

Sauer Health Care 1635 West Service Drive Winona, MN 55987

During an interview on 1/7/26 at 2:12 p.m., the administrator stated the facility had a food safety and thawing policy.

The administrator stated the importance of food safety is to make sure each resident is getting the healthiest, most nutritious, and safe food at each meal.A facility policy titled Food Preparation and Handling dated 11/19/24, food is cooked as soon as possible after defrosting.

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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

245102 01/07/2026

Sauer Health Care 1635 West Service Drive Winona, MN 55987

During interview on 1/6/26 at 9:45 a.m., NA-E stated stated staff receive infection control and PPE education annually. NA-E stated gowns and gloves are worn during catheter care and wound care.

NA-E stated they technically should have worn gowns when getting R22 for the day.

During an interview on 1/5/26 at 9:49 a.m., TMA-A stated staff receive online infection control training annually and a hand hygiene and PPE procedure skills fair twice a year. TMA-A stated staff should wear gown and gloves when performing catheter care however wasn't sure if nurse are required to for wound care.

During an interview on 1/6/26 10:26 a.m., RN-A stated R22 is on EBP due to having a urinary catheter.

Staff should wear PPE when changing urinary bags or performing catheter care. RN-A stated residents with chronic wounds do not require EBP During an interview on 1/7/26 at 12:15 p.m., the director of nursing stated staff receive infection control training online upon hire.

The infection preventionist also sends out information to staff instructing when PPE is used.

The DON stated she would expect staff to wear gloves and gowns during any high contact activities and confirmed staff should have worn proper PPE during R22's cares and dressing change.

Facility policy titled MDRO (Multidrug-resistant Organisms) Risk Assessment and Prevention Plan, revised 3/27/2024 referenced CMS Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of MDROs from March 20, 2024, which instruct staff to wear gloves and gown prior to high contact care activity which includes, dressing, bathing/showering, transferring, providing hygiene, changing linens, device care or use: urinary catheter.