Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Zumbrota Care Center during CMS and state inspections, most recent first.
The facility did not comprehensively assess or document the correct sling and harness sizes for two residents requiring mechanical lifts for transfers, resulting in staff relying on weight-based charts and informal communication rather than manufacturer-recommended measurements and documentation. This led to inconsistencies and lack of clear guidance in care plans and Kardexes regarding the appropriate equipment for safe resident transfers.
Surveyors found that food items such as soup, potato salad, and diced ham cubes were stored in facility refrigerators without required labels or dates. Staff were unable to confirm the age of these foods, and the facility's policy mandates labeling and dating of all prepared and opened food items. This deficiency had the potential to affect 35 residents receiving food from these refrigerators.
Two residents with cognitive impairment and a history of wandering successfully eloped from the facility due to a malfunctioning Wanderguard system and inadequate assessment and intervention for elopement risk. Staff failed to notify maintenance or test the system after the first incident, and care plans did not specify needed supervision or address risk factors. Testing revealed that most Wanderguard-equipped doors did not alarm as intended, leaving residents unsupervised and able to exit undetected.
The facility obtained nursing staff from an unregistered supplemental nursing service agency, Swenswen Staffing, LLC, which was not listed as approved by the state and had an expired registration certificate. Both nursing assistants and trained medication aides from this agency provided care to all residents during the review period. The administrator was unaware of the requirement to verify agency registration, and no policy on supplemental staffing was available.
The facility did not update its assessment to reflect that overnight nursing and aide staff were regularly shared with the assisted living facility, resulting in an inaccurate staffing plan that overstated the number of staff available to meet resident needs. The assessment failed to account for staff time spent outside the nursing home, and this discrepancy was confirmed by both the administrator and DON.
A resident with dementia and a history of elopement risk was found outside the facility after the Wanderguard alarm failed to activate. The incident was not reported to the administrator or state agency within the required two-hour timeframe, as outlined in facility policy, resulting in a delay in notification.
A resident identified as an elopement risk had a Wanderguard device in place and checked daily, but the MDS assessment failed to accurately document the use of this wander/elopement alarm. Staff confirmed the device was present and in use, and the MDS Coordinator acknowledged the omission.
Nurse staffing information posted by the facility did not accurately reflect the actual hours worked by nursing staff directly responsible for resident care, as staff assigned to the nursing home also provided care in the assisted living facility during their shifts. The posted forms failed to adjust for time spent away from the nursing home, resulting in inaccurate reporting of staff presence and hours worked.
The facility submitted inaccurate PBJ staffing data to CMS by failing to subtract hours that nursing staff spent assisting at an assisted living center during their scheduled shifts. Documentation and staff interviews confirmed that this practice resulted in overreported staffing hours for the facility, as the reported data did not reflect actual time spent providing care within the facility.
The facility did not ensure that the dietary manager was certified to oversee nutrition and food services in the absence of a full-time registered dietician. The DM had been employed for about a year without the necessary certification, although she had a ServSafe certificate. The RD and administrator were aware of this issue, which had the potential to affect all 32 residents.
The facility failed to submit accurate staffing data to CMS for Q1 FY2024, missing licensed nursing coverage on specific dates. Despite having scheduled and employed licensed nurses, the data submitted was incomplete due to a misunderstanding of requirements.
Failure to Assess and Document Proper Sling/Harness Sizes for Mechanical Lift Transfers
Penalty
Summary
The facility failed to comprehensively assess and document the appropriate sling and harness sizes for residents requiring mechanical lifts for transfers, as per manufacturer instructions. For two residents with significant mobility impairments and histories of falls, the care plans, Kardexes, and therapy/nursing communication forms did not specify the required sling or harness sizes. Although assessments noted residents' heights and weights, they did not include all manufacturer-recommended measurements, such as the distance from tailbone to base of neck or torso circumference, which are necessary for proper sizing and safe transfers. Direct care staff interviews revealed that nursing assistants determined sling and harness sizes primarily based on residents' weights and reference charts, rather than comprehensive assessments. Staff reported relying on slings or harnesses found in residents' rooms or consulting with other aides if uncertain about sizing. There was inconsistency among staff regarding which size should be used for each resident, and the required measurements for proper fit were not routinely obtained or documented. The lack of clear documentation in the care plans and Kardexes meant that staff did not have immediate access to the correct sling or harness size information during transfers. The assistant director of nursing confirmed that comprehensive sling and harness assessments had not been completed for the residents in question, which resulted in the absence of this information in their care plans. Manufacturer instructions for the mechanical lifts and harnesses emphasize the need for a full patient assessment to determine the appropriate accessory size and type prior to each use. The facility was unable to provide a policy and procedure for mechanical lift equipment upon request.
Failure to Label and Date Stored Food Items
Penalty
Summary
During a kitchen tour, surveyors observed that food items stored in the facility's refrigerators were not labeled or dated as required. Specifically, a large walk-in refrigerator contained an undated plastic container half full of soup, and the kitchen prep area refrigerator contained an undated three-quarters full plastic container of potato salad and an undated plastic container one-quarter full of diced ham cubes. Staff present at the time were unable to confirm how old these food items were or provide information on when they had been prepared or stored. The facility's policy on perishable food management requires all foods not in their original packaging to be labeled with a description and dates, including a use-by or discard date. The policy also states that leftover foods must be clearly labeled before refrigeration and used within three days, with disposal on the fourth day. The observed failure to label and date these food items was confirmed by the dietary manager, who stated that it is expected for all prepared foods and opened packages to be dated prior to storage. This deficiency had the potential to affect 35 residents who received food from these refrigerators.
Failure to Maintain Wanderguard System and Comprehensive Elopement Risk Assessment
Penalty
Summary
The facility failed to maintain a functioning Wanderguard system and did not comprehensively assess or implement appropriate interventions for residents at risk of elopement, resulting in two residents successfully eloping from the building. In one case, a resident with severe cognitive impairment and a history of wandering was able to exit the facility without the Wanderguard alarm sounding. Staff did not notify maintenance of the malfunction, did not test all doors or Wanderguard devices after the incident, and did not provide education to staff regarding system testing. The Director of Nursing was unaware of manufacturer recommendations for testing and did not know how the doors were being tested. Another resident, with multiple diagnoses including dementia, Parkinson's disease, and visual deficits, was not accurately assessed for elopement risk despite documented behaviors such as confusion, wandering at night, and exit-seeking. The resident exhibited multiple behaviors and verbalizations indicating risk, including calling 911, wandering the facility at night, and expressing a desire to leave. Despite these behaviors, the resident was not reassessed for elopement risk, and no interventions beyond the eventual placement of a Wanderguard were implemented. The care plan did not specify the needed level of supervision or address the management of elopement risk factors. Testing of the Wanderguard system revealed that four out of five doors did not alarm when tested with a Wanderguard bracelet, and one door did not alarm when opened with the automatic button. Staff and the Environmental Services Director were unaware of these issues, and daily testing logs were found to be incomplete. The administrator and staff relied on the Wanderguard system to alert them to elopement risks, but the system's failure left residents unsupervised and able to exit the facility undetected.
Use of Unregistered Supplemental Nursing Service Agency
Penalty
Summary
The facility failed to comply with state requirements regarding the use of supplemental nursing service agencies (SNSAs) by obtaining nursing staff from Swenswen Staffing, LLC, which was not registered with the commissioner as required. Document review confirmed that Swenswen Staffing, LLC was not listed as an approved SNSA on the Minnesota Department of Health website, and the certificate of registration provided by the agency had expired. Staffing schedules showed that Swenswen Staffing, LLC provided both nursing assistants and trained medication aides to the facility on multiple occasions within the reviewed period. During interviews, the staffing coordinator verified that Swenswen Staffing, LLC had provided staff in the past month, and the facility administrator stated she was unaware of the requirement to verify SNSA registration status prior to obtaining staff. Additionally, the facility was unable to provide a policy on supplemental staffing when requested. This deficiency had the potential to affect all 34 residents who received care from the supplemental staff during the period in question.
Failure to Accurately Assess and Document Staffing Needs Due to Shared Staff with Assisted Living
Penalty
Summary
The facility failed to review and update its facility-wide assessment to accurately identify the staffing plan necessary to meet residents' needs during both routine operations and emergencies. Documentation and interviews revealed that overnight staff assigned to the nursing home were also providing services at the assisted living facility, a practice not reflected in the facility's assessment or staffing plan. The staffing plan listed the number of licensed nurses, nursing assistants (NAs), and trained medication aides (TMAs) required for each shift but did not account for the time these staff spent working in the assisted living facility. As a result, the actual number of staff available to care for residents in the nursing home was less than what was documented in the assessment. The administrator and DON confirmed that staff had been providing care at the assisted living facility during their scheduled shifts at the nursing home, and that this practice had been ongoing for some time. The administrator acknowledged that the facility assessment was not accurate, as it included staff hours spent in the assisted living facility as part of the nursing home's staffing hours. The facility assessment policy was requested but not provided. No information was given regarding specific residents affected or their medical conditions at the time of the deficiency.
Failure to Timely Report Resident Elopement
Penalty
Summary
The facility failed to immediately report an elopement incident involving a resident with dementia, delirium, and a history of falls. The resident, who required supervision for transfers and had severe cognitive impairment, was identified as being at risk for elopement and had interventions in place, including a Wanderguard device. Despite these measures, the resident was found wandering outside the facility, and it was noted that the Wanderguard alarm did not activate when the resident exited, though it did sound upon re-entry. The incident was documented in the resident's progress notes and incident report, which indicated confusion and impaired memory as contributing factors. The nurse on duty did not report the elopement to the on-call nurse, administrator, or DON immediately after the event. The incident was not reported to the state agency until the following day, exceeding the facility's policy requirement to report such events to the administrator and state agency within two hours. Facility policies reviewed confirmed the expectation for immediate reporting of elopements and potential neglect, but these procedures were not followed in this case.
Inaccurate MDS Coding for Wander/Elopement Alarm Use
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was accurately coded to reflect the use of a wander/elopement alarm for a resident identified as being at risk for elopement. The resident's quarterly MDS assessment indicated that no wander/elopement alarm was used during the look-back period, despite documentation and care plans showing that a Wanderguard device was in place on the resident's wrist and checked daily. Observations and interviews with staff confirmed the presence and use of the Wanderguard device, and the MDS Coordinator acknowledged that the device should have been documented on the MDS but was missed. The facility's MDS assessment policy was requested but not provided.
Inaccurate Posting of Nurse Staffing Hours Due to Staff Coverage in Assisted Living
Penalty
Summary
The facility failed to accurately post daily nurse staffing information reflecting the total number and actual hours worked per shift by nursing staff directly responsible for resident care. Documentation showed that nursing assistants assigned to the nursing home were also providing care in the connected assisted living facility during their scheduled shifts. However, the posted nurse staffing forms did not account for the time these staff members spent away from the nursing home, resulting in inaccurate reporting of hours worked in the facility. For example, one nursing assistant was scheduled from 10:00 p.m. to 6:30 a.m., but records indicated that one hour of this shift was spent providing care in the assisted living facility, not the nursing home. Despite this, the posted staffing information listed the full shift as being worked in the nursing home and did not adjust the total hours accordingly. Interviews with staff, including the administrator, staffing coordinator, and DON, confirmed that it was common practice for nursing home staff to assist in the assisted living facility during overnight shifts, and that the posted staffing hours did not reflect the actual time spent in each location. The staffing coordinator acknowledged that adjustments to posted hours were not made in real time and were often updated the following day, if at all. The facility's policy on staffing was requested but not provided for review. This failure to accurately post nurse staffing information had the potential to affect all residents and visitors who relied on this information.
Inaccurate PBJ Staffing Data Submission Due to Unadjusted Staff Hours
Penalty
Summary
The facility failed to submit accurate and complete direct care staffing information to CMS for one reviewed quarter, as required by federal regulations. Payroll Based Journal (PBJ) data submitted for the quarter included total nursing staff hours for various roles, but did not account for time that facility staff spent providing services at the assisted living center during their scheduled shifts at the facility. Documentation, including the 'AL Filling in Time Book,' showed that staff regularly left the facility to assist at the assisted living center, with over 50 hours documented during the quarter. Some entries in the log were illegible or incomplete, making it difficult to determine the exact amount of time spent away from the facility. Interviews with the DON, administrator, and director of human resources confirmed that this practice had been ongoing and that the time spent by staff at the assisted living center was not subtracted from the hours reported to CMS in the PBJ submissions. The director of human resources acknowledged that the PBJ hours submitted were incorrect, as they were based solely on timecard data without adjusting for time spent away from the facility. The facility's PBJ policy was requested but not provided.
Uncertified Dietary Manager in Absence of Full-Time RD
Penalty
Summary
The facility failed to ensure that the dietary manager (DM) was certified to oversee nutrition and food services in the absence of a full-time registered dietician (RD). The DM had been employed at the facility for about a year but was not a certified dietary manager, although she had recently received her ServSafe certificate. The RD, who visited the facility every four to six weeks and worked online with staff, was aware that the DM did not meet the required credentials. The administrator was also aware of the DM's lack of certification and had been discussing the need for her to enroll in a course. This deficiency had the potential to affect all 32 residents residing in the facility.
Inaccurate Staffing Data Submission to CMS
Penalty
Summary
The facility failed to submit accurate and complete staffing data to the Centers for Medicare and Medicaid Services (CMS) for the first quarter of the fiscal year 2024. The CMS payroll-based journal (PBJ) staffing data report indicated that the facility did not have licensed nursing coverage 24 hours a day on specific dates in December 2023. However, upon review, it was found that licensed nurses were indeed scheduled and worked on those dates. The health unit coordinator, responsible for nurse staff schedules, confirmed that a licensed nurse was scheduled for each shift and verified the presence of licensed nurses on the infraction dates. The human resources representative, who entered staffing data into a spreadsheet for corporate submission to CMS, acknowledged that the data submitted was inaccurate and did not include all licensed staff who had worked. This discrepancy was attributed to a misunderstanding of the data requirements. The facility's Payroll Based Journal policy, dated April 1, 2019, outlines the process for gathering and preparing PBJ data, emphasizing the need for complete and accurate information for all care center, agency, and contract staff. Despite the policy, the facility failed to ensure the accuracy of the staffing data submitted to CMS.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Zumbrota
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Edenbrook Pine Haven | 6.1 mi | — | 0 | 0 |
| Rochester Rehabilitation And Living Center | 17.2 mi | — | 4 | 0 |
| Madonna Towers Of Rochester | 18.1 mi | — | 4 | 0 |
| St Crispin Living Community | 18.2 mi | — | 15 | 1 |
| Edenbrook Rochester West | 19.2 mi | — | 25 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.