Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cura Of Le Sueur during CMS and state inspections, most recent first.
Ice Machine Not Maintained in Sanitary Condition: A Manitowoc ice machine used for resident consumption was observed with heavy white/grey chalky, crusty buildup on the inside lid, outside lid, and exterior surfaces. The DD stated maintenance was responsible for cleaning it, but the facility no longer had maintenance staff and was unsure who was accountable. An RN confirmed the machine was not clean, and the admin stated the facility had chronic issues with the machine and had planned to replace it.
Resident council concerns were repeatedly raised by residents with no cognitive impairment, but the facility did not maintain a system to track issues or provide follow-up at later meetings. Meeting minutes showed recurring complaints about nursing, staffing, medication timing, housekeeping, laundry, maintenance, and social services, with little documented action beyond some dietary items. Residents stated the same concerns were brought up monthly and were not addressed or explained back to them, and the AD-F confirmed there was no established process to report back to residents.
Inaccurate PBJ Staffing Submission: The facility failed to submit complete and accurate PBJ staffing data to CMS after the report showed multiple days with less than 24 hours of licensed nursing coverage. Nursing schedules showed an RN or other licensed nurse was scheduled on all shifts, and interviews confirmed the shifts were worked by facility or agency nurses, but the facility could not identify which licensed nurse hours were omitted from the PBJ submission. The ADON, regional clinical director, and administrator described a breakdown in the payroll/timekeeping review and reporting process between the business office and corporate office.
Resident mail was not delivered on Saturdays for 7 residents reviewed during resident council. Residents stated they only received mail Monday through Friday, and the AD confirmed activity staff delivered mail only on weekdays even though the mail arrived from the post office on Saturday. The interim administrator stated residents were expected to receive Saturday mail if it was delivered to the facility, and the facility mail policy required delivery within 24 hours.
A resident with a recent diagnosis of invasive ductal carcinoma of the right breast experienced severe pain and visible changes to the affected area, but staff failed to perform comprehensive skin assessments or ongoing monitoring. Despite care plan references to skin integrity and comfort, there were no specific treatment orders or documentation addressing the breast cancer site. The lack of assessment and documentation persisted until the resident required emergency care for an abscess, revealing a significant gap in care and monitoring.
The facility failed to provide adequate staffing, resulting in delayed assistance with meals, personal hygiene, and health monitoring for residents. Observations and interviews revealed that residents waited excessively for help, and necessary health assessments were not conducted. The facility's staffing plan was not adhered to, leading to missed baths and delayed care, impacting residents' quality of life.
During an influenza A outbreak, the facility failed to implement effective infection control measures. Observations showed a lack of droplet precaution signage for residents with symptoms or positive tests, and improper PPE use by staff, including wearing the same mask from room to room. The infection preventionist was unable to focus on outbreak management due to staffing shortages, leading to delayed implementation of necessary precautions.
The facility did not complete annual performance reviews for four nursing assistants, citing leadership turnover as the reason. Personnel records for these staff members lacked evidence of completed reviews, and the administrator acknowledged the oversight. A policy on performance reviews was requested but not provided.
The facility failed to conduct annual performance reviews for four nursing assistants, resulting in a lack of individualized training based on identified weaknesses. Interviews revealed that the nursing assistants only completed standard annual computer training, with no additional training provided. The facility administrator and a registered nurse were unaware of any performance-based training processes, and a policy on performance reviews was not provided.
The facility failed to maintain two tub/shower rooms on the Prairie unit in good repair and sanitary conditions, affecting 15 residents. Observations revealed issues such as a heavily laden furnace filter, crumbling wall material, dusty vents, and worn shower floors. The maintenance director and administrator were unaware of most issues, despite a policy requiring regular maintenance.
A resident with a history of falls and moderate cognitive impairment experienced multiple falls without the care plan being updated to include new interventions. Despite assessments and expectations from the facility's administration, the care plan did not reflect necessary changes to prevent further incidents. Interviews revealed a lack of communication and responsibility among staff regarding updating the care plan.
The facility failed to provide necessary meal assistance to three residents, leading to deficiencies in care. A resident with moderate cognitive impairment struggled to open food containers without help, while another resident with dysphagia was left to eat in bed without staff assistance. A third resident with severe cognitive impairment was unable to remove straw wrappers or open a banana, and staff did not provide the expected meal setup assistance.
The facility failed to monitor weights as ordered for three residents, leading to deficiencies in care. A resident with severe cognitive impairment and multiple diagnoses had missing weight documentation despite a provider order for daily monitoring. Another resident with heart failure had inconsistent weight recordings, and a third resident with a stroke history was not weighed as required. Staff interviews revealed communication issues and non-functioning scales, contributing to the deficiencies.
A facility failed to act on a consulting pharmacist's recommendation for a resident with severe cognitive impairment and multiple diagnoses, including Parkinson's disease, who was taking quetiapine fumarate. The pharmacist recommended monthly blood pressure monitoring, but the order was entered incorrectly and not maintained, resulting in a lack of current monitoring. The regional nurse specialist confirmed the error, and the consulting pharmacist emphasized the need for monitoring to check for side effects.
The facility failed to serve meals at appropriate temperatures, affecting two residents and potentially all 25 residents. A resident with ALS and another with a pressure ulcer reported receiving cold meals, impacting their nutritional intake. Observations showed meal trays left in hallways, leading to delays and cold food. The facility's policy to ensure proper food temperatures was not followed, resulting in meals being served below optimal temperatures.
The facility did not hold QAPI meetings quarterly as required, with no documentation of meetings between July and December. The administrator, new to the facility, confirmed the lack of records for this period, despite the policy mandating quarterly meetings.
A facility failed to accurately code the MDS for a resident with pressure ulcers. The resident was admitted with an unstageable heel pressure ulcer and osteomyelitis, but the MDS did not reflect this condition. Medical staff confirmed the presence of the ulcer, and both the MDS coordinator and the nurse responsible for the MDS acknowledged the error. The facility's policy required accurate completion and transmission of MDS assessments.
The facility failed to perform weekly comprehensive skin assessments for two residents, leading to undetected and untreated pressure ulcers. One resident developed pressure injuries on the heel and coccyx without prior documentation or treatment, while another resident's heel ulcers were not measured weekly as required. Staffing shortages and poor communication contributed to these deficiencies.
Two residents in a LTC facility did not receive adequate restorative services to maintain their range of motion. One resident, recovering from heart surgery, was not walked as prescribed due to a lack of documentation and follow-through by staff. Another resident with ALS did not consistently receive ROM exercises due to short staffing and confusion over instructions. The facility's failure to adhere to restorative programs was compounded by poor communication and documentation practices.
A resident with moderate cognitive impairment and a history of falls experienced multiple falls without comprehensive reassessment or updated interventions. Despite discussions with the family for increased supervision, the resident was often found in their room rather than near the nursing station. Staff interviews revealed a lack of awareness and communication regarding the resident's fall risk and necessary interventions, leading to a failure in preventing further falls.
A staff member in an LTC facility diverted medications by signing them out of the narcotic logbook without documenting their administration in the MAR. This affected 12 residents who required pain management for various conditions. The issue was discovered when residents reported not receiving their medications, leading to an investigation that confirmed the diversion of 121 oxycodone tablets, one tramadol tablet, and two doses of liquid lorazepam. Despite the diversion, no negative outcomes were reported.
The facility failed to properly destroy and document narcotic and controlled substances, leading to potential risks of diversion or theft. Discrepancies were found in the documentation of destroyed medications, and discontinued medications were not promptly removed from the medication cart. Interviews with staff revealed lapses in handling and securing the med safe liner, which was not picked up in a timely manner, contrary to facility policies.
A resident with a right hip fracture, requiring two-person assistance for transfers, was allegedly mishandled by a nursing assistant who was unaware of the care plan requirements. The facility's investigation did not review the care plan or ensure staff compliance, concluding no abuse occurred despite the resident sustaining a skin tear.
A resident with a hip fracture was transferred by a single staff member without a transfer belt, contrary to the care plan requiring a two-person assist. Staff were unaware of the care plan requirements, and the facility's policy for reviewing care plans was not effectively implemented, leading to a deficiency.
The facility failed to submit accurate and complete direct care staffing information to CMS for Quarter 1, 2024. The PBJ Staffing Data report indicated missing RN hours and a lack of licensed nursing coverage 24 hours a day on several dates. It was revealed that salaried nursing leadership staff did not punch a timecard, leading to their hours not being reflected in the PBJ data.
Staff failed to disinfect mechanical transfer lifts after use for two residents, despite facility policy requiring cleaning before and after each use to prevent infection spread. Observations and interviews revealed a lack of adherence to the policy, leading to a deficiency in infection control practices.
The facility failed to assess and document the use of weighted blankets for two residents, who were using them without proper physician orders, nursing assessments, or care plan inclusion. The DON confirmed that the facility's policy on weighted blankets was not followed.
Ice Machine Not Maintained in Sanitary Condition
Penalty
Summary
The facility failed to maintain 1 of 1 ice machine in a clean and sanitary condition. During an initial kitchen tour with the dietary director, a Manitowoc ice machine located in a hallway adjacent to the kitchen was observed with white, grey, chalky, powdery, hard, crusty, rock-like, lumpy deposits on the inside lid, outside lid, front exterior surface, and both side exterior surfaces. The buildup was described as consistent with lime scale and mineral deposits, and the dietary director stated the ice machine was used for resident consumption. The dietary director stated maintenance staff were responsible for cleaning the ice machine, but the facility no longer had maintenance staff as of approximately two weeks earlier and she was unsure who was responsible for ensuring the machine was cleaned. A regional clinical director confirmed the machine was not clean and would not expect to see white residue on the inside or outside of it. Later, a sign was posted on the ice machine stating, "Out of order do not use." The administrator stated the facility had known chronic issues with the ice machine, had decided in April 2025 to replace it, and confirmed the machine should not have been used until it was cleaned, repaired, or replaced.
Resident Council Concerns Not Tracked or Followed Up
Penalty
Summary
The facility failed to establish and maintain a system to ensure concerns voiced during resident council meetings were addressed and followed up with residents. Residents with no cognitive impairment, including R1, R4, R5, R9, R18, and R20, attended monthly resident council meetings and repeatedly raised concerns about nursing, dietary, housekeeping, laundry, maintenance, social services, and staffing issues. The resident council policy stated that the Activity Director would read the prior minutes, address old business, and refer items to the appropriate departments, with the meeting adjourned when all concerns had been addressed. Review of resident council minutes from multiple months showed that concerns were documented, but the minutes generally lacked any further action or follow-up to the issues raised from one meeting to the next. Concerns included long call lights, delayed medication administration, short staffing, staff not helping residents get up, dirty gloves in hallways, grievances not processed in a timely manner, maintenance issues, laundry delays and missing clothing, and housekeeping concerns such as rooms and shower rooms needing cleaning. Dietary concerns were sometimes addressed in the minutes, but the other concerns were not shown to have any documented action or follow-up. During interview, residents stated the same concerns were brought up monthly and that departments failed to address or respond to them. R20 stated concerns had been voiced monthly regarding nursing, housekeeping, and other departments, and the facility had not provided follow-up. R1 and R8 stated they were not aware whether the facility had addressed the concerns or what follow-up had been done, and expected the concerns to be addressed and followed up. The AD-F stated concerns were communicated to department leaders during QAPI meetings, but follow-up was not brought back to residents at subsequent resident council meetings, and there was no established system to track concerns from one meeting to the next or ensure residents received feedback regarding resolution.
Inaccurate PBJ Staffing Submission
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS based on payroll and other verifiable and auditable data for Quarter 4, 2025. The CMS PBJ staffing data report triggered for four or more days within the quarter with less than 24 hours per day of licensed nursing coverage, and the identified infraction dates were 8/3/25, 8/23/25, 8/24/25, and 9/6/25. Review of nursing staff schedules for each of those dates showed a licensed nurse had been scheduled on each of the three shifts, including days, evenings, and nights. During interviews, the ADON stated she was responsible for scheduling nursing staff and that there was always a licensed nurse working every day on each shift. The regional clinical director stated all timecards were reviewed for each infraction date and confirmed that all shifts were worked by a licensed nurse, either facility-employed or agency, but the facility could not identify which licensed nurse hours were omitted from the PBJ submission. The regional clinical director said the business office manager had been responsible for reviewing timekeeping, payroll records, and agency invoices, and that the corporate office compiled and reported the information for PBJ submission. The administrator stated there was a switch in payroll companies in August 2025 and that the facility had the required nursing staff, but the information may not have been submitted accurately from the business office to the corporate office and then to the PBJ report. The facility PBJ policy stated it would electronically submit complete and accurate direct staffing information, including agency and contract staff when applicable, based on payroll and other verifiable and auditable data.
Resident Mail Not Delivered on Saturdays
Penalty
Summary
The facility failed to ensure resident mail was delivered on Saturdays for 7 of 7 residents reviewed during resident council, including residents with quarterly, admission, and annual MDS assessments showing no cognitive impairment for six residents and severe cognitive impairment for one resident. During the resident council interview, the residents stated they did not receive mail on Saturdays and instead received mail Monday through Friday. The activity director confirmed that resident mail was not delivered to residents on Saturdays, explaining that activity staff delivered mail Monday through Friday even though the mail arrived at the facility from the post office on Saturdays. The interim administrator stated residents were expected to receive mail on Saturday if the post office delivered it. The facility's Resident Mail policy stated mail would be delivered to residents' rooms within 24 hours in an obvious and accessible location, unopened and unread, unless assistance was requested.
Failure to Assess and Monitor Skin Integrity in Resident with Breast Cancer
Penalty
Summary
A deficiency occurred when the facility failed to complete a comprehensive skin assessment and ongoing monitoring for a resident with a known diagnosis of invasive ductal carcinoma of the right breast. Upon admission from the hospital, the resident's discharge summary and care plan identified breast cancer and associated pain, but the initial skin evaluation and risk audit did not document any impairments or specific observations of the right breast. Despite the resident experiencing significant pain and visible changes to the breast, including redness and tenderness, there was no comprehensive assessment or documentation of the breast's condition in the medical record. Throughout the resident's stay, multiple progress notes indicated ongoing and severe pain in the right breast, with repeated requests for pain medication. However, there were no detailed assessments or updates regarding the breast's appearance or any changes in its condition. Nursing staff interviews revealed a lack of awareness about the breast cancer diagnosis and an absence of treatment orders or monitoring instructions for the affected area. The care plan interventions focused on general skin integrity and comfort but did not address the specific needs related to the breast cancer site. The situation escalated when the resident's pain became unmanageable, leading to a transfer to the emergency department, where an abscess requiring surgical intervention was identified. The facility's documentation lacked admission photos and failed to provide a baseline or ongoing assessment of the breast cancer site. The director of nursing acknowledged that the admission and skin assessments did not reflect the condition of the right breast, despite being aware of the cancer diagnosis. Facility policies required care plans to address identified problem areas and risk factors, but these were not implemented for the resident's breast cancer site.
Staffing Shortages Lead to Deficiencies in Resident Care
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of its residents, resulting in several deficiencies. Observations and interviews revealed that residents were not receiving timely assistance with meals, personal hygiene, and other daily activities. For instance, residents requiring assistance with meals were left waiting, and call lights indicating the need for help were not answered promptly. One resident reported waiting over an hour to use the urinal, leading to discomfort and incontinence. Staff interviews confirmed that the facility was understaffed, with only two nursing assistants available for the entire building, which was insufficient to meet the residents' needs. The facility also failed to conduct necessary health monitoring and care for its residents. Residents with specific health conditions, such as edema and pressure ulcers, did not receive the required monitoring and assessments. For example, one resident's weight was not monitored as per the physician's order, and comprehensive skin assessments for pressure ulcers were not completed for two residents. Additionally, the facility did not provide services to maintain and prevent the loss of range of motion for residents requiring restorative services. Furthermore, the facility did not adhere to its own staffing plan, which was based on the resident population's acuity and needs. The nursing schedules showed numerous instances where the required number of nursing assistants and nurses were not present, leading to missed baths and delayed assistance. Staff interviews revealed that the facility resorted to using agency staff and offering overtime to address the staffing shortages, but these measures were not consistently implemented. The facility's failure to maintain adequate staffing levels and provide necessary care and assistance resulted in significant deficiencies affecting the residents' quality of life.
Inadequate Infection Control During Influenza Outbreak
Penalty
Summary
The facility failed to implement an effective infection prevention and control program during an influenza A outbreak. Observations revealed that the facility did not post appropriate droplet precaution signage for residents who exhibited symptoms or tested positive for influenza A. This lack of signage was noted for 11 residents, which included individuals with various medical conditions such as heart failure, Parkinson's disease, and type 2 diabetes mellitus. The absence of proper signage meant that staff, residents, and visitors were not adequately informed about the necessary precautions to prevent the spread of the virus. Additionally, the facility did not ensure the correct use of personal protective equipment (PPE). Staff members were observed wearing the same mask from room to room, contrary to infection control guidelines. Nursing assistants and licensed practical nurses were seen disposing of soiled gowns in a hallway garbage bin instead of in the resident's room, further increasing the risk of cross-contamination. Interviews with staff revealed a lack of awareness and training regarding the proper donning and doffing of PPE, as well as the specific precautions required for residents with influenza A. The infection preventionist, who was also the assistant director of nursing, was unable to focus on infection control duties due to staffing shortages and was required to work as a floor nurse. This contributed to the delay in implementing necessary infection control measures, such as posting precaution signs and ensuring the availability of PPE. The facility's administrator acknowledged the oversight and confirmed that the infection preventionist was not given designated time to address the outbreak effectively. This deficiency in infection control practices had the potential to affect all residents in the facility.
Failure to Conduct Annual Performance Reviews for Nursing Assistants
Penalty
Summary
The facility failed to conduct annual performance reviews for four nursing assistants (NA-A, NA-F, NA-B, NA-E) whose personnel records were reviewed. NA-A, hired on June 14, 2023, and NA-F, hired on November 7, 2023, both lacked evidence of any completed annual performance reviews. NA-B, hired on July 16, 2018, did not have a current annual performance review on file. NA-E, hired on June 7, 2021, also lacked evidence of any completed annual performance review. During interviews, administrative support and the administrator acknowledged the absence of performance reviews, attributing it to leadership turnover and stating that reviews had not been conducted. A policy on performance reviews was requested but not provided.
Failure to Conduct Annual Performance Reviews and Individualized Training
Penalty
Summary
The facility failed to conduct annual performance reviews for four nursing assistants, identified as NA-A, NA-F, NA-B, and NA-E. This deficiency was discovered through interviews and document reviews, which revealed that none of these nursing assistants had evidence of completed annual performance reviews in their personnel records. NA-A and NA-F, who were hired in 2023, along with NA-B and NA-E, hired in 2018 and 2021 respectively, all lacked documentation of such reviews. This failure to conduct performance reviews also meant that the facility did not provide individualized training based on any identified areas of weakness from these reviews. Interviews with the nursing assistants and a registered nurse further confirmed the lack of awareness and implementation of performance-based training. NA-B, NA-E, and NA-A all reported only completing the standard annual computer training required for all employees, with no additional individualized training. The registered nurse, RN-A, also stated he was unaware of any training based on performance reviews. The facility administrator, who was new, admitted to not being aware of any completed performance reviews or specific training processes. Additionally, a policy on performance reviews and training was requested but not provided, indicating a possible lack of established procedures in this area.
Deficiencies in Tub/Shower Room Maintenance and Sanitation
Penalty
Summary
The facility failed to maintain two of the three tub/shower rooms on the Prairie unit in good repair and sanitary conditions, affecting 15 residents who utilized these areas. During an observation, the east Prairie unit's tub/shower room was found to have a heavily laden furnace filter with gray fuzzy material partially under a wall-mounted heater, and the heater's grates were covered with dust and webs. Additionally, a section of the wall had missing sheetrock, exposing crumbling, discolored material. The ceiling vent was also covered with gray debris, and the shower floor appeared worn and stained, with the shower head secured by black zip ties. In the north Prairie unit's tub/shower room, the shower floor was similarly worn and stained, with black marks that could not be removed. During an interview, the maintenance director acknowledged the poor condition of the filter but was unaware of the other issues, while the administrator was only aware of the filter problem. The facility's policy on maintenance and cleanliness was reviewed, indicating that filters should be cleaned or discarded monthly during the summer, and air vents cleared annually, but these practices were not followed in the observed areas.
Failure to Update Care Plan for Resident with Fall Risk
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan to address falls for a resident with a history of falls and moderate cognitive impairment. The resident, who had diagnoses including a left femur fracture, dementia, and anxiety, experienced multiple falls without the care plan being updated to include new interventions. Despite the resident's history of falls and the family's expressed concerns, the care plan did not reflect necessary changes to prevent further incidents. The resident experienced two falls within a short period, with the first incident involving the resident crawling out of a recliner and the second fall occurring while the resident was seated on the floor. In both cases, immediate assessments were conducted, and no injuries were reported. However, the care plan was not updated with new interventions following these incidents, despite expectations from the facility's administration and policies. Interviews with facility staff revealed a lack of communication and responsibility regarding updating the care plan. The Director of Nursing was expected to ensure comprehensive reassessments and new interventions, but these were not consistently implemented. Staff members, including the Assistant Director of Nursing and nursing assistants, were either unaware of the resident's fall risk or not informed of new interventions, highlighting a breakdown in the facility's fall management procedures.
Failure to Provide Meal Assistance to Residents
Penalty
Summary
The facility failed to ensure that residents received necessary assistance with meals, leading to deficiencies in care for three residents who required staff assistance or supervision during dining. Resident 1, with moderate cognitive impairment and a self-care deficit related to dementia, was observed struggling to open a container of ice cream and remove lids from drinking glasses without assistance. Despite the expectation that staff delivering meal trays would provide necessary setup assistance, Resident 1 was left without help until prompted by a surveyor. Similarly, Resident 2, who was cognitively intact but required supervision due to conditions like dysphagia, was left to eat in bed without staff assistance, with drinking glasses placed out of reach and lids not removed. Resident 10, with severe cognitive impairment and multiple diagnoses including dementia and Parkinson's disease, was also observed without adequate meal setup assistance. The resident was unable to remove straw wrappers or open a banana, and these tasks were not completed by the staff delivering the meal tray. Staff members, including a housekeeping aide and a nursing assistant, acknowledged the oversight and confirmed that meal setup assistance was expected but not provided. The facility's policy required staff to follow the care plan and assist residents with meal setup, but this was not adhered to, resulting in the observed deficiencies.
Failure to Monitor Resident Weights as Ordered
Penalty
Summary
The facility failed to monitor weights as ordered for three residents, leading to deficiencies in care. Resident R10, who had severe cognitive impairment and multiple diagnoses including coronary artery disease and Parkinson's disease, had a provider order for daily weights with specific instructions to update the provider if there was a significant weight gain. However, there were no documented weights for several days, and the resident experienced a weight gain that was not reported as required. Interviews with staff revealed an expectation to follow provider orders, but the documentation was lacking. Resident R20, who was cognitively intact and had a history of coronary artery bypass surgery and heart failure, also had a physician order for daily weights to monitor his cardiac status. Despite this, only 13 out of 40 opportunities for daily weights were recorded. The resident expressed concerns about food choices and was unaware of his weight status due to inconsistent weight monitoring. Interviews with staff indicated that the process for communicating weight orders was not effectively followed, and there were issues with the scales not working properly. Resident R23, who had severe cognitive impairment and a history of stroke, was supposed to be weighed twice a week according to physician orders. However, only six out of 13 opportunities for weight measurement were recorded. Staff interviews highlighted a lack of awareness and communication regarding weight orders, and there were no documented refusals for weight measurement. The facility's policies on weight monitoring and refusal of care were not adhered to, contributing to the deficiencies observed.
Failure to Address Pharmacist Recommendations for Resident on Antipsychotic
Penalty
Summary
The facility failed to ensure that consulting pharmacist recommendations were addressed or acted upon for a resident reviewed for unnecessary medications. The resident, who had severe cognitive impairment and multiple diagnoses including dementia, Parkinson's disease, anxiety, depression, and a psychotic disorder, was taking an antipsychotic medication, quetiapine fumarate. The resident's care plan indicated a potential for drug interactions and adverse effects related to polypharmacy, with interventions including a monthly medication regimen review by a pharmacy consultant and forwarding recommendations to the medical doctor for review. The consulting pharmacist recommended adding an order for monthly blood pressures or documenting why this could not be completed. Although a registered nurse indicated that the order was placed, the resident's treatment administration record showed that the order for monthly orthostatic blood pressures was entered incorrectly and subsequently fell off. The last documented orthostatic blood pressure was dated over two months prior, and there was no current order for monthly orthostatic blood pressures. The regional nurse specialist confirmed the error, and the consulting pharmacist stated the expectation for monthly orthostatic blood pressures to monitor for side effects in residents on Seroquel.
Failure to Serve Meals at Appropriate Temperatures
Penalty
Summary
The facility failed to ensure that meals were served at a warm and palatable temperature, affecting the quality of life and nutritional intake for two residents, R22 and R16, and potentially impacting all 25 residents in the facility. R22, diagnosed with amyotrophic lateral sclerosis (ALS), required total assistance with meals and reported consistently receiving cold food, particularly breakfast. Observations confirmed that meal trays were left in the hallway on an open-sided cart, leading to delays in delivery and cold meals. R22's breakfast was observed to be cold, and the resident expressed dissatisfaction with the meal temperature. R16, who had an unstageable pressure ulcer and osteomyelitis, also reported receiving cold meals, which affected their ability to eat. Observations showed that meal trays were left on a cart in the hallway for extended periods before being delivered to residents' rooms. R16's meal was delivered late, and the resident stated that the food was cold and uneaten. The facility's policy required staff to ensure hot foods were hot and cold foods were cold, but this was not adhered to, resulting in meals being served at suboptimal temperatures. During the survey, it was noted that the facility was experiencing an influenza outbreak, and all residents were receiving meals in their rooms. Despite this, there was a lack of coordination among staff to ensure timely delivery of meals. The dietary manager and cook acknowledged the issue and stated that they would revert to using regular dishes and warmers to maintain food temperature. However, during the survey, the deficiency in meal service was evident, with food temperatures measured below the acceptable range, and staff not assisting promptly with meal delivery.
Failure to Conduct Quarterly QAPI Meetings
Penalty
Summary
The facility failed to ensure that Quality Assurance Performance Improvement (QAPI) meetings were held on a quarterly basis as required. A review of the QAPI meeting minutes and agenda revealed that meetings were conducted on 12/19/24, 7/11/24, and 4/11/24. However, there was no documentation of any QAPI meetings occurring between 7/11/24 and 12/19/24. During an interview on 1/16/25, the administrator, who had been at the facility for approximately four weeks, stated she was unaware of any QAPI meetings held during that period and confirmed the absence of documentation for such meetings. The facility's QAPI policy, dated 2/2024, mandates that the QAA committee meet quarterly, with activities and outcomes shared with staff, residents, and family members, and reported to the board of directors.
Inaccurate MDS Coding for Pressure Ulcers
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was accurately coded for a resident with pressure ulcers. The resident, identified as R16, was admitted with an unstageable pressure ulcer on the right heel and osteomyelitis. The admission MDS assessment did not reflect the presence of the heel pressure ulcer, despite the resident's care plan indicating a self-care deficit related to morbid obesity and decreased functional ability due to bilateral heel pressure injuries. The care plan included interventions such as administering treatments, floating heels while in bed, and using a wound vac on the right heel. Interviews and observations revealed discrepancies in the MDS coding. On separate occasions, medical staff, including a medical doctor and registered nurses, confirmed the presence of the heel pressure ulcer, which was not documented in the MDS. The MDS coordinator and the nurse who completed the MDS both acknowledged the inaccuracy. The facility's policy required all MDS assessments to be completed and transmitted accurately, which was not adhered to in this case.
Failure to Conduct Weekly Skin Assessments and Document Pressure Ulcers
Penalty
Summary
The facility failed to conduct weekly comprehensive skin assessments, including measurements, for two residents, R16 and R20, who were at risk for pressure ulcers. R20, who had a history of coronary artery bypass surgery, heart failure, diabetes, and chronic kidney disease, was admitted with no pressure ulcers and was considered low risk. However, over an eight-week period, skin checks were only completed five times, and a pressure injury to the right heel and coccyx was discovered without prior documentation or treatment orders. The lack of communication and documentation among staff led to a delay in addressing R20's pressure injuries. R16 was admitted with unstageable pressure ulcers on both heels and required weekly wound assessments with measurements. Despite this, the last documented wound check with measurements was on 12/16/24, and subsequent assessments failed to include necessary measurements. R16's care plan included interventions for pressure ulcer management, but the facility's staffing shortages and lack of a dedicated wound nurse contributed to the failure to perform comprehensive wound assessments as required. Interviews with facility staff revealed a lack of awareness and communication regarding the residents' conditions. Staff members, including nurses and nurse practitioners, were not informed of the presence of pressure wounds, and there was no documentation in the electronic medical records. The facility's policies required adherence to physician orders and comprehensive documentation of wound care, but these were not followed, leading to deficiencies in the care provided to R16 and R20.
Failure to Provide Adequate Restorative Services for Residents
Penalty
Summary
The facility failed to provide adequate restorative services to maintain and prevent the loss of range of motion (ROM) for two residents, R20 and R22. R20, who had undergone coronary artery bypass surgery and was recovering from a recent hospitalization, was supposed to be on a walking program as per the rehabilitation instructions. However, the walking program was not documented in the electronic medical record (EMR) TASK tab, which nursing assistants used to determine care tasks. Interviews revealed that R20 was not being walked as prescribed, and there was a lack of communication and follow-through from the nursing staff regarding the walking program. R22, diagnosed with amyotrophic lateral sclerosis (ALS), required ROM exercises to maintain muscle function. Despite having instructions for ROM exercises posted in his room and documented in the EMR, the exercises were inconsistently performed. The nursing assistants frequently cited short staffing as a reason for not completing the ROM exercises. Additionally, there was confusion among staff about the specific ROM instructions, as the instructions in the EMR differed from those posted in R22's room and from the occupational therapy recommendations. The facility's failure to adhere to the prescribed restorative programs for R20 and R22 was compounded by inadequate communication and documentation practices. Nursing staff were not consistently informed or aware of the residents' restorative needs, and there was a lack of oversight to ensure that the prescribed care was being delivered. This deficiency highlights a systemic issue in the facility's management of restorative nursing services, impacting the residents' ability to maintain or improve their physical function.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to conduct a comprehensive reassessment after falls to identify the root cause and ensure new interventions were implemented to prevent further falls for a resident with a history of falls. The resident, who had moderate cognitive impairment and was dependent on staff for various activities, experienced multiple falls without a comprehensive assessment or updated care plan to address the risks. The resident's care plan included interventions such as keeping the bed at an appropriate height and encouraging the use of appropriate footwear, but these were not updated following the falls. The resident experienced falls on two separate occasions, with incident reports failing to indicate new interventions or predisposing factors. The facility's interdisciplinary team (IDT) met to discuss the falls, but no new interventions were implemented, and the care plan was not updated. The administrator and other staff members acknowledged the gap in implementing interventions and completing comprehensive assessments post-falls. Despite discussions with the resident's family about increased supervision, the resident was often found in their room rather than near the nursing station as agreed. Staff interviews revealed a lack of awareness and communication regarding the resident's fall risk and necessary interventions. Some staff members were not informed about the resident's fall risk or the interventions required, and agency staff did not have access to the electronic medical record to review care plans. The facility's fall management policy required a fall risk evaluation and analysis, but these were not consistently followed, leading to a failure in preventing further falls for the resident.
Medication Diversion by Staff Member in LTC Facility
Penalty
Summary
The facility failed to protect residents from the wrongful use of their medications, resulting in drug diversion by a staff member. A trained medication aide (TMA-A) was found to have signed out controlled medications from the narcotic logbook without documenting their administration in the Medication Administration Record (MAR). This discrepancy was discovered when residents reported not receiving their prescribed medications, and an internal investigation revealed that 121 oxycodone tablets, one tramadol tablet, and two doses of liquid lorazepam were diverted. The issue came to light when a registered nurse (RN-A) was informed by residents that they had not received their as-needed medications. Upon reviewing the narcotic logbook and electronic medical records, RN-A found that TMA-A had been signing out medications but not documenting their administration. This led to the discovery of discrepancies in the records of 12 residents, who had various medical conditions requiring pain management, such as fractures, chronic pain syndrome, and anxiety. Despite the diversion, the records indicated that no negative outcomes occurred from the residents not receiving their medications. Interviews with staff and residents further highlighted the issue. Residents reported inconsistencies in their medication administration, and staff members noted that TMA-A had been signing out medications without proper documentation. TMA-A admitted to forgetting to document the administration of medications in the MAR, citing laziness and dissatisfaction with the job as reasons. The facility's director of nursing (DON) was notified, and an investigation was launched, confirming the diversion of medications by TMA-A.
Removal Plan
- Staff education was initiated which included the following topics: Medication Administration by Unlicensed Personnel and Controlled Substances training including: Ensuring the meds are secure at all times, Every dose given must be documented in the narcotic record and the electronic medication administration record, At the time of follow up for a PRN medication, if a resident denies receiving the medication, immediately report it to the nursing supervisor for review.
- AP was immediately suspended and then was terminated concluding investigation.
- Management conducted audits on all residents with prescribed controlled medications to confirm medications were not diverted.
Failure to Properly Destroy and Document Controlled Substances
Penalty
Summary
The facility failed to ensure the proper destruction of narcotic and controlled substances, as required by their policies and procedures, to mitigate the risk of diversion or theft. On October 2, 2024, a review of narcotic books and related documentation revealed discrepancies, including 123 tablets of Oxycodone, 175 tablets of lorazepam, 30 tablets of temazepam, 36 tablets of pregabalin, 44 tablets of tramadol, and 14.5 ml of morphine that were signed out as destroyed but not documented on the required forms. Additionally, medications that had been discontinued were found in the medication cart, indicating a failure to remove them promptly, which was acknowledged as a potential error or diversion risk by an LPN. Interviews with staff, including an LPN, RN, scheduler, business office personnel, pharmacy consultant, and the DON, highlighted lapses in the handling and documentation of controlled substances. The med safe liner, which should have been securely stored and promptly picked up, was left in the DON's office for an undetermined period and was not picked up in a timely manner. The facility's policies required immediate disposal of controlled substances and proper documentation, which were not adhered to, raising concerns about the security and accountability of these medications.
Failure to Investigate Alleged Abuse and Ensure Care Plan Compliance
Penalty
Summary
The facility failed to conduct a thorough investigation following an allegation of staff-to-resident abuse involving a resident who was reportedly mishandled during a transfer. The incident involved a nursing assistant (NA-B) who allegedly picked up the resident from a wheelchair and threw them into bed, resulting in a skin tear on the resident's elbow. The resident, who had a history of a right hip fracture and was non-weight bearing on the right leg, required assistance from two staff members for transfers according to their care plan. However, NA-B was unaware of this requirement and had been transferring the resident alone, contrary to the care plan. The facility's investigation concluded that no abuse occurred, but it did not include a review of the resident's care plan to ensure proper transfer procedures were followed. The assistant director of nursing (ADON) confirmed that there was no re-education or competency testing for NA-B or other staff regarding adherence to care plans or safe transfer practices, only education on abuse. The director of nursing (DON) believed the care plan was followed, but could not confirm the presence of a second staff member during the transfer. This oversight in the investigation process and failure to ensure compliance with the care plan put the resident at risk for future incidents.
Failure to Implement Care Plan for Resident Transfers
Penalty
Summary
The facility failed to implement the Self Care plan interventions for a resident, identified as R1, which put R1 at risk for falls during the provision of care. R1's significant change Minimum Data Set (MDS) indicated that R1 was dependent on assistance for transfers and was non-weight bearing on the right leg due to a hip fracture. Despite this, observations and interviews revealed that R1 was transferred by a single staff member, NA-B, without the use of a transfer belt, contrary to the care plan which required a two-person assist for transfers. NA-B was unaware of the care plan requirements and had always transferred R1 alone, indicating a lack of communication and training regarding care plan updates. Further interviews with other staff, including NA-A and the Director of Nursing (DON), revealed inconsistencies in the understanding and implementation of R1's care plan. NA-A confirmed that R1 was never transferred with two people and often refused the use of a transfer belt. The DON stated that staff were expected to review care plan updates on IPADs before each shift, but was unaware that this practice was not being followed. The facility's policy required care plans to be used in developing daily care routines and available to staff, but this was not effectively implemented, leading to the deficiency.
Failure to Submit Accurate Staffing Data to CMS
Penalty
Summary
The facility failed to submit accurate and complete direct care staffing information to CMS for Quarter 1, 2024. The PBJ Staffing Data report indicated missing RN hours on specific dates and a lack of licensed nursing coverage 24 hours a day on several other dates. During interviews, it was revealed that the nursing staff scheduler and the administrator were unaware of how the data was pulled for the report. The administrator noted that salaried nursing leadership staff, who did not punch a timecard, worked the shifts identified but their hours might not be reflected in the PBJ data. Verifiable information such as EMR log in/log out times was requested to confirm the shifts worked by these salaried staff members. Upon review of the provided documents, it was confirmed that RN coverage and licensed nursing staff coverage were indeed present on the dates identified in the PBJ report. The facility's policy on PBJ Reporting, revised in May 2022, indicated that the facility would electronically submit complete and accurate direct care staffing information based on payroll and other verifiable and auditable data. However, the failure to include the hours worked by salaried nursing leadership staff in the PBJ data led to the deficiency noted in the report.
Failure to Disinfect Mechanical Lifts After Resident Use
Penalty
Summary
Staff failed to ensure mechanical transfer lifts were cleaned after resident use for two residents. One resident, who was cognitively intact and dependent on staff for toileting and transfers, had a care plan indicating the use of a mechanical lift. Another resident, who was rarely/never understood and dependent on staff for toileting, dressing, and transfers, also required the use of a mechanical lift. Observations revealed that staff did not disinfect the mechanical lifts after use with these residents, despite facility policy requiring cleaning before and after each use to prevent infection spread. Multiple staff members, including nursing assistants and a trained medication aide, were observed not disinfecting the mechanical lifts after use. Interviews with these staff members revealed a lack of awareness or adherence to the facility's policy on disinfecting mechanical lifts. The Director of Nursing confirmed that the expectation was for staff to clean the lifts after each use, and disinfectant wipes were available for this purpose. However, staff practices did not align with this policy, leading to a deficiency in infection control practices.
Failure to Assess and Document Use of Weighted Blankets
Penalty
Summary
The facility failed to assess the use of weighted blankets for two residents, R12 and R20, who were using them without proper documentation and evaluation. R12, who had hemiplegia following a stroke, was observed using a weighted blanket without a physician's order, nursing assessment, or inclusion in her care plan. Staff members, including nursing assistants and a licensed practical nurse, were aware of the blanket but did not follow any guidelines for its use. The Director of Nursing (DON) confirmed that the necessary assessments and documentation were missing, and the facility's policy on weighted blankets was not followed. Similarly, R20, who had multiple diagnoses including autism, cerebral palsy, and severe cognitive impairment, was also using a weighted blanket without a physician's order, nursing assessment, or care plan inclusion. The DON acknowledged that the facility had not adhered to their weighted blanket policy, which required a physician's order, a physical device assessment to ensure the resident could remove the blanket independently, and care plan documentation. The facility's policy indicated that weighted blankets should be used as a therapeutic modality and required specific procedures to ensure resident safety, none of which were followed for R12 and R20.
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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 Le Sueur
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Benedictine Living Community Of St. Peter | 7.7 mi | ★★★★★ | 8 | 0 |
| Central Health Care Center | 10.1 mi | ★★★★★ | 3 | 0 |
| The Lutheran Home: Belle Plaine | 13.6 mi | ★★★★★ | 2 | 0 |
| Good Samaritan Society Arlington | 13.7 mi | — | 0 | 0 |
| Bayside Manor Llc | 16.6 mi | ★★★★★ | 13 | 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 July 2026) and official state health department websites.