Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cura Of Willmar during CMS and state inspections, most recent first.
Failure to Reposition Resident With Stage 4 Pressure Ulcer: A resident with diabetes, CAD, HTN, and a stage 4 coccyx pressure ulcer was assessed as needing repositioning every 2 hours, but during prolonged observation staff did not offer repositioning while the resident remained in the same position in bed. The care plan called for turning and repositioning per tissue tolerance, but the bedside Kardex did not specify how often to reposition. When the issue was identified, RN and the ADON turned the resident and noted blanchable redness on the left buttocks and upper thigh.
A resident with impaired cognition, cancer, non-Alzheimer's dementia, extensive ADL needs, and a fall history was identified as a high fall risk with care plan interventions including removing a movable bedside table. After a fall, the resident was found using the table as a walker, yet observations showed the table still placed beside the bed on multiple occasions, including when staff were present. Staff interviews confirmed they were unaware of the current fall prevention interventions and that the table remained at bedside for meals despite the care plan.
A resident with hemiplegia, HTN, and DM had an ordered restorative nursing program for ROM, stretching, and strengthening exercises to maintain function. Survey review found the program was repeatedly missed or only partially completed over several months, and interviews showed the restorative aide was the only aide covering the whole building, could not always complete all residents’ programs, and staff were unclear who covered when she was unavailable.
Failure to perform hand hygiene during wound care was identified for a resident with a stage 4 coccyx pressure ulcer, diabetes, CAD, and HTN. An RN and the ADON provided perineal and wound care, but the RN repeatedly changed gloves without sanitizing hands and did not sanitize hands or change gloves before removing soiled packing and applying new wound packing and a dressing. The DON stated staff were expected to sanitize hands every time gloves were removed, and facility policy required hand hygiene after glove removal and before moving from a contaminated body site to a clean body site.
Grievance forms and procedures were not posted in prominent locations, and three residents in council said they did not know how to file a grievance. An AD said residents could ask social services for help, but she did not have the form and was unsure which form to use after new ownership. An LSW said concerns were usually handled in progress notes, and the administrator confirmed residents could not file grievances anonymously, despite the facility policy stating grievance information, anonymous filing rights, and grievance official contact info would be posted.
A resident with stroke-related hemiplegia, ESRD, diabetes, legal blindness, and a care plan requiring assist of two for transfers was transferred to the toilet by one staff member and left there with a call light. The resident reported sliding or tipping off the toilet while attempting to wipe, landing on the floor, and being lifted under the arms by two unidentified female staff and returned to bed without a nursing assessment. Throughout the day, the resident complained of left leg and hip pain, which was documented by PT and nursing, and repeatedly reported that he had fallen from the toilet, while multiple NAs denied witnessing or assisting with the fall and gave inconsistent accounts. Despite a facility policy requiring immediate reporting of all actual, suspected, or resident-reported falls to a nurse, the fall was not promptly reported or assessed at the time it occurred, and the resident was moved from the floor back to bed without evaluation, with a later ED visit revealing a left intertrochanteric femur fracture requiring surgery.
The facility failed to maintain a working wander alert system, resulting in two residents with cognitive impairments being able to exit the building on separate occasions. Despite alarms sounding, the doors did not lock as intended, and staff reported the malfunction had persisted for several weeks. Maintenance and testing procedures were inadequate, and the system was not properly checked according to manufacturer guidelines.
Visible Uncovered Catheter Bag Compromised Resident Dignity: A resident with severe cognitive impairment and an indwelling external catheter had a urinary drainage bag repeatedly observed hanging on the side of the bed and visible to residents and staff, with dark amber urine noted in the bag. Staff interviews confirmed the bag should have been covered for privacy and dignity, and the DON acknowledged the bag had been visible from the hallway.
Failure to inform a cognitively intact resident before removing personally owned bird feeders. A resident with Parkinson's disease, CP, depression, and anxiety was upset when his window bird feeders were taken down after he returned from an outing. He and a family member said bird watching helped his anxiety and depression and was something he took pride in. Staff later said corporate had directed removal of all bird feeders, including resident-owned ones, and the admin stated residents were not informed because she believed the feeders were facility owned.
Failure to Complete Baseline Care Plan Within 48 Hours: A resident with moderate cognitive impairment, multiple chronic conditions including DM2, CHF, HTN, hemiplegia, malnutrition, depression, renal dialysis dependence, and hypothyroidism was admitted with no evidence of a baseline care plan initiated within 48 hours. The EHR showed the baseline care plan was developed later and identified dependence on staff for transfers, toileting, and grooming/bathing. The DON confirmed the baseline care plan was not completed within the required timeframe, and an RN-A stated these plans are important for resident safety and to guide care.
Unsafe Use of Wheeled Walker as a Wheelchair: A cognitively intact resident who was independent with cares and used a 4-wheeled walker was observed sitting on the walker and propelling it backward with the feet. Staff stated the resident routinely used the walker this way, despite being told it was not safe, and the resident said no staff had discussed the risks with him. The DON stated the walker could roll away or collapse, and the record lacked risk/benefit documentation and a therapy referral for a proper mobility device.
Dialysis communication and post-dialysis monitoring were not completed for two residents with ESRD-related conditions and fistulas. The facility often sent residents to dialysis without fully completed communication forms, leaving key sections blank, and the MAR/TARs did not include directions or evidence for checking bruit and thrill. Staff and the DON confirmed the forms should be completed and that fistula monitoring was expected, but documentation was lacking for both residents.
Failure to Complete Baseline TB Testing: A resident admitted to the facility had a baseline TB symptom screen completed, but the EMR lacked evidence of TB infection testing. The DON stated new residents should receive a first-step TST within 72 hours of admission and be read within 48 to 72 hours, but the resident did not receive the first TST before being rehospitalized. The facility policy required step-one and step-two TSTs for new admissions or re-admissions.
Missing and Improperly Posted Nursing Staff Schedule: Surveyors could not locate the required nursing staff posting showing the number of nurses and nursing assistants and their scheduled hours in the front entrance, LTC wings, or TCU during the initial review. A later-found posting on a hallway wall was dated the prior day and placed sideways in an acrylic frame, making it difficult to read. The administrator confirmed the posting should have been available on both the TCU and LTC units and said the assigned staff member was on family medical leave and the duty had been overlooked.
A resident with chronic diastolic congestive heart failure did not receive PRN Metolazone as ordered for significant weight gain on multiple occasions. Facility staff, including an LPN and RN, were unaware of the PRN order linked to the resident's daily weight task, leading to a failure in administering the medication. The DON confirmed the importance of following physician's orders, which was not done in this instance.
A facility failed to perform proper hand hygiene after caring for a resident on contact enteric precautions due to a C. Diff. infection. The resident had a history of end-stage renal disease, diabetes, and pressure ulcers, and required assistance for transfers. A nursing assistant did not wash or sanitize her hands after assisting with the resident's transfer and handling a meal tray. The DON confirmed the need for handwashing with soap and water, as hand sanitizer is ineffective against C. Diff.
A resident with moderately impaired cognition and multiple diagnoses was not offered the PCV20 vaccination as recommended by the CDC. Despite the facility's policy to verify immunizations upon admission and educate residents on vaccination benefits, the resident's record lacked evidence of shared clinical decision-making or an offer for the PCV20, highlighting a deficiency in following immunization guidelines.
A facility failed to educate and administer a COVID-19 booster to a resident with moderately impaired cognition and chronic conditions. The resident's last booster was in March 2023, with no further documentation or education provided. The DON admitted the oversight, acknowledging the lapse in following the facility's immunization policy.
Failure to Reposition Resident With Stage 4 Pressure Ulcer
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met for a resident with diabetes mellitus, coronary artery disease, hypertension, and a stage 4 coccyx pressure ulcer. The resident’s MDS identified dependence for lower-body dressing, transfers, toileting, and substantial to maximal assistance with rolling in bed. The care area assessment noted chronic pressure ulcers and diabetic foot ulcers, that the resident was often noncompliant with repositioning, and that he often refused to get out of bed. A tissue tolerance lying assessment identified existing wounds to the heels and coccyx and indicated the resident should be repositioned every two hours. The resident’s care plan included an air pressure mattress, nutritional supplements, and turning and repositioning per tissue tolerance, and the bedside Kardex stated the resident needed two staff for turns and boosts with a lift sheet, but it did not include how often to reposition him. During continuous observation from 7:06 a.m. to 9:51 a.m., the resident remained in the same position in bed while staff entered and exited the room for breakfast, lab work, snacks, and visits. No staff member offered to reposition him during that observation period, and he remained on his back with pillows supporting his sides and lower legs throughout the observation. When the surveyor informed the clinical manager that the resident had not been repositioned as care planned, RN-A and the ADON entered the room, checked the resident’s skin, and assisted him to turn onto his right side. RN-A noted redness on the left buttocks and upper thigh that was blanchable. During interviews, NA-C stated the usual practice was to assist the resident with repositioning every 2 to 3 hours, RN-A confirmed the tissue tolerance assessment called for repositioning every two hours, and the DON stated staff needed education to check on and reposition the resident following the care plan. The facility policy on pressure ulcers/injuries described pressure injuries as resulting from prolonged pressure or pressure with shear, but it lacked interventions for care and prevention of pressure ulcers.
Failure to Follow Fall Prevention Care Plan
Penalty
Summary
The facility failed to implement care planned interventions to prevent further falls for one resident who was reviewed for falls. The resident had moderate impaired cognition, diagnoses including cancer and non-Alzheimer's dementia, required extensive assistance with ADLs including toileting, transfers, and locomotion, and had a history of falls. The resident's care plan identified the resident as a high fall risk related to de-conditioning, cognitive deficits, and prior falls, and included interventions such as anti-rollbacks on the wheelchair, appropriate footwear, keeping a wheelchair behind the resident when ambulating, and removing the mobile bedside table from beside the bed. After a fall in which the resident was found on the floor by the room doorway with the mobile bedside table in the hallway next to him, the resident stated he had been using the table as a walker. Despite the care plan and post-fall assessment identifying removal of the mobile bedside table as an intervention, observations showed the movable bedside table still placed alongside the bed on multiple occasions, including when staff were present in the room. Staff interviews confirmed they were unaware of the current fall prevention interventions, acknowledged the table was movable, and stated it remained at the bedside to facilitate meals. The DON confirmed the table had been at the bedside and was removed only after the surveyor discussed it with staff.
Failure to Provide Ordered Nursing Rehab Services
Penalty
Summary
The facility failed to provide nursing rehab services as ordered for one resident with intact cognition, left-sided hemiplegia, hypertension, and diabetes. The resident’s care plan directed staff to follow the nursing rehab program, and discharge and rehab follow-up recommendations identified a maintenance program that included self-range of motion, passive range of motion, stretching, and use of a seven-pound dumbbell or power web flex gripper three times a week to maintain strength and ROM in the left upper and lower extremities. Documentation showed the ordered restorative program was not completed as scheduled. The survey review found repeated gaps in both the dumbbell/gripper exercises and ROM program across February, March, April, May, June, and July 2026, with multiple weeks showing fewer than three completed sessions and some weeks showing no ROM completion at all. The resident stated the restorative nursing aide came to work on his arms, but the resident believed the exercises were occurring only once a week even though they were ordered more often. Interviews showed the restorative program was not consistently covered when the restorative nursing aide was unavailable. The restorative nursing aide stated she was the only restorative aide, was responsible for the whole building, and could not always see all residents each day because of appointments, activities, or residents staying in bed. She was unsure who covered restorative when she was off. The RN clinical coordinator was unaware who completed restorative programs when the restorative aide could not see all residents, and the DON stated that when the restorative aide was not working, the programs were supposed to be triggered for nursing assistants to complete. The DON reviewed the documentation and confirmed the restorative programs were not being done as ordered for the resident.
Failure to Perform Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to ensure infection prevention practices, including hand hygiene, were followed during wound care for a resident with a stage 4 coccyx pressure ulcer. The resident was cognitively intact and had diagnoses including diabetes mellitus, coronary artery disease, and hypertension. The resident’s assessment and care plan identified chronic pressure ulcers, diabetic foot ulcers, dependence for several activities of daily living, and a history of being noncompliant with repositioning and often refusing to get out of bed. During observation of wound care, the clinical manager RN and the ADON entered the resident’s room wearing gowns and gloves and began perineal care and wound care. The RN removed and replaced gloves multiple times while cleansing stool from the resident’s buttocks and upper thigh, but did not sanitize her hands after removing soiled gloves. The RN then gathered wound care supplies, removed the wound packing, measured the wound, and packed the pressure ulcer with new packing and applied a dressing without sanitizing hands or changing gloves before beginning the new wound packing and dressing application. During interview, the RN confirmed she had not sanitized her hands after each glove change and had not sanitized her hands or changed gloves after removing the soiled packing before applying the new wound packing and dressing. The DON stated her expectation was that staff sanitize hands every time gloves are removed and that after a wound is cleansed, staff should remove gloves, wash hands, and apply new gloves before applying new dressings. The facility policy stated hand hygiene should be performed after removing gloves, after handling clean or soiled dressings, and before moving from a contaminated body site to a clean body site during resident care.
Grievance Forms and Anonymous Filing Information Not Posted
Penalty
Summary
The facility failed to ensure grievance forms and grievance procedures were posted in prominent locations throughout the facility for residents and resident representatives to use, including the option to file anonymously. During a resident council meeting, three residents stated they were not aware of how to file a grievance. A walk-through of each unit found no grievance forms or procedures posted for residents or resident representatives to refer to. During interviews, the activity director stated residents had been told they could ask social services to help complete a grievance form, but she did not have a copy of the form and was not aware of which form to use since the facility had new owners. The licensed social worker stated her usual process was to address concerns right away and document the results in progress notes, and said residents could file a grievance with her or with the ombudsman. She also stated residents could obtain a form from her if they wanted to keep it anonymous, but the administrator later confirmed residents were not able to file a grievance anonymously. Review of the grievance log showed the last grievance form was completed in December 2025, and the facility policy stated grievance information would be posted in the facility and include the right to file grievances anonymously and the grievance official’s contact information.
Failure to Report and Assess Resident-Reported Fall From Toilet Resulting in Hip Fracture
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect when staff did not follow required fall reporting and assessment procedures after the resident fell from a toilet. The resident had multiple diagnoses including stroke, ESRD, diabetes, CVA with left-sided hemiplegia/hemiparesis, was legally blind, required assistance of two staff for transfers and toileting per the care plan, and used a wheelchair or walker for mobility. The admission MDS indicated the resident was cognitively intact, frequently incontinent, dependent for transfers, and had a prior fall history. The care plan and Kardex specified assistance of two staff for ambulation, transfers, and toileting due to left-sided weakness and fall risk. On the day of the incident, an activity assistant/nursing assistant (AA-A) reported that the resident requested to use the bathroom. AA-A stated she asked staff what level of assistance the resident required and was told he was assist of one with a transfer belt to the toilet. AA-A transferred the resident from bed to the toilet with assist of one, left him on the toilet with his call light, and reported she was told that other staff would transfer him off the toilet and back to bed while she went on break. Later, the resident reported that while sitting on the toilet he attempted to wipe himself, slid or tipped off the toilet, and fell forward onto the floor, landing on his left side. The resident, who was blind, stated that two female staff came into the room, lifted him under his arms from the floor, and put him back into bed, but he could not identify who they were. Following the fall, the resident complained of left leg and knee pain, including during a physical therapy session where the PTA documented that the resident reported a fall from the toilet while staff reported no fall had occurred. The PTA noted left lower extremity knee, hip, and intertrochanteric band area pain with all movement and that attempts at transfer training were unsuccessful due to pain, and nursing was informed of these findings. Later that day, the resident continued to complain of worsening left leg pain, and during an evening nursing assessment he yelled out in pain with repositioning, with swelling noted to the left hip area. The resident again reported he had fallen off the toilet earlier. Nursing review of the earlier shift report showed that the resident had reported tipping off the toilet, but staff stated they had not witnessed a fall. The facility’s own fall communication policy required that all fall events, including resident-reported or suspected falls, be reported immediately to a nurse for prompt assessment, and that staff must never fail to notify the nurse if they are aware a fall occurred. Despite the resident’s report of a fall and subsequent pain, the fall was not promptly reported or assessed at the time it occurred, and the resident was moved from the floor back to bed without a nursing assessment, leading to delayed identification of a left hip fracture that required emergency evaluation and surgical repair. Interviews with multiple nursing assistants revealed inconsistent accounts and denials of witnessing or assisting with the fall, even though the resident and his family member consistently reported that he fell from the toilet and was assisted from the floor by two staff. One NA reported receiving a social media message instructing her to "stick to the story" about the fall and that another NA had put the resident back into bed, though the message disappeared and could not be produced. Another NA acknowledged getting the resident up earlier in the day and later sending a message asking if anyone had called about the fall, but denied assisting him from the floor. The LPN on duty stated that when she was informed the resident wanted Tylenol and went to his room, the resident told her he had fallen from the toilet, but after interviewing the NAs, none admitted seeing a fall, and the nurse thought the resident was confused and simply passed the information to the next shift at the end of her shift. The facility’s investigation concluded that the resident had been transferred to the toilet by one employee despite a care plan requiring assistance of two, that the resident fell from the toilet, and that he was moved back into bed without assessment, constituting neglect as defined by regulation.
Failure to Ensure Functioning Wander Alert System
Penalty
Summary
The facility failed to develop and implement a process to ensure the wander alert system was functioning properly, affecting two residents who utilized wander alert devices. One resident, who had diagnoses including vascular dementia, Alzheimer's disease, and bilateral below-the-knee amputations, was identified as high risk for elopement and wore wander alert bracelets on both the left wrist and wheelchair. Despite these precautions, the resident was able to exit the facility on two separate occasions. In one incident, the wander guard did not work, allowing the resident to leave through the front entrance doors, which had not locked after being recently opened. In another incident, the resident was found outside in a culvert with the wheelchair on top of him after pushing and holding the exit door long enough for the emergency release to activate, despite wearing the wander alert device. Interviews with staff revealed ongoing issues with the door locking mechanism. Nursing assistants and an LPN reported that the doors would alarm when the resident was near but did not physically lock, and this issue had been occurring for several weeks. Staff stated that the malfunction had been reported to management, but the problem persisted. The administrator confirmed that the facility had been without a maintenance director for about two weeks and had relied on maintenance staff from another facility to inspect the doors. However, the inspections did not identify or resolve the underlying issue with the wander alert system and door locks. Further review of the facility's testing procedures and manufacturer recommendations indicated that the required weekly testing of the wander alert system was not being conducted as specified. The former maintenance director admitted to not testing whether the doors would unlock if a wander alert device was near and was unsure who to contact for technical issues. The regional director of operations and other staff used a handheld remote to test the doors, but this did not replicate the actual conditions under which the system failed. Documentation and interviews confirmed that the process for ensuring the wander alert system's functionality was inadequate, leading to repeated failures to prevent elopement.
Visible Uncovered Catheter Bag Compromised Resident Dignity
Penalty
Summary
The facility failed to maintain resident dignity for one resident who had severe cognitive impairment, required assistance with activities of daily living, and had diagnoses of non-Alzheimer's dementia, weakness, and localized edema. The resident also had an indwelling external catheter. During multiple observations, the resident's urinary catheter drainage bag was hanging on the left side of the bed and was visible to residents and staff who walked past. The bag was observed partially filled with dark amber liquid on several occasions, and it was not covered. During interviews, a nursing assistant stated that a resident with a catheter bag should always have it covered so others could not see it, and confirmed the resident's bag was not covered and was visible. A TMA stated the drainage bag should be covered at all times for dignity. An RN stated the bag should be hung on the more private side and always covered with a catheter cover bag to respect privacy and dignity. An LPN stated the bag should be covered so no one could see it for privacy. The DON stated staff would be expected to place and cover the urinary catheter drainage bag so it was not visible, and confirmed she had noticed the bag not covered and visible from the hallway earlier in the week. The facility's dignity policy stated residents shall be treated with dignity and respect at all times and that staff shall help residents keep urinary catheter bags covered.
Failure to Inform Resident Before Removing Bird Feeders
Penalty
Summary
The facility failed to inform a cognitively intact resident that all bird feeders, including personally owned bird feeders, were being removed before the removal occurred. The resident had diagnoses of Parkinson's disease, cerebral palsy, major depression with moderate recurrence, and anxiety disorder, and his assessments showed he was cognitively intact with mild depressive symptoms. His care plan documented mood and psychosocial concerns, including that he loved cats, found comfort socializing with the household cat, and had personal preferences that were important to him. During interview, the resident and a family member stated the resident was upset that his window bird feeders had been taken down. The resident said he had fed birds all his life and had built a bird feeder out of a bird cage so black birds and squirrels could not get into the food meant for song birds. The family member stated bird watching helped with the resident's anxiety and depression and was something he took pride in. The resident said he noticed the bird feeders were missing after returning from an outing, and staff told him corporate had directed the facility to remove all bird feeders, including resident-owned ones, based on a pest control recommendation. The administrator stated she requested maintenance remove all bird feeders and did not think about informing residents, believing the feeders were facility owned.
Failure to Complete Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to complete and implement a baseline care plan within 48 hours of admission for one resident, R22. R22’s quarterly MDS identified moderate cognitive impairment and the need for assistance with all ADLs. R22’s diagnoses included type II diabetes mellitus with diabetic chronic kidney disease, heart failure, hypertension, hemiplegia, malnutrition, depression, dependence on renal dialysis, and hypothyroidism. The MDS also indicated that R22 received dialysis services and was on a therapeutic diet. R22’s EHR showed admission to the facility in 12/2024, but there was no evidence that a baseline care plan had been initiated within 48 hours of admission. The EHR showed the baseline care plan was developed on 12/26/24 and identified that R22 was dependent on staff for transfers, toileting, and grooming/bathing. During interview, the DON stated baseline care plans should be completed within 48 hours of admission and confirmed that this did not occur for R22. An RN-A stated baseline care plans are important for resident safety and to inform staff how to care for the resident. The facility’s baseline care plan policy stated that the facility would develop and implement a baseline care plan for each resident within 48 hours of admission.
Unsafe Use of Wheeled Walker as a Wheelchair
Penalty
Summary
The facility failed to ensure a wheeled walker was not used as a wheelchair for one resident who was cognitively intact, independent with cares, and identified in the care plan as up ad lib, ambulatory, and a slow and steady transfer with a four-wheeled walker. The resident’s care plan also identified the resident as at risk for falls related to decreased functional strength, decreased activity tolerance, and impaired standing balance. On observation, the resident was seen sitting on the four-wheeled walker and using the feet to propel it backward, and the two wheeled legs were observed to be bowed outward from the walker. No wheelchair was observed in the resident’s room. The resident was later observed entering the building while sitting on the four-wheeled walker and propelling it backward with the feet. The resident stated no facility staff had spoken with him about the risks of using the wheeled walker as a wheelchair and stated he did not have a wheelchair. The resident also reported a prior fall before admission when propelling the walker backward down a sidewalk, causing the walker to hit a bump and flip out from under him, resulting in his head hitting the sidewalk. Nursing staff stated the resident normally used the walker as a seat and propelled backward, and that he had been told the wheels were flared out due to weight and was not safe to use. The RN stated the resident had been informed that sitting on the walker while propelled backward was not safe, but continued to use it that way. The DON stated the walker could roll away or collapse and that anyone using a walker inappropriately was at increased risk for a fall, and also stated there was no risk/benefit documentation in the resident’s record and no therapy referral for a proper and safe mobility device.
Dialysis Communication and Fistula Monitoring Not Completed
Penalty
Summary
The facility failed to ensure coordination of dialysis care and failed to complete post-dialysis assessment and monitoring for 2 residents who required hemodialysis. One resident had diagnoses including heart failure, hypertension, renal failure, diabetes mellitus, malnutrition, chronic obstructive pulmonary disorder, dependence on renal dialysis, and an acquired absence of the right leg below the knee. The other resident had diagnoses including type II diabetes mellitus with diabetic chronic kidney disease, heart failure, hypertension, hemiplegia, malnutrition, depression, dependence on renal dialysis, and hypothyroidism. Both residents had provider orders for regular dialysis treatments, and both had fistulas. The facility’s electronic health record showed that the first resident went to dialysis 11 times since admission, but only 2 communication forms were sent with the resident. The second resident went to dialysis 26 times since 5/12/25, but only 10 communication forms were sent with the resident, and 8 of those forms had the facility’s top section left blank. The communication form was intended to include resident name, date of birth, code status, mental status, access site location and type, bleeding, signs of infection, medications given before dialysis, diet/fluid restriction, vital signs, new medications, changes in condition, and additional comments. Interviews with nursing staff and the DON confirmed the top portion of the form was expected to be completed and sent with the resident to the dialysis clinic. The medical records for both residents lacked documentation of monitoring of the fistula for bruit and thrill. Their MARs and TARs also lacked directions for staff to check for bruit and thrill, and lacked evidence that this monitoring was completed. During interviews, nursing staff stated they expected fistula monitoring for bruit and thrill, and one nurse stated she checked for it but did not document it because it was not on the MAR/TAR. The DON confirmed the documentation regarding dialysis had been lacking, that the communication forms were important for communication with the dialysis clinic, and that there was no monitoring for bruit and thrill in place for either resident even though it should have been.
Failure to Complete Baseline TB Testing
Penalty
Summary
The facility failed to ensure tuberculosis (TB) testing was completed for 1 of 6 sampled residents, R68, during baseline TB screening. The CDC guidelines cited in the report directed that all residents and staff receive a baseline TB screening consisting of assessment for TB risk factors and history, assessment for current symptoms of active TB, and testing for the presence of infection with mycobacterium tuberculosis. R68’s MDS tracking record showed admission to the facility in 7/2025, and an initial baseline TB screening for signs and symptoms was completed on 7/11/25, but the electronic medical record lacked evidence of testing for the presence of TB infection. During interview on 8/5/25, the DON stated all new residents were screened for TB and would receive the first step TST upon admission or within 72 hours of admission. The DON stated the TST must be read 48 to 72 hours after administration and that the second step occurs seven to 21 days after step one to verify TB status. The DON confirmed R68 did not receive the first TST before being re-hospitalized on [DATE]. The facility’s 2025 Tuberculosis screening policy stated new admissions or re-admissions would be screened for TB infection in compliance with state regulations, including first-step TST within 72 hours of admission and reading within 48 to 72 hours, followed by a second TST one to three weeks later if the first step was negative.
Missing and Improperly Posted Nursing Staff Schedule
Penalty
Summary
The facility failed to ensure the required nursing staff posting, including the number of nurses and nursing assistants and the hours they were scheduled, was posted and available for residents, families, and visitors. Surveyors observed the posting of Resident Rights and the facility’s survey results upon entering the facility on Monday 8/4/25 at 10:30 a.m., but did not find the required staff posting in the front entrance or in either front wing of the facility, including the LTC units [NAME] Cottage and [NAME] House. The report states this affected all 20 residents in [NAME] House, all 20 residents in [NAME] Cottage, and their families and visitors. The survey team continued to look for the posting from 8/4/25 through 8/7/25 and still could not locate it on the TCU units 100 and 200 during the initial walk-through. On 8/7/25 at 7:56 a.m., a surveyor found the staff posting on a hallway wall on 100 unit dated 8/6/25, but it was placed sideways in an acrylic frame, requiring a person to remove it or turn their head sideways to read it. During interview on 8/07/2025 at 11:17 a.m., the administrator confirmed the staff posting should be on both the TCU and LTC units and stated the posting for the LTC wings should be at the receptionist desk in the main entrance area. The administrator also stated the staff person responsible for the task was on family medical leave and the reassignment of that duty had been overlooked.
Failure to Administer PRN Medication for Weight Gain
Penalty
Summary
The facility failed to administer as-needed (PRN) medications according to a physician's order for a resident with chronic diastolic congestive heart failure. The resident, who had moderate cognitive impairment and required assistance with all activities of daily living, had a physician's order for Metolazone 5 mg to be given by mouth as needed for fluid retention or weight gain. However, the electronic health record (EHR) lacked documentation of the administration of this PRN medication on several occasions when the resident's weight increased significantly overnight. The resident's weight documentation indicated multiple instances of weight gain exceeding the parameters set by the physician's order, yet the PRN medication was not administered. Interviews with facility staff, including a licensed practical nurse (LPN), a registered nurse care coordinator (RN), and the director of nursing (DON), revealed a lack of awareness and communication regarding the PRN order linked to the resident's daily weight task. The RN care coordinator acknowledged that the PRN order was not linked to the daily weight task, which should have prompted the nursing staff to administer the medication. The director of nursing confirmed that the PRN medication should have been administered with the increased weight gain, emphasizing the importance of following physician's orders for the management of the resident's congestive heart failure. The consultant pharmacist also stated that the medication should have been administered according to the provider's order. The facility's Medication Guidelines policy indicated that medications should be administered accurately and in a timely manner by qualified personnel, but this was not adhered to in this case.
Failure to Perform Hand Hygiene After Resident Care
Penalty
Summary
The facility failed to perform proper hand hygiene after high-contact direct care for a resident, identified as R114, who was on contact enteric precautions due to a Clostridium difficile (C. Diff.) infection. R114 had a history of end-stage renal disease, diabetes, pressure ulcers, and had recently been hospitalized for diabetic ketoacidosis and inflammation of the colon caused by C. Diff. The resident was frequently bowel incontinent, deconditioned, and dependent on staff for transfers and mobility. A sign indicating the need for transmission-based precautions was placed outside R114's room, instructing staff to wash hands or use hand sanitizer, don gown and gloves before entry, and wash hands upon leaving the room. During an observation, a nursing assistant (NA-A) failed to wash or sanitize her hands after assisting with R114's transfer and proceeded to handle a meal tray without performing hand hygiene. NA-A acknowledged the oversight during an interview, stating she was unaware of the specific precautions required for R114. The Director of Nursing (DON) confirmed that R114 was on contact enteric precautions due to C. Diff. and emphasized the importance of handwashing with soap and water, as hand sanitizer does not kill the C. Diff. organism. The facility's hand hygiene policy, dated January 2023, required washing hands with soap and water after contact with residents with infectious diarrhea, including C. Diff.
Failure to Offer Pneumococcal Vaccination
Penalty
Summary
The facility failed to ensure that a resident, identified as R55, was offered and/or provided the pneumococcal vaccination series as recommended by the CDC. R55, who had moderately impaired cognition and diagnoses of hypertension, peripheral vascular disease, and diabetes, was [AGE] years old. The resident's immunization record indicated that they had received a PPSV23 on 7/13/2017 and a PCV13 on 4/20/16. However, there was no evidence of shared clinical decision-making with the physician for a PCV20 at least five years after the last pneumococcal dose, nor was there evidence that R55 or their representative was offered or received a PCV20. During an interview, the DON, who also serves as the infection preventionist, confirmed that immunizations are verified upon admission through MIIC and resident medical records. The DON stated that residents and/or their representatives would be offered and educated on the risk/benefit of the PCV20, and consents are obtained if eligible. The DON also mentioned that the facility follows policies based on CDC recommendations for immunization guidelines. Despite these procedures, the DON verified that R55 had not been offered or provided education on PCV20, indicating a lapse in following the facility's policy on pneumococcal immunization.
Failure to Educate and Administer COVID-19 Booster
Penalty
Summary
The facility failed to ensure proper education and administration of the COVID-19 booster vaccination for one resident, identified as R55, who was reviewed for COVID-19 vaccination status. According to the report, R55 had moderately impaired cognition and diagnoses of hypertension, peripheral vascular disease, and diabetes. The resident's electronic medical record indicated that the last COVID-19 booster was administered on March 15, 2023. However, there was no documentation of any additional booster vaccination or evidence of education regarding the benefits and potential side effects of the booster. Furthermore, there was no indication of any contraindication to the COVID-19 vaccination in R55's records. During an interview, the Director of Nursing (DON), who also serves as the infection preventionist, acknowledged that the process of verifying immunizations and offering education on the COVID-19 booster was missed for R55. The DON explained that immunizations are typically verified upon admission through the Minnesota Immunization Information Connection and resident medical records. The facility's policy, dated October 2023, states that COVID-19 vaccinations should be offered to all staff and residents unless medically contraindicated or if the individual has already received all recommended doses. The DON admitted that the facility's process, which involves collaboration with the facility pharmacy and resident providers, was not followed in this instance.
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What surveyors actually found near you
We read the 54 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Willmar
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bethesda | 1.7 mi | ★★★★★ | 14 | 0 |
| Glenoaks Senior Living Campus | 14.6 mi | ★★★★★ | 14 | 0 |
| Clara City Care Center | 18 mi | ★★★★★ | 9 | 1 |
| Olivia Restorative Care Center | 23.1 mi | ★★★★★ | 1 | 0 |
| Belgrade Nursing Home | 23.5 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.