Zumbrota Care Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689May 27, 2025

  Based on observation, interview, and document review, the facility failed to maintain a functioning Wanderguard system and failed to comprehensively assess risk for elopement and appropriate interventions, resulting in elopement for 2 of 7 residents (R1, R2). R1's elopement occurred due to the failure of the Wanderguard system, which did not sound an alarm when R1 exited the building. R2's elopements occurred due to R2's risk of elopement was not accurately comprehensively assessed leading to insufficient supervision and lack of intervention, followed by a failure of the Wanderguard system. The facility's failures resulted in an immediate jeopardy (IJ). […]

• No harm, potential for more than minimal, widespreadF812Aug 7, 2025

  Based on observation, interview, and document review, the facility failed to ensure food stored in the refrigerators were labeled and dated appropriately. This deficient practice had the potential to affect 35 residents who received food from the refrigerators. Findings include: During an initial kitchen tour on 8/5/25 at 10:15 a.m., the large walk-in refrigerator contained an undated plastic container 1/2 full of soup. The refrigerator in the kitchen prep area contained an undated 3/4 full plastic container of potato salad and an undated plastic container 1/4 full of diced ham cubes. [NAME] (C)-A was unaware how old the soup was. C-A was unavailable to confirm date of potato salad or ham cubes. […]

• No harm, potential for more than minimal, widespreadF836May 27, 2025

  Based on interview and document review, the facility failed to be in compliance with the supplemental nursing service agency (SNSA) requirements when the facility obtained nursing services from Swenswen Staffing, LLC (an SNSA) which was not registered with the commissioner as required. This had the potential to affect all 34 residents of the facility who received services from the supplemental staff. Findings include: Review of the SNSA website on [DATE], did not identify [NAME] Staffing, LLC as being registered with the commissioner as required. […]

• No harm, potential for more than minimal, widespreadF838May 27, 2025

  Based on interview and document review, the facility failed to review and update the facility assessment to identify the facility's staffing plan for number of staff needed to ensure sufficient qualified staff were available to meet residents' needs. Findings include: In an email dated 5/19/25 at 5:50 p.m., the administrator noted overnight staff at the facility also worked at the assisted living facility. She noted this was an oversight if that isn't listed in the facility assessment and she would work on getting it corrected as soon as possible. […]

• No harm, potential for more than minimal, widespreadF801May 30, 2024

  Based on interview and document review, the facility failed to ensure that in the absence of a full-time registered dietician (RD), the dietary manager (DM) was certified to oversee nutrition and food services. This had potential to affect all 32 residents who resided in the facility. Findings include: During an interview on 5/28/24 at 5:24 p.m., dietary manager (DM)-D stated she had been employed at the facility for about a year and was not a certified dietary manager. DM-D stated she had been talking about taking a course but didn't know which course to take. DM-D stated she had recently received her ServSafe certificate. During a telephone interview on 5/29/24 at 4:30 p.m., registered dietician (RD)-E stated she was aware DM-D did not meet the required credentials for dietary manager. […]