Warroad Care Center

In the surveyor’s words

From the most serious findings on record at Warroad Care Center, in the surveyor’s own words.

• Immediate jeopardy, patternF812Aug 13, 2021

  Based on observation, interview, and document review, the facility failed to ensure unpasteurized shell eggs were fully cooked and prepared in a manner to prevent foodborne illness. This resulted in an immediate jeopardy (IJ) situation for 1 of 1 residents (R20) who was observed to consume undercooked unpasteurized eggs; 9 of 9 residents (R3, R5, R6, R16, R24, R33, R44, R45, R46) who were identified to frequently request and consume undercooked unpasteurized eggs on a routine basis. The IJ that began on 8/11/21, when the facility prepared and served unpasteurized egg(s) on a made to order basis with runny yolk(s), which were not fully cooked resulting in an increased potential for foodborne illness. On 8/11/21, at 4:47 p.m. […]

• Immediate jeopardy, isolatedF600Nov 6, 2024

  Based on observation, interview and document review, the facility failed to ensure 1 of 1 resident (R39) with a known history of sexual behaviors towards others was comprehensively assessed and interventions implemented to mitigate risk to prevent ongoing sexual abuse for 2 of 2 residents (R31, R6) who were cognitively impaired, dependent on staff for their care, and were sexually abused by R39. The immediate jeopardy (IJ) began on 9/6/24, when R39 came up behind R31 and fondled her breasts. The facility failed to comprehensively assess and develop interventions to help manage and reduce the risk of injury or assault to others. This contributed to R39 continued episodes of sexual abuse toward R31 on 9/25/24, and again on 10/14/25, and toward R6 on 10/15/24. […]

• Immediate jeopardy, isolatedF689Nov 6, 2024

  Based on observation, interview and document review, the facility failed to ensure staff were following care planned interventions of two staff assist when transferring residents with a ceiling lift; and failed to complete therapy/or nursing assessments to determine the appropriate sling sizes per manufacturers guidelines for 3 of 4 residents (R12, R7, R2) reviewed who were transferred via ceiling lifts. These deficient practices resulted in immediate jeopardy (IJ) for R12, R7 and R2 who were at risk of serious injury as a result of the deficient practice. The IJ began on 10/29/24, when R7 was observed to be transferred in the ceiling lift from her bed to the toilet by assist of one staff when R7 was care planned to be transferred with two staff. […]

• Immediate jeopardy, isolatedF803Jun 13, 2024

  Based on observation, interview and document review the facility failed to provide the physician ordered mechanically altered diet for 1 of 3 residents (R1) reviewed who was at risk for choking and served the wrong textured diet. This resulted in an immediate jeopardy (IJ) for R1. The IJ began on 5/28/24, when R1 was served a regular diet instead of the physician ordered pureed diet which resulted in R1 choking and requiring the Heimlich Maneuver to dislodge a corn dog. The administrator was notified of the IJ on 6/12/24, at 3:21 p.m. The IJ was removed on 6/13/24, at 1:15 p.m., but noncompliance remained at the lower scope and severity level D, with no actual harm with potential for more than minimal harm that was not immediate jeopardy. […]

• Immediate jeopardy, isolatedF689Sep 8, 2023

  Based on observation, interview, and document review the facility failed to maintain resident safety when a resident with a history of exiting the facility unsupervised, eloped through the Assisted Living (AL) wing of the facility at approximately 4:15 a.m. on 8/22/23. This resulted in an immediate Jeopardy (IJ) situation for R1. In addition, the facility failed to implement a system to ensure proper functioning of their Wander Alert system resulting in 1 of 3 residents (R3) reviewed for elopement, exiting the unit unnoticed by staff during the survey. The IJ began on 8/22/23, when R1 exited the facility via the attached AL wing of the facility after staff left her unattended in the lobby for the second time during the overnight shift at 4:15 a.m. R1 was not located again until 4:45 a.m. […]