South Shore Care Center

F-F944.

Findings include:

Review of the QAPI meeting minute attendance from the 3/25/25 QAPI Meeting (meetings are held monthly) identified attendees present were the administrator, the director of nursing (DON) the assistant director of nursing (ADON), the infection preventionist (IP) the social services designee (SSD) and the pharmacist. The medical director was absent for this meeting. During the meeting, topics discussed were as follows:

1) Pressure Ulcers: There were 14 active pressure ulcers involving 5 residents. The facility goal was to have 5% pressure ulcer rate. Current facility percentage was left blank. After discussion, actions present were the facility was working on care plans and turning and repositioning, working on healing wounds. There was no measurable action or presentation of evaluation of the data to define commonalities such as where pressure ulcers were located on residents, possible causes, co-morbidities, areas for improvement, or potential education to staff or audits that should occur in order to achieve compliance.

2) Falls: There were a total of 16 falls in February. 2 documented minor injuries. There was no goal or current facility percentage listed. Actions identified were staff reviewed all care plans (CP) causative factors were reviewed. Isolation was a top contributor; however possible urinary tract infections (UTI) were noted as well. Staff were still looking at Resident R1 t see if she could be care planned to safe transfers from bed in the lowest position as it seemed to be when she had been found on the floor. It was not plausible at that time. No other factors were identified or discussed such as time of day, residents requiring increased supervision, staff competence with transfers etc.

3) Infection control and antibiotic stewardship: There was no facility goal or current benchmark listed. There were 39 active cases of infection the previous month with 22 respiratory (26 new) with COVID, pneumonia, and RSV identified. 4 UTI, 1 case of bone infection, and 2 others noted but not identified. Actions taken were to continue isolation and testing and keeping residents on droplet precautions. It was noted they were working on getting the IP classes in infection control and surveillance, working on appropriate personal protective equipment (PPE) audits and handwashing. It was noted to continue for the foreseeable future There was no indication it had been discussed how the facility was to ensure the IP had received time to complete her training, who was in charge of oversight until that occurred, or how the facility was to achieve their goal or what education may be needed or evaluation of actions already in progress.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 55 245596 Department of Health & Human Services Printed: 09/07/2025 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 245596 B. Wing 03/04/2025

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

The Shores of Worthington 1307 South Shore Drive Worthington, MN 56187

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 0837 4) Plan of correction (deficiencies from the previous survey): Auditing for compliance with previous deficient practice had begun. Another area identified was regarding psychotropic diagnosis. Actions identified QAPI Level of Harm - Minimal harm or was to create/locate resources for training that could be implemented within the organizational structure. A potential for actual harm few residents need to have their diagnoses reviewed and updated to ensure they had the appropriate diagnoses. There was no indication to identify any goals, or plans of action noted as to how the facility was Residents Affected - Many going to achieve compliance, who was designated to oversee compliance of certain areas, or how they would achieve compliance noted as discussed.

5) Open positions: There were 20 positions open. There was no facility goal or current status noted, nor was there any discussion of how QAPI would work toward filling positions. There was also no mention of how staff shortages were affecting care at the facility, if staffing was being maintained according to positions noted to be required in the facility assessment in order to care for residents, or if the shortages had affected other areas such as the high number of pressure ulcers or resident falls etc

6) Grievances/Abuse reporting: 2 grievances were noted for call light response, 3 involving cares, 1 for environment, and 1 for diet. Actions noted were:

a) A call light audit was run, and education was to continue with staff. Audits showed an average of a 10-minute response time, however, there was no indication staff had observed call lights to ensure the electronic data was accurate and staff were not simply shutting off the light. 1 family reported the light was on for an extended time and made her worry that if it was related to something serious, the resident could have

a poor outcome. There was no indication what was an acceptable call light wait time was, how long or what

the results identified were, or it the long wait times could have been a result of a lack of staff availability.

b) Cares: A family felt care wasn't being provided to their standards. The care plan was changed to reflect requests. 1 resident felt staff treated her differently as she must wait longer for care. A meeting was held with family and the county case worker. Another family had voiced concerns over staff knowledge.

c) Diets: A resident continued to be served food that are listed as foods she can't have. Staff had been educated and signed an understanding of the food identified. There was no indication QAPI identified competencies may be warranted if this was an ongoing issue.

d) Antipsychotic Use: The facility goal was to have no more than 15%. there was no indication on what the present percentage was. Discussion: there was roughly 21% of antipsychotic medications used in the facility. Information was presented to the assistant DON (ADON) by the pharmacist (RPh). The notes included the last gradual dose reduction (GDR) and when drugs had been started. This was noted to help the MDS and keeping things more organized. There was no indication staff had reviewed deficiency related information regarding to correct diagnoses or if the pharmacist had reviewed all residents affected as part of his contractual service.

e) Other areas: were noted in QAPI for Adverse events, resident immunizations, abuse allegations etc. Those areas also lacked thorough analysis of data.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 55 245596 Department of Health & Human Services Printed: 09/07/2025 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 245596 B. Wing 03/04/2025

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

The Shores of Worthington 1307 South Shore Drive Worthington, MN 56187

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 0837 f) Emergency Meeting: Discussion was left blank. Action identified were each tag cited for the recertification survey previous to this survey. Audits were noted to be going forward from that point on to identify deficient Level of Harm - Minimal harm or practice. No staff were designated to make sure actions identified by the facility had been completed, potential for actual harm residents identified or found to be at risk reviewed etc. QAPI identified the QAPI program deficiency cited needed to be more cognizant about documentation that reflects accuracy; however, no plan had been placed Residents Affected - Many to ensure its completion by 4/3/25 (the completion date listed on the plan of correction) would occur.

Interview and document review on 4/8/25 at 1:02 p.m., with the administrator identified he indicated the QAPI committee met to discuss the results of their previous survey. He had not provided oversight himself, as the regional nurse consultant was responsible to write the POC and determine what steps were necessary to ensure compliance. He noted the facility had such a short window to get deficient practice corrected. He was unaware the DON and ADON had not ensured the IP had time to complete her education to be able to oversee the infection control (IC) program independently, nor was he aware the DON and ADON were not providing direct oversight of the program until the IP was trained and deemed competent. The administrator also agreed he was ultimately responsible to ensure staff such as the director of nursing (DON), had provided the appropriate oversight to ensure all items identified in their POC were implemented to correct the deficient practice. The facility had educated staff to the policies, but agreed meaningful education and competencies to check staff had understood the education and applied it correctly had not occurred. He also had not ensured staff were educated to what the facility's specific QAPI plans, and monitoring was, nor had

he ensured they were educated to the QAPI 's new PIP programs. He identified the facility was planning to change how they did QAPI to ensure they could be compliant with analyzing data, and providing oversight of any deficient practice, education, etc., but that had not occurred yet.

Review of the 1/29/25, QAPI Policy identified the facility was to maintain a QAPI committee for continuous quality improvement and overall performance. One of QAPI's objectives was to establish and implement plans to correct deficiencies, and to monitor the effects of these actions plans on resident outcome. The governing body shall be ultimately responsible for the QAPI program.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 55 245596 Department of Health & Human Services Printed: 09/07/2025 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 245596 B. Wing 03/04/2025

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

The Shores of Worthington 1307 South Shore Drive Worthington, MN 56187

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 0838 Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Level of Harm - Minimal harm or potential for actual harm 49336

Residents Affected - Many Based on interview and document review the facility failed to implement 1 of 1 facility assessment protocol related to ensuring staff competencies were identified and completed respective to staff duties performed.

This has the ability to affect all 56 residents.

Findings include:

Interview on 3/04/5 at 8:15 a.m., with medical director voiced agreement the facility was to review, identify and determine appropriate interventions and oversight of outcomes brought forth

Interview on 3/04/25 at 2:26 p.m., with administrator identified the merge of two nursing homes, that included residents and staff, added an extra layer of challenges the facility was currently navigating. He identified updates of the facility assessment, had not yet been implemented, including staff education. However, He identified there was decisions made in relation to resident cares, resources and services that were to relay to all staff the facility's operational goals and performance improvement projects (PIP).

Review of August 2024 Facility Assessment Tool identified the leadership team would discuss goals to ensure direct care staff are trained to provide services to residents. The facility identified staff education, training, certifications, testing, and facility policies to support the care needed for the residents. In addition,

the facility would gather input from residents, family members and staff of concerns and expectations that would meet residents needs through regulatory, operational, maintenance and staff training requirements. Lastly, the facility would review resources annually, and would evaluate day to day operations, including emergencies, to identify and act on opportunities for improvement and to ensure residents care maintain their highest practicable physical, mental and psychosocial well-being.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 55 245596 Department of Health & Human Services Printed: 09/07/2025 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 245596 B. Wing 03/04/2025

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

The Shores of Worthington 1307 South Shore Drive Worthington, MN 56187

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 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm 39988

Residents Affected - Some Based on interview and document review the facility failed to include the run/communication report from dialysis in the facility medical record for 2 of 2 residents (Resident R18 and Resident R42) reviewed for dialysis, in addition the facility failed to transcribe physician order for 1 of 1 resident (Resident R44) following an appointment.

Findings include:

Resident R18's Admission Record identified Resident R18 was admitted to the facility at the end of January 2025. Resident R18 had the following diagnoses of chronic kidney disease stage 5, anemia, type 2 diabetes mellitus, and vitamin D deficiency.

Resident R18's 1/29/25, admission Minimum Data Set (MDS) assessment identified Resident R18's cognition was intact. Resident R18 had no behavior and required moderate assistance with cares. Resident R18 took a daily anticoagulant, diuretic, and antiplatelet. Resident R18 attended dialysis.

Resident R18's 1/24/25, care plan identified Resident R18 required hemodialysis related to renal failure. Staff were to encourage her to attend dialysis. The care plan lacked identification of dialysis schedule or where Resident R18 attended dialysis.

Resident R18's electronic medical record, point click care (PCC) identified Resident R18 had 2 copies of her dialysis run/communication report. One report was dated 1/24/25 and the second report was dated 1/27/25. The facility electronic medical lacked all other dialysis run/communication reports from dialysis.

Resident R42's Admission Record identified Resident R42 was admitted to the facility in August of 2024. Resident R42 had the following diagnoses of type 2 diabetes mellitus, end stage renal disease, cirrhosis of liver, and history of traumatic fractures.

Resident R42's 2/19/25, quarterly MDS assessment identified Resident R42's cognition was intact. Resident R42 was dependent on staff for most cares. Resident R42 had some behaviors towards others and rejection of care. Resident R42 took insulin daily, an antidepressant and antiplatelet daily. Resident R42 attended dialysis.

Resident R42's undated, care plan identified nutritional status as resident will consume 75% of meals and to modify diet as appropriate according to the resident's food tolerances and preferences. Resident R42's care plan lacked identification that Resident R42 was on dialysis, the location of an access site, any precaution that may be needed, or for any monitoring of an access site. The care plan lacked Resident R42's dialysis schedule or where Resident R42 attended dialysis.

Resident R42's 3/4/25, Order Summary Report identified Resident R42 was on a renal diet. The order summary lacked identification of dialysis access site monitoring and lacked dialysis schedule.

Resident R42's electronic medical record PCC identified the last dialysis run/communication report was from 1/27/25 with no further reports in Resident R42's facility medical record.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 55 245596 Department of Health & Human Services Printed: 09/07/2025 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 245596 B. Wing 03/04/2025

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

The Shores of Worthington 1307 South Shore Drive Worthington, MN 56187

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 0842 Interview on 3/3/25 at 11:24 a.m., with registered nurse (RN)-B identified contracted licensed nurses working at the facility were unable to access hospital medical records. We used to have a medical records person, Level of Harm - Minimal harm or that could obtain and add records from the hospital to the facility medical record, but we no longer have the potential for actual harm position.

Residents Affected - Some Review of 6/19/19, Dialysis Agreement identified communication would be shared between dialysis and the nursing home regarding the run summary, any related dialysis complications, new orders, and any changes

in condition or concerns related to the vascular access site.

Review of 11/3/21, Dialysis Care External Facility policy identified shared communication between the dialysis center and the nursing home would be coordinated by the director of nursing or designee. The communication would include post weight, blood pressure and dialysis site condition. Nutritional management will be coordinated between the dialysis dietitian and the facility dietician with recommendation initiated when received.

47497

Resident R44's 1/28/25, admission Minimum Data Set assessment identified her cognition was moderately impaired.

She required extensive assistance with her activities of daily living (ADL)'s. Resident R44 had diagnosis of atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat), heart failure, renal insufficiency, dementia, anxiety, depression, and morbid obesity.

Interview on 2/27/25 at 9:18 a.m., with FM-H identified that Resident R44 had seen a physician last week and at the appointment Resident R44 had increased swelling to her lower legs. The physician placed orders to add a water pill to decrease fluid in legs, and for staff to wrap her legs or put compression stocking on daily. He reported that

on 2/23/25 he went to the facility to visit and Resident R44 did not have any leg wraps on. FM-H spoke with the charge nurse, and she identified she was not aware of the new orders but would check into it.

Observation on 3/3/25 at 9:50 a.m., Resident R44 is seated in a wheelchair, head facing downward with eyes closed. Legs are wrapped from her feet to just below the knee in ace bandages and feet are down on the floor.

Resident R44's March 2025 medication administration record identified an order to apply ace wraps to bilateral lower extremities daily. The order entry date was 2/27/25, the order had been transcribed 8 days after it was received from the physician. Furosemide oral tablet 20 mg twice daily in addition to 20 mg for a total of 40 mg twice daily for 30 days transcribed on 2/21/25, 2 days after the order was received. Resident R44's medication/treatment administration record lacked any direction for nursing staff to elevate lower extremities or to apply antifungal powder under abdominal folds.

Interview on 3/3/25, at 11:15 a.m., with RN-B and RN-D, identified their process is to review the new order upon receiving, transcribe the order, make a nursing progress note, and place the original copy in a wall pocket behind the nurse's station for the medical records person to scan into the medical record. They identified the orders received following Resident R44's 2/19/25 appointment had been transcribed late and the original order was not yet scanned into the medical record. RN-B reported they did not currently have a medical

record person, and she was told they had planned to resolve that position, she stated nursing does not have time to scan all the orders in, she further revealed that they only complete a second check on narcotic orders and admission orders.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 55 245596 Department of Health & Human Services Printed: 09/07/2025 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 245596 B. Wing 03/04/2025

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

The Shores of Worthington 1307 South Shore Drive Worthington, MN 56187

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 0842 Subsequent interview on 3/3/25, at 11:58 a.m., RN-B came to the conference room with the original order.

She reported she found the order in a pile of papers that were waiting to be scanned in. Level of Harm - Minimal harm or potential for actual harm Resident R44's 2/19/25, original physician order identified staff were to apply antifungal powder under abdominal folds, apply compression stockings or ace wraps to lower extremities daily, keep lower extremities elevated Residents Affected - Some as much as possible, and increase Lasix to 40 milligrams (mg) twice daily for 30 days.

Interview on 3/4/25 at 8:15 a.m., with the facility medical director identified he would expect facility staff to transcribe and implement physician orders upon receipt.

A facility policy for order transcription was requested but nothing was provided by the end of the survey period.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 55 245596 Department of Health & Human Services Printed: 09/07/2025 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 245596 B. Wing 03/04/2025

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

The Shores of Worthington 1307 South Shore Drive Worthington, MN 56187

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 0865 Have a plan that describes the process for conducting QAPI and QAA activities.

Level of Harm - Minimal harm or 49336 potential for actual harm Based on interview and document review, the facility failed to ensure data submitted to 1 of 1 Quality Residents Affected - Many Assurance Performance Improvement (QAPI) committee was analyzed and documented to ensure areas identified had oversight for their perspective outcomes brought forth. This had the potential to affect all 56 residents.

Findings include:

Review QAPI minutes from February 2024 through January 2025, identified department heads were bringing data forth to QAPI on various topics such as infection control, falls, incident reports, vaccinations, etc. However, there was no documented benchmarks for goals the facility was trying to achieve, nor monitoring to determine if goals were met or QAPI needed to continue monitoring to ensure compliance.

Interview on 3/04/5 at 8:15 a.m., with medical director voiced agreement the facility was to review, identify and determine appropriate interventions and oversight of outcomes brought forth.

Interview on 3/04/25 at 2:09 p.m., with administrator identified the merge of two nursing homes, that includes residents and staff, added an extra layer of challenges the facility was currently navigating. He identified there was no measurable goals set, or if goals were met to improve areas identified in QAPI. He and the QAPI committee would need to formalize a process to identify improvements that would reflect changes as needed in QAPI.

Review of December 20219 Quality Assurance and Performance Improvement (QAPI) policy identified the facility would review clinical and nonclinical systems to determine areas of improvement. The facility's performance improvement project (PIP) was identified in areas that were unique to the facility's needs. The QAPI committee would establish benchmarks to determine facility improvements, analyze data for accuracy and determine root cause. Lastly, the QAPI committee would modify QAPI template, as well as the facility assessment as needed to identify complexities and/or evolving resources and services.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 55 245596 Department of Health & Human Services Printed: 09/07/2025 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 245596 B. Wing 03/04/2025

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

The Shores of Worthington 1307 South Shore Drive Worthington, MN 56187

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 0867 Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Level of Harm - Minimal harm or potential for actual harm 49336

Residents Affected - Many Based on interview and document review, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to identify facility specific concerns, implement an action plan to correct the identified concerns or to ensure the committee participated in the development and oversight of implementation of systems, and to ensure quality of life and quality of care were maintained for 57 residents residing in the facility.

Findings include:

Review of QAPI minutes from February 2024 to January 2025, identified on 4/19/24 the facility was to implement a performance improvement project (PIP) of abuse allegations. There was no mention on how the facility would meet goals, monitor progress or evaluate current measures to ensure compliance.

Interview on 3/04/5 at 8:15 a.m., with medical director voiced agreement the facility was to review, identify and determine appropriate interventions and oversight of outcomes brought forth.

Interview on 3/04/25 at 2:26 p.m., with administrator identified the merge of two nursing homes, that includes residents and staff, added an extra layer of challenges the facility was currently navigating. He identified there were challenges and improvements related to resident cares, resources and services to be streamlined and identified in QAPI. He identified the facility had no performance improvement projects in place at this time.

Review of December 20219 Quality Assurance and Performance Improvement (QAPI) policy identified the facility would review clinical and nonclinical systems to determine areas of improvement. The facility's performance improvement project (PIP) was identified in areas that were unique to the facility's needs. The QAPI committee would establish benchmarks to determine facility improvements, analyze data for accuracy and determine root cause. Lastly, the QAPI committee would modify QAPI template, as well as the facility assessment as needed to identify complexities and/or evolving resources and services.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 55 245596 Department of Health & Human Services Printed: 09/07/2025 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 245596 B. Wing 03/04/2025

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

The Shores of Worthington 1307 South Shore Drive Worthington, MN 56187

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 38687 potential for actual harm Based off document and interview, the facility failed to ensure 1 of 1 resident (Resident R41) with a highly infectious Residents Affected - Many disease (Hepatitis C) was placed into the infection control (IC) surveillance data for monitoring. In addition,

the facility failed to ensure oversight of the IC program was maintained for tracking, trending, and analysis of data to prevent potential spread of infection. The facility also failed to include staff return to work information

in surveillance to identify if they were appropriately vetted before their return for 1 of 3 months (January 2025) reviewed. This has the potential to affect all 56 residents.

Findings include:

Resident R41's face sheet identified he was admitted to the facility in September 2024. Resident R41 had a recent hospital stay 11/4/24 through 11/6/24 and had diagnoses of hypoparathyroidism (parathyroid glands do not produce enough parathyroid hormone and treated with medication), history of a lumbar spinal fracture, right leg fracture, right artificial hip, hypothyroidism (thyroid gland does not produce enough thyroid hormone), generalized anxiety disorder, and multiple fractures of ribs.

Resident R41's 11/25/24, quarterly Minimum Data Set (MDS) identified Resident R41 was admitted to the facility (from the now closed sister facility) in September 2024. Resident R1 was noted to have delusions with no behaviors identified.

Resident R41's 11/19/24, physician progress note identified the PCP noted additional diagnoses from the previous visit of chronic hepatitis C.

Resident R41's current, undated care plan identified there was also no mention of his Hepatitis C diagnosis.

Review of the surveillance for February and March identified infections were getting logged into the tracking system in the facility electronic medical records system (Point Click Care (PCC) by facility staff. Resident R41 was not listed as being included in surveillance for his diagnosis of Hepatitis C.

Review of the facility's previous revisit directed plan of correction for a deficiency cited in January 2025 identified the facility was to have contracted with a contracted infection preventionist (CIP). The contract began 2/17/25, The CIP was to have begun working immediately with the facility in assisting with the root cause analysis of the program related to the deficient practice, review the program as a whole, review the plan of correction, and support the facility in developing audit tools.

Interview on 3/3/25 at 11:00 a.m., with the administrator identified the infection preventionist was out on medical leave and registered nurse (RN)-B was to oversee the program in her absence.

Interview on 3/3/25 at 2:15 p.m., with RN-B identified she was never told to assist in oversight of the IC program. She had no knowledge of what was being inputted into the PCC program for tracking infections.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 55 245596 Department of Health & Human Services Printed: 09/07/2025 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 245596 B. Wing 03/04/2025

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

The Shores of Worthington 1307 South Shore Drive Worthington, MN 56187

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 Review of the employee line listings for December 2024 through February 2025 identified in January, 2025, there were 3 staff illnesses reported. The symptoms resolved category and the return to work column were Level of Harm - Minimal harm or left blank. Illnesses recorded were coughs, fever, and abdominal pain. During follow-up email potential for actual harm correspondence with the director of nursing (DON) on 3/4/25, The DON had to check with payroll for 2 staff, however she was also listed as having been ill that month. She noted she had forgot to put in her return to Residents Affected - Many work date into the IC surveillance. The DON agreed all data needed to be inputted to ensure illnesses were tracked and staff were kept off work for the appropriate amount of time.

Interview on 3/03/25 at 5:37 p.m., with the DON identified the IP was off work beginning right after the State Agency revisit on 2/14/25. They had not had a meeting with a consultant until last week. The CIP had not yet reviewed or provided assistance with the IC program. The DON agreed Resident R41's Hepatitis C was a highly infectious disease and should be on the surveillance. The facility had no one to cover IC during the IP continued absence. The facility had only first spoken to the hired consultant last week. They did not have a plan to cover the IP while on medical leave. Agreed IC needed appropriate oversight at all times to review data.

Interview on 3/4/25 at 8:16 a.m. with the medical director (MD)-A identified he was unaware that facility had no active IP due to medical leave and no staff had replaced her. He agreed the IC program required direct oversight. He was also unaware the CIP was not advised of the facility's inability to designate an IP in IP-A's absence. Resident R41's Hepatitis C should be included on the facility's surveillance as it is a highly infectious disease.

There was no policy related to oversight of the IC program provided by the end of survey.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 55 245596 Department of Health & Human Services Printed: 09/07/2025 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 245596 B. Wing 03/04/2025

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

The Shores of Worthington 1307 South Shore Drive Worthington, MN 56187

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 0882 Designate a qualified infection preventionist to be responsible for the infection prevent and control program in

the nursing home. Level of Harm - Minimal harm or potential for actual harm 38687

Residents Affected - Many Based off document and interview, the facility failed to ensure oversight of the IC program was maintained to provide appropriate oversight for tracking, trending, and analysis of data to prevent potential spread of infection. This had the ability to affect all 56 residents.

Based off document and interview, the facility failed to ensure 1 of 1 resident (Resident R41) with a highly infectious disease (Hepatitis C) was placed into the infection control (IC) surveillance data for monitoring. In addition,

the facility failed to ensure oversight of the IC program was maintained for tracking, trending, and analysis of data to prevent potential spread of infection. The facility also failed to include staff return to work information

in surveillance to identify if they were appropriately vetted before their return for 1 of 3 months (January 2025) reviewed. This has the potential to affect all 56 residents.

Findings include:

Resident R41's face sheet identified he was admitted to the facility in September 2024. Resident R41 had a recent hospital stay 11/4/24 through 11/6/24 and had diagnoses of hypoparathyroidism (parathyroid glands do not produce enough parathyroid hormone and treated with medication), history of a lumbar spinal fracture, right leg fracture, right artificial hip, hypothyroidism (thyroid gland does not produce enough thyroid hormone), generalized anxiety disorder, and multiple fractures of ribs.

Resident R41's 11/25/24, quarterly Minimum Data Set (MDS) identified Resident R41 was admitted to the facility (from the now closed sister facility) in September 2024. Resident R1 was noted to have delusions with no behaviors identified.

Resident R41's 11/19/24, physician progress note identified the PCP noted additional diagnoses from the previous visit of chronic hepatitis C.

Resident R41's current, undated care plan identified there was also no mention of his Hepatitis C diagnosis.

Review of the surveillance for February and March identified infections were getting logged into the tracking system in the facility electronic medical records system (Point Click Care (PCC) by facility staff. Resident R41 was not listed as being included in surveillance for his diagnosis of Hepatitis C.

Review of the facility's previous revisit directed plan of correction for a deficiency cited in January 2025 identified the facility was to have contracted with a contracted infection preventionist (CIP). The contract began 2/17/25, The CIP was to have begun working immediately with the facility in assisting with the root cause analysis of the program related to the deficient practice, review the program as a whole, review the plan of correction, and support the facility in developing audit tools.

Interview on 3/3/25 at 11:00 a.m., with the administrator identified the infection preventionist was out on medical leave and registered nurse (RN)-B was to oversee the program in her absence.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 55 245596 Department of Health & Human Services Printed: 09/07/2025 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 245596 B. Wing 03/04/2025

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

The Shores of Worthington 1307 South Shore Drive Worthington, MN 56187

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 0882 Interview on 3/3/25 at 2:15 p.m., with RN-B identified she was never told to assist in oversight of the IC program. She had no knowledge of what was being inputted into the PCC program for tracking infections. Level of Harm - Minimal harm or potential for actual harm Review of the employee line listings for December 2024 through February 2025 identified in January, 2025, there were 3 staff illnesses reported. The symptoms resolved category and the return to work column were Residents Affected - Many left blank. Illnesses recorded were coughs, fever, and abdominal pain. During follow-up email correspondence with the director of nursing (DON) on 3/4/25, The DON had to check with payroll for 2 staff, however she was also listed as having been ill that month. She noted she had forgot to put in her return to work date into the IC surveillance. The DON agreed all data needed to be inputted to ensure illnesses were tracked and staff were kept off work for the appropriate amount of time.

Interview on 3/03/25 at 5:37 p.m., with the DON identified the IP was off work beginning right after the State Agency revisit on 2/14/25. They had not had a meeting with a consultant until last week. The CIP had not yet reviewed or provided assistance with the IC program. The DON agreed Resident R41's Hepatitis C was a highly infectious disease and should be on the surveillance. The facility had no one to cover IC during the IP continued absence. The facility had only first spoken to the hired consultant last week. They did not have a plan to cover the IP while on medical leave. Agreed IC needed appropriate oversight at all times to review data.

Interview on 3/4/25 at 8:16 a.m. with the medical director (MD)-A identified he was unaware that facility had no active IP due to medical leave and no staff had replaced her. He agreed the IC program required direct oversight. He was also unaware the CIP was not advised of the facility's inability to designate an IP in IP-A's absence. Resident R41's Hepatitis C should be included on the facility's surveillance as it is a highly infectious disease.

There was no policy related to oversight of the IC program provided by the end of survey.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 55 245596 Department of Health & Human Services Printed: 09/07/2025 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 245596 B. Wing 03/04/2025

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

The Shores of Worthington 1307 South Shore Drive Worthington, MN 56187

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 0944 Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Level of Harm - Minimal harm or potential for actual harm 49336

Residents Affected - Many Based on interview and document review, the facility failed to provide mandatory training on 1 of 1 facility specific Quality Assurance Performance Improvement (QAPI) Program to include goals and various elements of the program, how the facility intends to implement the program, staff's role in the facility's QAPI program, or how to communicate concerns, problems, or opportunities for improvement to the facility's QAPI program. This had the ability to affect all 57 residents.

Findings include:

Interview on 3/03/25 at 2:58 p.m., with Registered nurse (RN)-B and RN-D identified the facility held scheduled meetings for residents and staff. Both RN-B and RN-D had not attended QAPI meetings and was not aware of any facility specific performance improvement projects.

Interview on 3/03/25 at 3:04 p.m., with admission coordinator identified the facility plan was to prevent further infection control outbreaks related to COVID and respiratory syncytial virus (RSV).

Interview on 3/03/25 at 3:09 p.m., with licensed practical nurse (LPN)-A identified she was not aware of QAPI meetings held and/or specific QAPI goals.

Interview on 3/03/25 at 4:10 p.m., with RN-A identified she was aware the facility had monthly QAPI meetings and had not attended them. There were care areas and services the facility would need to address, but she could not identify any specific QAPI goals the facility had in place.

Interview on 3/03/25 at 4:23 p.m., with nursing assistant (NA)-A identified she has attended QAPI meetings,

in the past, if her schedule allowed, but was not aware of any QAPI goals the facility was monitoring.

Review of email correspondence on 3/04/24 at 9:15 a.m., with director of nursing identified there was no formal education for employees of QAPI training.

Interview on 3/04/25 at 2:09 p.m., with administrator identified the facility provided QAPI education to staff upon employment and would work towards formalizing QAPI requirements for all employees going forward.

Review of December 20219 Quality Assurance and Performance Improvement (QAPI) policy identified the facility would review clinical and nonclinical systems to determine areas of improvement. The facility's performance improvement project (PIP) was identified in areas that were unique to the facility's needs. The QAPI committee would establish benchmarks to determine facility improvements, analyze data for accuracy and determine root cause. Lastly, the QAPI committee would modify QAPI template, as well as the facility assessment as needed to identify complexities and/or evolving resources and services.

Employee QAPI training was requested and not provided during survey.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 55 245596