Average — CMS composite of the measures below.
The next survey window likely opens around February 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 Sauk Centre during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple diagnoses, including Alzheimer’s disease and spinal stenosis, was observed seated in a wheelchair with a mechanical lift sling left underneath and the leg straps sticking up between the resident’s legs in common areas. Staff confirmed the sling was typically left in place, but the straps should have been tucked in or removed from view, and the RN case manager and DON stated the visible straps were a dignity concern.
MDS inaccurately coded a fall with major injury. A resident with severe cognitive impairment and extensive ADL needs had multiple documented falls, but the record did not show any major injury such as a fracture, dislocation, closed head injury with altered consciousness, or another injury requiring extensive medical intervention. The MDS Coordinator confirmed the fall with major injury was coded incorrectly, and the DON stated the resident had not had a major injury since admission.
Failure to comprehensively care plan resident pain management: A resident with a cervical fracture, cervicalgia, and shoulder sprain had documented frequent pain, sleep disruption, and use of a C-collar, but the comprehensive care plan did not clearly address the pain issue. Although pain meds and nonpharmacologic measures were documented in the chart, the care plan lacked pain-specific documentation, and pain meds were instead referenced under a nutritional problem.
A resident’s comprehensive care plan was not revised after healed ischial tuberosity wounds and discontinued EBP. The plan still listed gown and glove use, PPE, signage, and resident/visitor education for a Stage 2 pressure ulcer even though progress notes, the RNCM, and the IP confirmed the wounds had resolved and EBP was no longer in place. During observation, no EBP signage or PPE cart was present, and the DON stated care plans should be updated when a resident’s condition changes.
A resident with severe cognitive impairment and multiple diagnoses, including dementia, diabetes, and obstructive sleep apnea, used oxygen at night and needed staff help to apply and remove the nasal cannula. Surveyors repeatedly observed the oxygen tubing lying on the floor at the end of the bed with the cannula prongs touching the floor. Staff, including an NA, LPN, RN case manager, MDS RN, and DON, stated the tubing should not be on the floor and identified it as an infection control concern.
A resident with cognitive impairment and multiple health conditions was given another resident's medications after a nurse pre-prepared and mislabeled medication cups. The error resulted in the resident experiencing a fall, minor head injury, tachycardia, and hypertension, requiring emergency department evaluation and monitoring. The incident was attributed to the nurse's failure to follow policy by preparing medications for more than one resident at a time.
The facility did not accurately post required daily nurse staffing information, with postings missing the facility name, current census, and containing inaccuracies such as listing TMAs under LPN sections. Staff confirmed that postings were made for multiple days at a time and did not meet regulatory requirements.
A resident with severe cognitive impairment and a documented history of recurrent UTIs did not have their UTI history, treatment goals, or preventive interventions included in their care plan. Staff interviews confirmed that this information should have been documented to ensure appropriate monitoring and response, in accordance with facility policy.
The facility failed to provide timely x-ray results for three residents, leading to delayed medical interventions. A resident with Alzheimer's disease experienced a fall and had a fracture identified only after a six-day delay. Another resident with brain dysfunction had a foot x-ray delayed by seven days, and a third resident with heart and respiratory failure had a chest x-ray delayed by eleven days. The delays were due to a shortage of radiologists and a lack of a formal process for timely x-ray result expectations.
A resident with a deep tissue pressure ulcer on the coccyx did not receive proper documentation of wound assessments during dressing changes. Despite the LPN observing worsening conditions and notifying the RN and DON, there was no formal reassessment or documentation in the medical record. The facility's policy required such documentation and physician notification for wound changes, which was not followed, leading to a deficiency.
A resident with a history of depression and cognitive impairment attempted self-harm using a nasal cannula. Despite the severity, the facility staff failed to notify the resident's physician or family about the incident in a timely manner. The LPN documented the event but did not take further immediate action or disclose the full details to the family. The facility's documentation lacked evidence of interventions until the following morning when social services assessed the resident and contacted the physician.
Resident Left with Visible Hoyer Sling Straps
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect for 1 of 3 residents reviewed for dignity. R26 had severe cognitive impairment and required assistance with all ADLs. R26’s diagnoses included non-traumatic brain dysfunction, arthritis, Alzheimer’s disease, and spinal stenosis. During observation, R26 was seen sitting in a wheelchair in the dining room and later in the chapel with a mechanical lift sling left underneath the resident. The sling’s leg straps were positioned upright between R26’s legs and were visible to others in both common areas. R26’s care plan stated it was acceptable to leave the sling underneath the resident for safety and potential skin alteration, but it did not include instructions for how the sling should be positioned while seated in common areas. Staff interviews confirmed the sling was typically left under R26 while seated, but the straps should have been tucked in or removed from between the resident’s legs so they were not visible. The RN case manager and DON both stated the straps left between R26’s legs and sticking up were a dignity concern. The facility policy on dignity stated residents shall be cared for in a manner that promotes and enhances dignity, respect, and individuality, and that residents shall be treated with dignity and respect at all times.
MDS inaccurately coded a fall with major injury
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected R3’s clinical status. R3’s significant change MDS, dated [DATE], identified severe cognitive impairment and the need for assistance with all activities of daily living. The assessment also indicated that R3 experienced one fall with a major injury since admission, while the record review showed multiple falls documented in progress notes and incident reports from 8/28/25 through 11/30/25, including falls on 8/28/25, 9/2/25, 9/5/25, 9/7/25, 9/18/25, 9/23/25, 9/25/25, 10/5/25, 10/20/25, 10/22/25, 10/24/25, 10/28/25, and 11/3/25. The documentation reviewed did not identify that R3 sustained a major injury, such as a fracture, dislocation, closed head injury with altered consciousness, or another injury requiring extensive medical intervention, from any of the falls. During interview, the MDS Coordinator confirmed the MDS showed a fall with major injury and stated it had been coded incorrectly. The DON stated R3 had not experienced a fall with a major injury since admission and said MDS assessments should be double-checked to ensure accurate and correct information before submission. The facility policy titled Minimum Data Set, Management of, Long Term Care, dated 1/25, stated the facility would ensure the MDS was accurately and comprehensively completed.
Failure to comprehensively care plan resident pain management
Penalty
Summary
The facility failed to comprehensively develop a care plan for one resident reviewed for pain management. The resident had diagnoses including displaced dens fracture with routine healing, cervicalgia, and sprain of the right acromioclavicular joint. The quarterly MDS indicated the resident was independent with ADLs, frequently experienced pain, and had a BIMS score of 13, indicating cognitive intactness. The CAA dated 11/04/25 documented that the resident had been admitted for continued rehab and pain control after a fall that caused a Type III odontoid fracture, with a cervical collar in place and pain that varied depending on neck position even with the collar on. The CAA further documented that the resident described pain as aching, sharp, tender, shooting, and dull at times, reported difficulty sleeping and waking often due to pain, and used scheduled and PRN pain medication, frequent position changes, cold packs, and distraction for relief. The resident’s medication review showed tizanidine, Voltaren gel, acetaminophen, lidocaine patch, cholecalciferol, and ascorbic acid were ordered, but the MARs for February 2026 and March 1-5, 2026 showed the resident only received ascorbic acid, acetaminophen, and cholecalciferol. The MARs also showed the resident had not been requesting the PRN tizanidine, lidocaine patch, or Voltaren gel. The comprehensive care plan dated 3/04/26 lacked evidence that the resident’s pain concerns were comprehensively care planned. During interview, the care manager stated the care plan lacked documentation of the resident’s pain issues, and the MDS coordinator stated pain medications had been mentioned under the resident’s nutritional problem rather than as a separate pain issue. The DON stated the expectation was that all identified areas of concern would be comprehensively care planned so staff would be aware of each resident’s issues.
Care plan not updated after wounds healed
Penalty
Summary
The facility failed to revise R13’s comprehensive care plan to reflect current conditions and interventions after the resident’s right and left ischial tuberosity wounds healed. R13’s annual MDS identified moderate cognitive impairment, need for assistance with some ADLs, and diagnoses including non-traumatic brain dysfunction, non-Alzheimer’s dementia, low back pain, obesity, and nonrheumatic mitral valve insufficiency. The care plan, printed on 2/24/26, still included Enhanced Barrier Precautions interventions initiated on 11/5/25 for a Stage 2 pressure ulcer, including use of gown and gloves for high-contact care, PPE availability, signage, and resident/visitor education, even though the wounds had resolved and EBP was no longer being implemented. Progress notes showed the wounds were healed by 1/8/26, with subsequent skin assessments documenting no open areas and intact, blanchable skin. During observation on 3/2/26, no EBP precautions were in place, including no signage outside the room and no PPE cart present. The resident stated prior buttock sores had healed about one month earlier and there were no current open areas. The RNCM and IP confirmed the wounds had resolved and that the resident was no longer on EBP precautions, and they acknowledged the care plan should have been updated to remove those interventions. The DON stated care plans were to be updated with changes in condition or care needs and that related signage should be removed when no longer applicable.
Oxygen Tubing Left on Floor With Cannula Prongs Touching Floor
Penalty
Summary
The facility failed to ensure infection control practices were implemented to prevent potential contamination of oxygen equipment for a resident who used supplemental oxygen at night. The resident had severe cognitive impairment and required assistance with all activities of daily living. Her diagnoses included non-traumatic brain dysfunction, hypertension, diabetes mellitus, non-Alzheimer's dementia, anxiety disorder, depression, chronic pain, and obstructive sleep apnea. She stated she wore oxygen only at nighttime and needed staff assistance to apply and remove the nasal cannula. During multiple observations, the resident's oxygen tubing was seen lying on the floor at the end of her bed and next to the oxygen concentrator, with the nasal cannula prongs touching the floor. This condition was observed repeatedly while the resident remained in the room. Staff interviews confirmed the tubing should not touch the floor and that it was an infection control concern. The facility policy titled Infection Prevention and Control stated equipment was to be maintained in a sanitary condition and appropriate infection control practices were to be implemented to prevent contamination and the spread of infection.
Medication Error Leads to Resident Harm Due to Pre-Prepared Medications
Penalty
Summary
A resident with moderate cognitive impairment and multiple medical diagnoses, including hypertension, diabetes, and dementia, was administered another resident's medications during a morning medication pass. The nurse responsible for medication administration had prepared multiple residents' medications in advance, labeling the medication cups with initials and storing them in the medication cart drawer. Due to a mislabeling error, the nurse gave the resident the wrong set of medications. Following the administration of the incorrect medications, the resident experienced an unwitnessed fall, resulting in a laceration above the left eyebrow. The resident was subsequently sent to the emergency department for evaluation. Clinical documentation indicated that the resident developed tachycardia and hypertension after receiving the wrong medications, which included high doses of blood pressure and seizure medications not prescribed for her. The emergency department performed diagnostic tests and provided monitoring instructions due to the risk of adverse effects from the medications ingested. The nurse involved acknowledged the error, stating that she had pre-prepared medications for multiple residents, which was not in accordance with facility policy. The consultant pharmacist reviewed the incident and confirmed that the combination and dosage of medications administered in error were significant and likely contributed to the resident's fall and subsequent symptoms. The facility's policy required medications to be prepared for one resident at a time and prohibited pre-pouring or pre-setting medications.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that required nurse staffing information was accurately posted each day, as observed and documented over a three-day review period. On each day, the posted staffing information was either outdated, missing required elements such as the facility name and current census, or contained inaccurate information. Specifically, trained medication aides (TMAs) were incorrectly listed under sections designated for LPNs, and postings were made for two days at a time rather than daily. These postings were located inside the facility entrance but did not meet regulatory requirements for content and accuracy. Interviews with the business office manager and the director of nursing confirmed these deficiencies. The business office manager acknowledged posting two days at a time, omitting the facility name and census, and misclassifying TMAs under LPN sections. The director of nursing also confirmed that TMAs should not be listed under LPN sections and that the postings lacked required information. The facility's own policy required daily posting of accurate staffing data, including the facility name, current date, and actual hours worked by each category of nursing staff, which was not followed during the review period.
Failure to Include Recurrent UTI Management in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with a significant history of urinary tract infections (UTIs). The resident, who had severe cognitive impairment and required assistance with all activities of daily living, had multiple diagnoses including hypertension, renal insufficiency, non-Alzheimer's dementia, and morbid obesity. The resident's medical record documented several episodes of UTIs over a period of months, with corresponding antibiotic and preventive treatments ordered by the physician. Despite this documented history and ongoing risk, the resident's care plan did not include any mention of UTIs, the history of recurrent infections, goals of treatment, or interventions to monitor, prevent, or address UTIs. Interviews with facility staff, including a registered nurse clinical coordinator and the director of nursing, confirmed that the care plan should have included the resident's history of UTIs and related interventions. Both staff members acknowledged the importance of documenting such information to ensure staff awareness and timely response to symptoms. The facility's own policy required comprehensive, person-centered care plans that incorporate measurable objectives, timetables, identified problem areas, and risk factors, none of which were present in the resident's care plan regarding UTIs.
Delayed X-ray Results Lead to Deficiency in Timely Diagnostic Services
Penalty
Summary
The facility failed to provide timely x-ray results for three residents, leading to delayed medical interventions. Resident 1, diagnosed with Alzheimer's disease and severe cognitive impairment, experienced an unwitnessed fall resulting in a head laceration and later developed swelling and bruising on her left arm. An x-ray was ordered on January 9, 2025, but the results were not reviewed until January 15, 2025, when the resident's physician personally checked the x-ray and identified a fracture, prompting an emergency room evaluation. Similarly, Resident 2, with a diagnosis of non-traumatic brain dysfunction and dementia, had an x-ray ordered on January 16, 2025, but the formal results were not available until January 23, 2025. Resident 3, diagnosed with debility, heart failure, and respiratory failure, had a chest x-ray ordered on November 21, 2024, with results not available until December 2, 2024. The delays in receiving x-ray results were attributed to a shortage of radiologists, as stated by the Director of Nursing and the Director of Regional Hospital Imaging Department. The facility lacked a formal process for timely x-ray result expectations, and the Contract for Radiology Services required timely completion of medical records. The Assistant Director of Nursing and the facility administrator expressed concerns about the delays, emphasizing the need for x-ray results within a couple of hours to ensure prompt medical care. The facility did not have a diagnostic testing policy, contributing to the deficiency in providing timely diagnostic services.
Failure to Document Pressure Ulcer Assessments
Penalty
Summary
The facility failed to document assessments during pressure ulcer dressing changes for a resident with a deep tissue pressure ulcer on the coccyx. The resident had multiple diagnoses, including osteomyelitis of the vertebra, extradural and subdural abscess, severe protein-calorie malnutrition, acute infarction of the spinal cord, and a pressure ulcer. The care plan included specific interventions such as administering pain medications, using an air mattress, and repositioning the resident every two hours. However, it did not include instructions for documenting findings during dressing changes. The resident's wound was noted to have worsened, with changes in the wound bed observed by an LPN, who notified the RN and DON via email. Despite this notification, there was no evidence of a formal reassessment or documentation of the wound's characteristics in the resident's medical record. The facility's policy required staff to document wound assessments, including measurements and visual data, and notify the physician if the wound showed signs of infection or deterioration. Interviews with facility staff revealed that the LPN observed changes in the wound but did not document these findings in the medical record. The DON confirmed the lack of documentation and reassessment following the LPN's notification. The facility's failure to document wound assessments and follow up on identified changes led to a deficiency in providing necessary treatment and services to promote healing and prevent infection, as outlined in their policy.
Failure to Notify Physician and Family of Resident's Self-Harm Attempt
Penalty
Summary
The facility failed to ensure timely notification of a resident's physician and responsible parties when the resident, who had increasing depression, attempted to harm herself. The incident involved a resident with a history of major depression, cognitive impairment, and several chronic health conditions, including COPD and liver cirrhosis. On the evening of the incident, the resident expressed suicidal thoughts and attempted to strangle herself with her nasal cannula. Despite the severity of the situation, the facility staff did not immediately contact the resident's primary physician or any on-call physicians, nor did they inform the resident's family about the specific details of the incident. The report highlights that the LPN on duty documented the resident's suicidal statement and the removal of the cannula but failed to take further immediate action to ensure the resident's safety or notify the necessary parties. The LPN suggested moving the resident to a more observable area and called a family member to sit with the resident, but did not disclose the full extent of the incident. The facility's documentation lacked evidence of any interventions or safety measures implemented between the time of the incident and the following morning when social services assessed the resident and contacted the physician and family. Interviews with facility staff, including the DON and social work designee, confirmed the lack of appropriate documentation and communication regarding the incident. The resident's primary physician was not informed until the next morning, at which point the resident was transferred to the emergency room for further assessment. The physician noted that elevated liver function and ammonia levels could have contributed to the resident's mental disturbance. The facility's policy on suicide prevention was not adequately followed, as staff did not notify the appropriate parties or document the incident thoroughly.
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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 Sauk Centre
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cura Of Melrose | 8 mi | ★★★★★ | 14 | 0 |
| Galeon | 13 mi | ★★★★★ | 7 | 0 |
| Cura Of Long Prairie | 16.6 mi | ★★★★★ | 1 | 0 |
| Benedictine Living Community Mother Of Mercy | 19.7 mi | ★★★★★ | 8 | 0 |
| Belgrade Nursing Home | 20.7 mi | ★★★★★ | 0 | 0 |
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