Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
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 Melrose during CMS and state inspections, most recent first.
Unauthorized photos and video of two residents were taken and shared by staff using personal phones and Snapchat. One resident’s soiled brief and exposed buttocks were photographed during care and sent to other staff, and the resident later said it made her feel nasty and fearful about having a BM. Another resident’s voice was recorded while repeatedly saying, “help me,” and the video was shared with a caption stating, “I want to kill myself.”
A resident with dementia, osteoporosis, and a history of falls had a care plan and Kardex directing that her electric lift recliner remain unplugged and be used only as a stationary chair, with additional interventions such as signage, grip strips, and appropriate non-slip footwear. Despite this, staff and possibly family intermittently plugged in the recliner, staff did not consistently check whether it was plugged in, and the resident was twice found face down on the floor in front of the recliner when it was in the highest position, sustaining a large frontal hematoma, skin tear, and pain requiring ED evaluation. Observations also showed the resident wearing regular nylon socks instead of anti-slip footwear, and staff interviews confirmed that the care-planned interventions for the recliner and footwear were not reliably implemented, contrary to facility policy that staff follow the care plan and Kardex.
A resident with parkinsonism, dementia, and other conditions had a care plan and hot liquid safety evaluation requiring use of covered mugs for hot beverages outside the dining room after prior coffee spills and documented thigh burns from a coffee spill. Despite this, the resident was later observed in her room with a hot coffee cup without a lid, and she reported that staff had not been providing the required cover. A NA-C, an RN, and the interim DON all acknowledged that the resident was supposed to have covered cups per the care plan, but this intervention was not consistently implemented.
A resident with dementia and impaired mobility, requiring a full body mechanical lift and two staff for transfers, was instead pivot-transferred by a nursing assistant who did not consult the care plan or use a gait belt. The resident fell, later developed pain and swelling, and was diagnosed with a fractured fibula. Staff interviews confirmed the care plan was not followed and facility policy was not adhered to.
A resident with dementia and impaired mobility, who required transfer with a mechanical lift, was instead pivot transferred by a staff member, resulting in a fall and a fractured ankle. The facility's report to the SA omitted the fact that the care plan was not followed, and the DON did not provide full details about the incident or the root cause, despite being aware of the deviation from the care plan.
The facility failed to notify the Ombudsman of a resident’s hospitalization and related transfer/discharge. The resident was cognitively intact and had CHF, HTN, ESRD, and DM, and was hospitalized for sepsis related pneumonia. The DON stated the social worker was responsible for Ombudsman notifications and confirmed the hospitalization was not included on the facility’s notification list.
A licensed pharmacist failed to accurately complete the monthly drug regimen review for a resident who returned from the hospital after sepsis. The resident had multiple chronic conditions, and discharge paperwork included restart orders for atorvastatin and linaclotide, but the CP said she missed those orders and did not document a recommendation; the DON confirmed the transcription error was missed.
Unlocked Medication Cart Left Unattended: A medication cart in a common area was observed unlocked and unsupervised while multiple staff members walked past it, including an RN, the DON, and housekeeping staff. RN-C later confirmed she had left the cart unlocked, and the DON stated carts were expected to be locked whenever staff turned away or left them unattended. The facility policy required medication compartments to be locked when not in use and not left unattended.
A resident's code status was documented as DNR in the EMR banner and current orders, but the Advance Directive link still showed FULL CODE. Staff interviews showed RN, TMA, and LPN staff used different locations to find code status and did not access the Advance Directive link, while the DON confirmed the resident's code status did not match across all locations. The facility policy addressed obtaining advance directives but did not include a process to ensure all code status locations matched.
Improper Disinfection of Shared Glucometer: An RN used a shared glucometer on a resident with diabetes and dementia, then disinfected the device for less time than the wipe label required and did not follow the glucometer manufacturer's instructions for cleaning and disinfection after each patient. The DON stated the glucometer was expected to be disinfected between uses per policy.
A resident did not receive appropriate care for existing pressure ulcers, and the facility did not implement adequate measures to prevent new ulcers from developing.
Staff did not promptly inform a resident, their physician, and a family member about important events such as injury, decline, or room changes, resulting in a breakdown of required communication.
Staff failed to follow enhanced barrier precautions and proper hand hygiene while providing care to a resident with a suprapubic catheter, open wound, and UTI. Despite clear signage and available PPE, staff did not consistently wear gowns or perform hand hygiene during high-contact care activities, including catheter and wound care, as confirmed by staff interviews and direct observation.
The facility failed to provide timely call light responses for four residents, leading to incidents of incontinence and frustration. Device activity reports showed response times exceeding two hours. Staff felt rushed, contributing to delays, and the DON acknowledged the issue, with expected response times not being met.
The facility failed to implement necessary interventions for two residents to prevent further decline in range of motion and mobility. One resident with a history of stroke and hemiplegia had inconsistent completion of passive range of motion exercises, while another cognitively impaired resident's program was rarely completed. Staff cited time constraints as a reason for not performing the exercises, and documentation often lacked rationale for non-completion.
Unauthorized photos and video of residents shared by staff
Penalty
Summary
The facility failed to protect two residents from abuse when staff used personal cell phones to take and share images and video involving the residents. One resident had hemiplegia/hemiparesis, anxiety, depression, was cognitively intact, and was dependent on staff for toileting with bowel and bladder incontinence. During brief care, a nursing assistant took a photo of the resident’s soiled brief, exposed buttocks, and a large bowel movement, then sent the image through Snapchat to other staff members. The resident later stated the incident made her feel “nasty” and said it would be hard to have a bowel movement, and her family member stated the staff had broken her trust. A second resident had anxiety, depression, non-traumatic brain dysfunction, schizophrenia, severe cognitive impairment, verbal behavioral symptoms, and required assistance with activities of daily living. Staff recorded a video that captured the resident repeatedly saying, “help me, help me,” while the camera was pointed at a staff member’s face and the video included a caption stating, “I want to kill myself.” The video was sent to multiple staff phones through Snapchat. The resident was identified in the background audio, and the incident involved unauthorized recording and sharing of a resident’s voice and distressing statements. The investigation confirmed that a nursing assistant admitted taking the photo of the first resident and another nursing assistant admitted taking the video of the second resident. The facility’s own policy identified unauthorized photographs and recordings of a resident as emotional or psychological abuse. The report states the noncompliance began when staff took and shared the image of the first resident and the video of the second resident, both using personal phones and social media messaging among facility staff.
Failure to Follow Care Plan for Lift Recliner and Fall-Prevention Interventions
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow care-planned safety interventions for a resident with a history of falls and use of an electric lift recliner, resulting in an avoidable accident with actual harm. The resident had dementia, depression, overactive bladder, and osteoporosis, and the MDS showed intact cognition but a need for substantial to maximal assistance with transfers and toileting. The care plan, revised in December, identified risk for injury related to falls and specifically to electric recliner use, with interventions including keeping the electric lift recliner unplugged so it functioned only as a stationary chair, use of appropriate footwear, grip strips in the room, and signage. The Kardex also instructed staff, per therapy, to keep the recliner unplugged to promote safety. Despite these documented interventions, the resident experienced multiple falls associated with the recliner. An incident report from late May documented the resident being found face down on the floor in front of the recliner, which was in the highest position, suggesting an attempted self-transfer; the post-fall investigation concluded the resident appeared to have attempted to self-transfer and directed that the recliner remain unplugged. A subsequent incident in mid-December again found the resident face down on the floor with pooling blood, a large frontal hematoma, a skin tear, and complaints of hip, elbow, and neck pain, with the recliner again in the highest position. The post-fall investigation and ED provider note both indicated the resident attempted to get out of the lift chair after it had been plugged in, despite the care plan stating the chair was to remain unplugged. Staff interviews confirmed that the care plan intervention to keep the recliner unplugged was not consistently followed. Nursing staff and NAs acknowledged awareness that the recliner was not supposed to be plugged in due to prior falls but reported they did not routinely check whether it was plugged in, sometimes assuming no one would have plugged it in. Staff and a family member stated that both staff and family had plugged in the chair at times, and the family member reported the resident would not have been able to plug it in herself. Observations also showed the resident seated in a wheelchair with regular nylon socks rather than anti-slip footwear, even though appropriate footwear was a listed intervention in the care plan. The facility’s own policy stated that the care plan is to guide daily care and that the Kardex is comprised of care plan interventions, and that health care personnel are responsible for following the care plan, yet the interventions related to the recliner and footwear were not implemented as written.
Failure to Follow Care Plan for Hot Liquid Burn Prevention
Penalty
Summary
The deficiency involves the facility’s failure to implement care-planned interventions to reduce a resident’s risk for burns from hot liquids. The resident had diagnoses including parkinsonism, depression, anxiety, and dementia, but was care planned as having intact cognition and able to eat independently. Her care plan, dated 12/11/25, identified a risk for altered nutritional status and directed staff to provide covered mugs for hot liquids when she was outside the dining room. A Hot Liquid Safety Evaluation dated 9/19/25 documented that hot liquid temperatures were not to exceed 180 degrees and noted an isolated coffee spill event on 9/16/25, with follow-up completed on 9/17/25. Progress notes from 9/17/25 recorded that the resident reported spilling coffee in her lap while watching television and stated the coffee was “luke warm at best,” and the event was considered isolated. On 12/10/25, progress notes documented pink/red areas on the resident’s left inner thigh (10 cm x 6 cm) and right inner thigh (13 cm x 3 cm), warm to touch and tender, with the cause identified as the resident spilling coffee in her lap. Staff were then directed to put covers on hot liquids when she took them outside the dining room, and an interdisciplinary team review on 12/11/25 confirmed that she had spilled coffee while attending a movie activity and that the care plan was updated to require covered mugs for hot beverages outside the dining room. However, during an observation on 1/14/26, the resident was seen in her room with a hot coffee cup without a lid and stated she was supposed to have a lid but staff had not given her one. A NA-C and RN both indicated the resident was supposed to have covered cups when not in the dining room, and the interim DON stated the resident should have a cover on her cup as directed in the care plan. Facility policy stated that the care plan is to be used to develop residents’ daily care routines and that health care personnel are responsible for following the care plan, but this was not followed for this resident’s hot liquid precautions.
Failure to Follow Care Plan During Transfer Results in Resident Fracture
Penalty
Summary
A deficiency occurred when staff failed to follow a resident's care plan during a staff-assisted transfer, resulting in a fall and subsequent fracture. The resident, who had diagnoses including Alzheimer's disease, vascular dementia, and osteoporosis, was non-ambulatory and had a care plan requiring the use of a full body mechanical lift (EZ lift) with assistance from two staff members for transfers due to being non-weight bearing on the right lower extremity. Despite this, a nursing assistant attempted a pivot transfer without a gait belt, believing the resident could stand independently, and did not consult the resident's Kardex or care plan prior to the transfer. During the transfer, the resident's legs became weak, and the staff member assisted her to the floor. Initially, no injuries were noted, but the resident later developed pain, swelling, and bruising in the right foot. An x-ray confirmed a slightly displaced fracture of the distal fibula. The resident reported significant pain following the incident, and her family was notified. Interviews revealed that the nursing assistant had not worked regularly at the facility and did not review the care plan or use a gait belt as required by facility policy. Other staff members confirmed that the resident's transfer status had recently changed and that staff were expected to review each resident's Kardex before providing assistance. The facility's policy required verification of transfer status and the use of appropriate equipment, such as a gait belt or mechanical lift, based on the resident's care plan. The failure to follow these protocols directly led to the resident's fall and injury.
Failure to Accurately Report Incident and Care Plan Deviation to State Agency
Penalty
Summary
The facility failed to submit a report to the State Agency (SA) with sufficient and accurate information regarding an incident involving a resident with Alzheimer's disease, vascular dementia, and impaired mobility. The resident, who was non-ambulatory and required transfer assistance using an EZ mechanical stand with one staff member, experienced a staff-assisted fall when a nursing assistant attempted a pivot transfer instead of using the required mechanical lift. This deviation from the care plan resulted in the resident being lowered to the floor, and subsequent imaging revealed a slightly displaced fracture of the distal fibula. The incident report submitted to the SA did not include the critical detail that the resident was transferred by pivot with one staff member rather than with the mechanical lift as required by the care plan. Further review of communications and interviews revealed that the Director of Nursing (DON) did not provide complete information to the SA regarding the root cause of the fall or the failure to follow the resident's care plan, despite being aware of these facts from internal reports and staff communications. The DON confirmed that the report was submitted after the fracture was identified but was unsure why the report omitted the details about the improper transfer method. Additionally, the facility had not conducted a full investigation or interviewed the involved staff or resident before submitting the report, even though the incident report and verbal communications indicated the care plan was not followed.
Failure to Notify Ombudsman of Resident Hospitalization
Penalty
Summary
The facility failed to notify the Ombudsman of a resident transfer/discharge related to hospitalization for 1 of 3 residents reviewed for hospitalizations. The resident’s quarterly MDS indicated the resident was cognitively intact and had diagnoses including heart failure, hypertension, end stage renal failure, and diabetes mellitus. Progress notes showed the resident was hospitalized from 4/29/25 through 5/5/25 with sepsis related pneumonia, but the facility’s April and May 2025 Ombudsman notification lists did not include the hospitalization. During interview, the DON stated the social worker was responsible for notifying the Ombudsman of all hospitalizations, transfers, and discharges, and confirmed the resident’s hospitalization was not included on the notification list provided by the facility. The DON also stated it was her expectation that all hospitalizations, discharges, and transfers be reported to the Ombudsman.
Pharmacy Review Missed Restart Orders After Hospital Return
Penalty
Summary
The facility failed to ensure that a licensed pharmacist completed an accurate monthly drug regimen review that included the medical chart and irregularity reporting as outlined in its policy. For one resident, R6, the quarterly MDS indicated diagnoses including heart failure, hypertension, end stage renal failure, diabetes mellitus, and irritable bowel syndrome with constipation. R6 was emergently transferred to the hospital on 4/29/25 with sepsis and returned to the facility on 5/5/25. R6’s discharge transfer paperwork dated 5/5/25 included orders for Atorvastatin 40 mg and Linaclotide 145 mcg to begin on 5/6/25. During interview, the Consulting Pharmacist stated she completed the monthly pharmacy review on 5/21/25 and reviewed the discharge paperwork, but did not see the orders to restart Atorvastatin and Linaclotide and did not write a recommendation related to those medications. She stated she missed the order and should have written a recommendation for the medications to be restarted. The DON stated the consultant pharmacist reviewed resident medications at least monthly for errors and irregularities, and confirmed the pharmacist did not catch the transcription error for R6.
Unlocked Medication Cart Left Unattended
Penalty
Summary
The facility failed to maintain safe storage of medications when 1 of 3 medication carts was left unlocked and unattended in the common area of the 100's unit. On 9/9/25 at 7:55 a.m., the medication cart was observed unlocked and unsupervised outside the dining room, across from the unattended nurse's station. Over the next several minutes, multiple staff members passed by the unlocked cart, including a staff person who placed something in the nurse's station, a second staff person, a staff person with a laundry cart, RN-C while pushing a resident in a wheelchair, the DON, RN-C again with supplies, and housekeeping staff, without anyone locking the cart until RN-C noticed it at 8:07 a.m. and secured it. During interview on 9/9/25 at 8:09 a.m., RN-C confirmed she had left the medication cart unlocked and was unsure when it had been left that way. RN-C stated it was never acceptable to leave a medication cart unlocked. During interview on 9/10/25 at 10:54 a.m., the DON stated medication carts were expected to be locked any time someone turned away or left the cart, and that this was important to prevent staff and visitors from accessing medications. The facility policy titled Medication Guidelines - Long Term Care, dated July 2025, stated that all compartments containing medications should be locked when not in use and should not be left unattended.
Inconsistent Advance Directive Documentation
Penalty
Summary
The facility failed to maintain a complete, accurately documented, and readily accessible medical record for 1 of 24 residents reviewed for advance directives documentation. The resident was admitted with diagnoses including hypertension, hyperlipidemia, arthritis, respiratory failure, and depression. The quarterly MDS and the EMR banner showed the resident's code status as DNR, and current orders also indicated DNR. However, the Advance Directive link in the EMR contained an outdated advance directive that listed the resident as FULL CODE. A progress note documented that during hospitalization the resident's code status was changed to Do Not Resuscitate and that the change was verified with the resident's spouse, with social services to follow up on updating healthcare directives. During interviews, RN-C stated staff should look to the EMR or paper chart and that the paper chart and EMR should match; however, the Advance Directive link was not identified as the source she used. TMA-A, RN-B, and LPN-A each described looking in other locations such as the Kardex, POC banner, or hard chart, and did not access the Advance Directive link. The DON confirmed the EMR banner showed DNR while the Advance Directive link still showed FULL CODE, and stated all locations listing code status were expected to match. The facility policy described obtaining advance directives and carrying out wishes in the event of cardiac arrest, but did not include a procedure to ensure all available locations of a resident's advance directives were matching.
Improper Disinfection of Shared Glucometer
Penalty
Summary
Provide and implement an infection prevention and control program was not met when the facility failed to properly disinfect a shared glucometer between uses. During observation, RN-C performed a blood sugar check on R126 in the resident's room using a shared glucometer, then returned it to the medication cart and wiped it with a Sani-Cloth germicidal disposable wipe for approximately 10 to 15 seconds before placing it back in the cart. RN-C confirmed she wiped the glucometer for about 5 to 10 seconds and that it dried soon after, and she checked the label and stated the wipe's contact time was one minute. R126's admission MDS indicated severe cognitive impairment and diagnoses of diabetes mellitus and dementia. The glucometer owner's manual required cleaning and disinfection after each patient with a CAVIPES disinfecting towelette containing isopropanol, with instructions to keep the surface wet for 2 minutes and allow it to air dry. Facility policy for blood glucose sampling dated September 2025 required following the manufacturer's instructions for cleaning and disinfecting after each use.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not take adequate measures to prevent the development of new ulcers. This deficiency indicates that the necessary interventions and monitoring to manage existing pressure ulcers and prevent additional ones were not implemented as required.
Failure to Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors as a deficiency in the facility's process for keeping relevant parties informed about significant events impacting the resident's care or condition.
Failure to Implement Enhanced Barrier Precautions and Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to implement adequate infection prevention and control practices for a resident requiring enhanced barrier precautions (EBP) due to the presence of an indwelling suprapubic catheter, an open stage three pressure ulcer, and a current urinary tract infection (UTI). The resident had multiple diagnoses, including neurogenic bladder, dementia, Parkinson's disease, and osteoporosis, and required substantial assistance with activities of daily living. The care plan directed staff to monitor the catheter and wound but did not include EBP instructions. During direct care, staff entered the resident's room without donning required personal protective equipment (PPE), specifically gowns and gloves, despite clear EBP signage and available supplies outside the room. Staff assisted the resident with transferring, catheter care, wound care, and personal hygiene without consistently using gowns, and at times failed to perform hand hygiene between glove changes. Observations included staff handling soiled items, performing dressing changes, and providing peri care without proper PPE or hand hygiene, even after exposure to urine and wound sites. Interviews with the involved nursing assistants and LPN confirmed awareness of the EBP requirements and acknowledged lapses in following protocol, attributing failures to forgetfulness or unexpected care needs. The director of nursing also confirmed that staff were expected to follow EBP signage and that sitting on the floor during care was not recommended due to infection control concerns. Facility policy and posted signage clearly outlined the need for gown and glove use during high-contact care activities for residents on EBP, which was not followed in this instance.
Excessive Call Light Response Times in LTC Facility
Penalty
Summary
The facility failed to provide a reasonable call light response time for four residents, all of whom were cognitively intact and had various medical conditions such as anemia, hypertension, depression, and post-traumatic stress disorder. The device activity reports indicated numerous instances of excessive call light response times, with some exceeding two hours. These delays resulted in residents being unable to reach the restroom in time, leading to incidents of incontinence and feelings of frustration and anger among the residents. Interviews with staff, including a nursing assistant and an LPN, revealed that they felt rushed and unable to spend adequate time with residents, contributing to the long response times. The director of nursing acknowledged the issue, confirming that the facility's call light logs reflected excessively long wait times. The expected response time was stated to be 15 minutes, but this standard was not met, as evidenced by the residents' experiences and the device activity reports.
Failure to Implement Range of Motion Interventions
Penalty
Summary
The facility failed to implement necessary interventions to prevent further decline in range of motion and mobility for two residents. One resident, who had a history of stroke, arthritis, and hemiplegia, was observed with limited range of motion in his upper body. Despite having a care plan that included passive range of motion exercises, documentation showed inconsistent completion of these exercises, with numerous instances of missing documentation or the task being marked as not applicable. Interviews with staff revealed that the exercises were often not performed due to time constraints, and the importance of these exercises was emphasized by the director of therapy. Another resident, who was severely cognitively impaired and had multiple diagnoses including dementia and malnutrition, was also on a restorative nursing program for passive range of motion. However, documentation indicated that the program was rarely completed, with many days marked as not applicable. Interviews with staff and family members confirmed that the exercises were only performed when staff had time, and there was no rationale documented for the lack of completion. The director of nursing acknowledged the importance of completing these exercises to maintain the residents' current health status.
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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.
Illustrative
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Nursing homes near Melrose
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cura Of Sauk Centre | 8 mi | ★★★★★ | 7 | 0 |
| Benedictine Living Community Mother Of Mercy | 12.1 mi | ★★★★★ | 8 | 0 |
| Belgrade Nursing Home | 18.1 mi | ★★★★★ | 0 | 0 |
| Cura Of Long Prairie | 20.6 mi | ★★★★★ | 1 | 0 |
| Galeon | 21 mi | ★★★★★ | 7 | 0 |
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