Below average — CMS composite of the measures below.
The next survey window likely opens around March 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 Onamia during CMS and state inspections, most recent first.
Medication labels for multiple residents were found without an expiration date or beyond use date. An ADON, LPNs, RN, and pharmacists confirmed that labels from both pharmacies did not clearly show when medications should be discarded, and staff were relying on fill dates or general refill timing instead of a visible expiration or BUD on the label.
Medication labels for multiple residents did not include an expiration or beyond use date, and staff relied on fill dates or a one-year rule instead of clear label information. Expired injectable supplies were also found in active stock in the med room, and the ADON confirmed they should have been removed. Pharmacy and nursing staff acknowledged the labels from both pharmacies did not clearly show when meds should be discarded.
The facility failed to ensure residents were offered a substantial evening snack when more than 14 hours separated dinner and breakfast. Mealtimes were set at 8:00 a.m., 12:00 p.m., and 5:00 p.m., and staff reported that evening snacks were only provided to certain residents with orders or if a resident asked for one, rather than as a routine offering for all residents. Two residents stated they were not usually offered snacks in the evening.
Infection control paperwork lacked documentation of resident and staff illness symptoms, symptom trends, or any monitoring for possible outbreak activity. The ADON/IP stated there had been no tracking and trending since taking over the IP program and was not aware it was required, while the RCD stated the facility should have a system to track symptoms and the IP should monitor it frequently. Facility policies stated infection surveillance was intended to identify cases and trends to guide interventions and prevent future infections.
Resident trust funds were not fully covered by adequate surety bond protection. The business office manager confirmed the resident personal funds account balance totaled $40,688.56 for 34 residents, while the CFO confirmed the bond penalty amount was only $10,000 and said it should have been $100,000. Review of the bond and rider showed the lower coverage was in effect before the rider increased it, despite facility policy requiring a surety bond to secure all resident personal funds.
A resident with dementia and inflammatory arthritis was found with a bruise on her hand, which staff failed to assess and report according to the facility's skin integrity process. Despite the care plan requiring weekly skin audits during showers, the bruise was not documented or communicated to the charge nurse, leading to a lapse in monitoring and notification procedures.
A facility failed to monitor medication interactions for a resident with cognitive impairment and multiple diagnoses. The resident was given Allopurinol, Diltiazem, and Carafate together, despite Carafate's potential to decrease Allopurinol's effects if not administered separately. Staff were unaware of this interaction, and the facility's policy for monthly drug regimen reviews was not effectively implemented.
A resident with severe cognitive impairment was found with unexplained bruising, which was not reported to the State Agency and administrator within the required timeframe. The bruising was discovered by a nursing assistant and reported to an LPN, who informed an RN later. The RN filed a report, but the director of nursing and administrator were notified the next day, contrary to facility policy.
A facility failed to thoroughly investigate an injury of unknown origin for a resident with severe cognitive impairment and multiple medical conditions. The resident was found with unexplained bruising, and the DON's investigation did not include interviews with other residents or a complete assessment of the resident's behavior. The facility's policy requires immediate investigation to rule out abuse, but the procedures were not fully followed.
A resident with severe cognitive impairment and multiple health issues was found to have significant bruising, but the facility failed to monitor the bruising as required. Staff interviews revealed a lack of adherence to procedures for monitoring new skin impairments, and the care plan did not include specific instructions for bruising. The Director of Nursing admitted to the oversight, and the facility's policy for skin assessments was not followed.
Medication Labels Missing Expiration or Beyond Use Dates
Penalty
Summary
The facility failed to ensure resident medications were properly labeled with an expiration date or beyond use date. During medication pass observations, multiple residents’ medication labels were reviewed and found to lack either an expiration date or beyond use date, including medications for R17, R7, and R1. The same issue was observed again for R7 during a later medication observation, showing the labeling concern was present across multiple medication carts and at different times during the survey. Two medication carts were reviewed with the ADON, who confirmed that medication labels from both Mille Lacs pharmacy and Onamia Drug store did not include an expiration or beyond use date. During interviews, an LPN stated staff used the fill date and would not use a medication if it was a year past the filled date, while another LPN confirmed the medication cards did not list an expiration or beyond use date. An RN also confirmed that labels from both pharmacies did not include expiration or beyond use dates and stated staff had been told PRN medications expired a year from the fill date and scheduled medications should not be expired because they were refilled every 28 days. The ADON stated they had been working on the medication label concern and had contacted the pharmacy, but was not aware of either pharmacy’s policies or whether the facility had access to them. The Onamia Drug pharmacist confirmed their labels had a place for an expiration date but that it was not currently used, and that nursing staff could not determine from the label whether a medication was expired or should be discarded. The consultant pharmacist and Mille Lacs pharmacist also confirmed the labels did not include a medication expiration or beyond use date, and stated the pharmacy used one year from the fill date unless otherwise labeled.
Medication Labels Lacked Expiration Dates and Expired Supplies Remained in Stock
Penalty
Summary
Medication labels in the facility did not include an expiration date or beyond use date for multiple residents’ medications. During medication pass observations, labels for medications used by R17, R7, and R1 were reviewed and found to lack an expiration or beyond use date. Two medication carts were also reviewed with the ADON, who confirmed that medication cards filled by both Mille Lacs pharmacy and Onamia Drug store did not include an expiration or beyond use date. During review of the medication room, expired injectable supply items were found still stored in active stock, including three boxes of various needle sizes used for injection, a box of safety syringes with a 25-gauge needle, and a bundle of chlamydia swabs. The ADON confirmed these items were expired and stated they should have been discarded when they expired to prevent accidental use on a resident. Nursing staff interviewed during the observations also confirmed that the medication labels did not contain expiration dates and stated they relied on the fill date or a one-year timeframe from the fill date. Further interviews with nursing and pharmacy staff confirmed that the labels from both pharmacies did not provide a clear expiration or beyond use date that nurses could use before administration. The Onamia Drug pharmacist stated their cards had a place for an expiration date but it was not currently used, and that nursing staff would not be able to determine from the label whether a medication was expired or should be discarded. The consultant pharmacist and Mille Lacs pharmacy staff also confirmed that their labels did not include a medication expiration or beyond use date and that nurses were expected to verify expiration before administration, even though the current labels did not clearly show that information.
Failure to Provide Routine Evening Snacks
Penalty
Summary
The facility failed to ensure residents were offered a substantial snack when there were more than 14 hours between the dinner and breakfast meals. The facility-submitted document identified breakfast at 8:00 a.m., lunch at 12:00 p.m., and dinner at 5:00 p.m., creating a span of more than 14 hours between the evening meal and breakfast. The facility’s policy stated there would not be more than a 14-hour span between the substantial evening meal and breakfast unless resident council approved a longer span and a nourishing snack was provided before bed. During interviews, the manager of nutrition services confirmed the mealtimes, and the ADON stated snacks were available in the evening only if a resident asked for one, with no routine evening snack offering. NA-A said evening snacks were sent from the kitchen for specific residents between 6:30 p.m. and 7:00 p.m., labeled with resident names, and not all residents received them, though snacks were available upon request. LPN-A stated dietary brought a snack tray to some residents with orders for an evening snack, and staff were always asking residents if they wanted something to eat. Two residents stated they were not routinely offered snacks in the evening, though one believed staff would provide one if asked.
Infection Control Program Lacked Symptom Tracking and Trending
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program by not tracking and monitoring residents and staff with symptoms of possible illness. During review of the infection control program paperwork, there was no information related to staff and resident illness symptoms reported to the facility, and there was no documentation of symptoms, trends in the facility, or indications that the facility was monitoring to prevent a potential outbreak. During interviews, the assistant director of nursing/infection preventionist stated there had been no tracking and trending of resident or staff symptoms since she took over the IP program in 1/26, and she was not aware that tracking and trending of symptoms needed to be done. The regional clinical director stated the facility should have a way to keep track of resident and staff symptoms and that the IP should monitor that system frequently to know when residents and staff have symptoms that could be contagious to try to prevent an outbreak. The IP also stated the facility should do any monitoring needed to prevent outbreaks and keep residents, visitors, and staff safe. Facility policies for Infection Control and Surveillance for Infections stated the objective was to prevent, detect, investigate, and control infections and to identify individual cases and trends to guide interventions and prevent future infections.
Resident Trust Funds Not Fully Covered by Surety Bond
Penalty
Summary
Assure the security of all personal funds of residents deposited with the facility was not maintained because the facility did not ensure resident personal fund accounts were insured with adequate surety bond coverage to cover the total account balance. During interview and document review, the business office manager confirmed the residents' personal funds accounts totaled $40,688.56 for 34 residents. The CFO confirmed the facility's surety bond for resident personal funds identified a penalty amount of $10,000 and stated the bond should cover $100,000, noting they needed to contact their insurance representative for clarification. Review of surety bond number 2653018 showed a $10,000 bond in effect from 7/23/25 through 7/23/26, and a rider dated 4/23/26 showed the bond increased from $10,000 to $100,000 effective 4/23/26. The facility policy stated it would maintain a surety bond to assure the security of all resident personal funds deposited with the facility.
Failure to Monitor and Report Resident's Bruising
Penalty
Summary
The facility failed to assess and monitor bruising for a resident with impaired skin integrity. The resident, who has moderately impaired cognition and diagnoses including dementia and inflammatory arthritis, was observed with a dark purple bruise on her left hand. Despite the facility's care plan directing weekly skin audits during showers or baths, the bruise was not documented or reported by staff during the resident's shower. The resident stated she bruised easily and did not recall how the bruise occurred. Interviews with staff revealed a lack of adherence to the facility's process for checking and reporting skin issues. A registered nurse and a clinical manager confirmed that skin checks should occur on bath or shower days, and any findings should be reported to the charge nurse for further assessment and notification. However, the nursing assistant and clinical manager who assisted the resident with her shower did not report the bruise, and the clinical manager did not notice it during the shower. The director of nursing acknowledged that the process for reporting and monitoring skin impairments was not followed for this resident.
Failure to Monitor Medication Interactions
Penalty
Summary
The facility failed to ensure that physician-prescribed medications were reviewed and monitored for interactions, specifically for one resident with moderate cognitive impairment and multiple medical diagnoses, including unspecified dementia, anxiety, and major depression. The resident was prescribed several medications, including Allopurinol, Diltiazem, and Carafate. During a medication observation, it was noted that the trained medication assistant administered these medications together, without knowledge of potential interactions, assuming the electronic medication record's schedule was correct. The pharmaceutical reference indicated that Carafate could decrease the effects of Allopurinol if not administered with a time gap. The pharmacy consultant and primary physician confirmed that Carafate should be given separately from other medications to avoid absorption issues. The facility's policy required the consultant pharmacist to review drug regimens monthly and report irregularities, but this was missed in the review of the resident's medications. Interviews with staff revealed a lack of awareness regarding the interaction between Carafate and other medications, leading to the deficiency.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident within the required timeframe to the State Agency and the administrator. The resident, who had a history of stroke, aphasia, dementia, and hemiplegia, was found to have unexplained bruising on the left arm, hand, and fingers. The bruising was discovered by a nursing assistant during morning care and reported to an LPN, who then informed an RN later in the afternoon. The RN filed a report with the Minnesota Adult Abuse Reporting Center, but the facility's director of nursing and the administrator were not notified until the following morning. The facility's policy requires that injuries of unknown origin be reported immediately or within two hours if severe, and within 24 hours if not severe. However, the report to the State Agency was delayed, and the administrator was not informed until the next day. The director of nursing confirmed that reeducation had not been provided to the involved staff regarding timely reporting of such incidents. The facility's policy outlines the conditions under which an injury should be classified as unknown and mandates reporting per federal and state law.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to conduct a thorough investigation into an injury of unknown origin for a resident with severe cognitive impairment and multiple medical conditions, including stroke, aphasia, dementia, and hemiplegia. The resident was found with unexplained bruising on the left arm, forearm, hand, and fingers, which was tender to the touch. The Director of Nursing (DON) attempted to interview the resident, who was unable to communicate effectively due to aphasia, and did not appear fearful. The DON also interviewed staff but did not interview other residents on the unit. The facility's policy on abuse, neglect, and mistreatment requires immediate investigation of injuries of unknown origin to rule out abuse, including interviewing the affected resident and others in the vicinity. However, the DON did not follow these procedures, as she did not interview other residents or fully document the resident's behavior and response to interaction. The policy also mandates providing a safe environment during the investigation, but the report does not indicate that this was ensured. The DON acknowledged uncertainty in ruling out abuse, highlighting a gap in the investigation process.
Failure to Monitor Resident's Bruising
Penalty
Summary
The facility failed to ensure proper monitoring of bruising for a resident with a history of stroke, aphasia, dementia, and hemiplegia. The resident, who had severely impaired cognition and exhibited behavioral symptoms, was reported to have significant bruising on the left forearm and hand. Despite the presence of these bruises, the resident's progress notes lacked any additional monitoring or documentation of the bruising after the initial report. The care plan for the resident, which was revised earlier, did not include specific instructions for monitoring bruising, although it did direct staff to inspect the skin daily. Interviews with facility staff revealed a lack of adherence to procedures for monitoring new skin impairments. An LPN acknowledged not entering an order to monitor the bruising, and an RN was unaware of the facility's procedure for additional monitoring. Another RN confirmed that there was no treatment order for monitoring the bruising, although it was expected. The Director of Nursing admitted to the oversight and confirmed the absence of a treatment order in the resident's record. The facility's policy required nurse aides to inspect the skin every shift and licensed nurses to perform weekly skin assessments, but these procedures were not followed in this case.
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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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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
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| St Clare Living Community Of Mora | 21.6 mi | ★★★★★ | 8 | 1 |
| Milaca Elim Meadows Health Care Center | 21.8 mi | ★★★★★ | 7 | 0 |
| Pierz Villa Inc | 21.9 mi | ★★★★★ | 6 | 0 |
| The Gardens At Foley Llc | 30.8 mi | ★★★★★ | 10 | 0 |
| Good Samaritan Society - Bethany | 31.6 mi | ★★★★★ | 4 | 0 |
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