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 Divine Providence Community Home during CMS and state inspections, most recent first.
QAPI minutes showed repeated reporting of falls, infections, medication errors, VA reports, and pharmacy concerns, but the committee did not document benchmarks, goals, or analysis for most areas. Social services, DON, pharmacy, and other departments presented data across multiple quarters, yet issues such as missing money, resident altercations, inappropriate touching, high fall counts, infection trends, and medication storage/count concerns were not shown to have been thoroughly analyzed or overseen. Only limited PIP discussion was documented, and the administrator agreed the minutes lacked the needed oversight and analysis.
The facility failed to use a consistent employee surveillance and RTW process based on national standards for staff with illness symptoms. A nurse aide, another nurse aide, and a TMA were allowed to return to work without documented screening for fever, symptom improvement, or other criteria tied to CDC or State guidance, and the administrator stated staff were not being vetted before RTW.
Failure to attempt GDRs for 2 residents receiving psychotropic meds. One resident with severely impaired cognition, psychosis, depression, restlessness, and agitation remained on Zoloft and Ativan with repeated provider continuation requests, but no documented GDR attempt or psychotropic review recommendation. Another resident with moderate cognitive impairment, dementia, depression, restlessness, and agitation received sertraline and Seroquel, yet records showed no GDR attempt within the first 6 months of admission and staff/pharmacy did not identify the need for one.
A resident receiving Xarelto for atrial fibrillation had a care plan that addressed falls, weakness, confusion, and mobility needs, but it did not identify increased bleeding risk or include bleeding precautions. RN and admin interviews confirmed the omission, and the facility had no anticoagulation monitoring policy provided by the end of survey.
Failure to update a resident’s care plan after repeated falls. A resident with severe cognitive impairment, dementia, incontinence, and multiple comorbidities had two unwitnessed falls, including one with a laceration and one with a pelvic fracture. Although fall reports and an IDT note identified added supervision and location-based monitoring interventions, the care plan only reflected transfer/toileting assistance and alarms and did not include the newer fall interventions.
Failure to Weekly Assess and Measure a Pressure Ulcer: A resident with severe cognitive impairment, dementia, incontinence, and an unhealed buttock pressure ulcer had an order for weekly wound measurement and dressing changes, but documentation showed multiple missed or undocumented weekly measurements over several months. Wound notes were inconsistent, and during observation the RN described and measured the wound as a small open area/stage 2 lesion with pink tissue and surrounding dark discoloration. The RN and administrator confirmed the expectation for weekly wound assessment and measurement until healed.
QA committee failed to receive infection preventionist reports on employee surveillance for 4 of 4 quarters reviewed. QAPI minutes showed resident infection counts were discussed, but there was no documentation of employee surveillance review, benchmarks, goals, or data analysis. The administrator acknowledged there was no evidence the IP brought employee surveillance to QAPI for oversight, despite the QAPI plan and infection control policy calling for committee review of infection-related data.
A resident with multiple chronic conditions did not receive the recommended walking program due to staff unavailability, despite a care plan and therapy referral indicating the need for daily walks. Observations and interviews revealed inconsistencies in the implementation of the walking program, with several days showing no walks documented in the EHR.
The facility failed to monitor oxygen administration for two residents, leading to empty oxygen tanks while they were in the dining room. One resident with congestive heart failure and another with COPD were affected. Staff acknowledged the oversight, and the facility's policy lacked guidance on periodic oxygen level checks.
A resident with multiple diagnoses and limited mobility was injured when staff used a toileting sling instead of the prescribed full body sling for a transfer. This resulted in significant pain, bruising, and a humeral fracture. The facility's policy required adherence to care plans, which was not followed in this case.
QAPI Minutes Lacked Analysis and Oversight of Facility Data
Penalty
Summary
The facility failed to ensure that data submitted to the QAPI committee for four quarters was analyzed and documented with oversight of the outcomes identified. Review of QAPI meeting minutes showed that multiple departments attended various meetings, but the documentation largely listed counts and brief comments without showing benchmarks, goals, analysis, or evidence that the committee reviewed whether identified issues were being monitored appropriately. The administrator stated that the DON documented the QAPI minutes and agreed there was a need for all data to include benchmarks, goals, actions, interventions, and analysis of how well plans worked. In the first quarter reviewed, QAPI minutes included falls, infections, medication errors, elopements, skin tears, bruises, abrasions, admissions, discharges, social services concerns, ethics concerns, and pharmacy review. Social services documented five VA reports submitted to MDH and law enforcement, including missing money, residents slapping one another, and an inappropriate touching allegation, but there was no evidence of what was investigated, whether investigations were timely, or whether all relevant staff and residents were interviewed. The minutes also noted bowel incontinence and medication error reduction as PIP projects, but there was no indication of comprehensive QAPI review of benchmarks, goals, or IDT data, and no evidence that employee surveillance was reviewed. In the second and third quarters, the minutes again listed falls, infections, skin tears, bruises, medication errors, elopements, discharges, and pharmacy concerns, but there was no documentation of analysis or oversight. Falls increased to 46 in one quarter and later remained high, yet the committee did not document a comprehensive review of each resident’s falls, benchmarks, goals, or analysis of IDT findings. Infection data was reviewed, but there were no benchmarks, goals, or documented analysis, and employee surveillance was not reviewed. Pharmacy documentation noted concerns such as no open or expiration dates on insulin, expired medications, missing narcotic signatures, an unlocked cart, and controlled drug count issues, but these concerns were not brought forward in the QAPI discussion as issues requiring analysis. In the fourth quarter, QAPI minutes showed more detailed discussion for a UTI PIP and a walking PIP, including root cause analysis, barriers, education, and estimated completion dates. However, falls, infections, and medication errors were still only summarized by numbers, with no documented benchmarks, goals, or analysis for those areas. The committee also did not document review of employee surveillance or other departments such as dietary, maintenance, or activities. Survey findings also identified that one resident’s care plan was not revised after new fall interventions were identified, and the administrator agreed the QAPI committee needed more information to show that topics discussed were monitored appropriately and that oversight was documented.
Employee Surveillance and Return-to-Work Screening Failure
Penalty
Summary
The facility failed to have a system for employee surveillance based on national standards or to identify specific criteria used to determine staff return to work (RTW) for 3 of 5 sampled staff: a nurse aide, another nurse aide, and a trained medication aide. During interview and document review, the interim infection preventionist stated that when staff called in sick, the only RTW process was that any absence of 3 days or longer required a physician RTW note. There was no evidence that staff were being screened against national or State guidelines before returning to work, and the administrator stated the facility was unaware that employees needed to be vetted prior to RTW to ensure they were appropriate to return and not potentially expose residents or other staff to infectious disease. The sampled staff records showed inconsistent and undocumented RTW decisions. One nurse aide called in ill multiple times for vomiting and was allowed to return the next day; the cause of illness was later found to be pregnancy, but that was unknown at the time. Another nurse aide called in with sore throat and runny nose and returned the next day, with no documentation of fever status and no evidence she had been cleared for possible respiratory infectious disease under CDC guidance. A trained medication aide left work with RSV, had a physician RTW clearance date, then called in again with continued RSV symptoms and returned to work the next day, with no evidence she had been fever free or had improved symptoms for 24 hours before returning. The facility policy required staff to report symptoms such as vomiting, diarrhea, cough, runny nose, chills, fatigue, temperature, and sore throat, and stated staff could return once temperature was normal for 24 hours without fever-reducing drugs and other symptoms were absent, depending on the infection; however, the policy did not show that national standards or State guidelines were being used for RTW decisions.
Failure to Attempt GDRs for Residents Receiving Psychotropic Medications
Penalty
Summary
The facility failed to ensure gradual dose reductions (GDRs) were attempted for 2 of 5 sampled residents receiving psychotropic medications. For one resident, the quarterly MDS showed severely impaired cognition, fluctuating inattention, and scheduled pain, antianxiety, and antidepressant medications. Her diagnoses included unspecified psychosis, depression, restlessness, and agitation, and she had a physician order for Zoloft 25 mg daily for depression. The facility’s records showed repeated faxed requests to the provider asking only whether the resident should continue Zoloft and Ativan, with responses indicating the resident was stable and the medications should continue, but no documented GDR attempt was identified. The resident’s pharmacy reviews for multiple months did not mention psychoactive medication review or a GDR recommendation. Her care plan addressed anxiety, anger, sadness, confusion, forgetfulness, and depression, with staff interventions focused on reorientation, choices, and relaxation techniques. During interview, the administrator stated she would expect the regulations to be followed and GDRs to be attempted as required. For the second resident, the comprehensive MDS showed moderate cognitive impairment, a PHQ-9 score of 1, and diagnoses of depression, restlessness and agitation, and unspecified dementia without behavioral or psychotic disturbance. She was receiving sertraline and Seroquel. Pharmacy reviews noted medication issues at times, including a recommendation to discontinue a PRN Seroquel dose, but there was no indication that a GDR was recommended within the first 6 months of admission. Nursing and pharmacy staff stated they understood medication continuation reviews were being done, but they did not identify that GDRs were due or being discussed.
Care Plan Missing Bleeding Precautions for Resident on Xarelto
Penalty
Summary
The facility failed to ensure the care plan was appropriately developed for a resident who received anticoagulant therapy. The resident’s comprehensive MDS assessment, accepted on 9/11/25, identified that she was admitted in August 2025 and had moderate cognitive impairment, diagnoses of heart disease, cardiovascular and coagulation treatment, atrial fibrillation, and a history of heart attack. She required staff assistance with ADLs including bathing, dressing, and toileting, and used a walker, wheelchair, and cane or crutch for mobility. Her current MAR showed she received Xarelto 15 mg daily for atrial fibrillation, and her care plan addressed fall risk, weakness, fatigue, dementia, confusion, muscle weakness, and unsteadiness with a goal to stay safe while moving about and transferring. The care plan did not mention that the resident was at increased risk of bleeding and did not include bleeding precautions. During interview and care plan review on 4/15/26, RN-A agreed there were no bleeding precautions listed to alert staff what to monitor for since the resident was on an anticoagulant and stated they probably had not thought of that. The administrator also stated she was unaware the resident’s care plan did not include bleeding precautions and was unaware whether any residents on anticoagulants had interventions related to their high bleeding risk. The report also noted there was no policy related to anticoagulation monitoring provided by the end of survey.
Failure to Update Care Plan After Repeated Falls
Penalty
Summary
The facility failed to revise the care plan for a resident with severely impaired cognition, substantial ADL dependence, bowel and bladder incontinence, and a history of falls. The resident’s accepted admission MDS identified delirium, inattention, disorganized thinking, and altered mental status that fluctuated. She also had diagnoses including dementia with psychotic disturbance, anxiety, cardiac arrhythmia, hypertension, depression, osteoporosis, weakness, and malnutrition, and she was receiving multiple medications including scheduled pain, antipsychotic, antianxiety, antidepressant, diuretic, opioid, and antibiotic therapy, along with OT and PT. The resident had two falls after admission, including one unwitnessed fall in her room and another unwitnessed fall in the living room that resulted in a laceration near her eye and a fractured pelvis. The fall reports and IDT note identified interventions such as alarms and increased supervision in the dining and living room areas, but the resident’s undated care plan only reflected assistance with transfers and toileting, inability to understand instructions, a wander guard, and bed and chair sensor alarms. The care plan did not include the additional fall-related interventions identified after the second fall, and the RN confirmed the care plan had not been updated after the fall that resulted in the pelvic fracture.
Failure to Weekly Assess and Measure a Pressure Ulcer
Penalty
Summary
The facility failed to weekly assess and measure a pressure ulcer for one sampled resident with severe cognitive impairment, partial assistance needs for ADLs, dementia with anxiety, panic disorder, major depressive disorder, legal blindness, osteoarthritis, mixed urinary incontinence, and a history of skin and subcutaneous tissue disorder of the right buttock. The resident had an unhealed pressure ulcer that was not present on admission, along with moisture associated skin damage, and had pressure-relieving devices on the bed and in the wheelchair. The care plan directed staff to assist with reducing pressure and friction, keep the resident clean and dry, use barrier cream on red or previous problem areas, and have the wound assessed and measured weekly. The treatment record showed an order to measure the right buttock open area weekly on Mondays until healed, and to apply an Allevyn dressing every 3 days until healed. Review of February, March, and April documentation showed multiple Mondays were charted as held and not performed, one Monday had no documentation of measurement completion or noncompletion, and only two weekly measurements were documented during that period. The wound notes also showed inconsistent descriptions of the area, including intact dressings on several dates, open areas on others, and a note that the left buttock was observed on one date without documented concern. During observation, the wound was described by the RN as a small open area with a pink wound bed, while the RN measured it and identified it as stage 2. The wound assessment on that date documented the right buttock wound as stage 2 with pink tissue and surrounding dark discolored tissue, measuring 1 cm by 0.7 cm, and an Allevyn dressing was applied. The RN confirmed that the wound should have been assessed and measured every Monday until healed, and the administrator stated licensed nurses were expected to follow the facility policy requiring weekly evaluation, measurement, and documentation of wound characteristics.
QA Committee Failed to Review Employee Surveillance Data
Penalty
Summary
The Quality Assurance (QA) committee failed to receive reports from the infection preventionist regarding employee surveillance for 4 of 4 quarters reviewed. Review of the QAPI meeting minutes for Quarter 1, Quarter 2, Quarter 3, and Quarter 4 showed discussion of resident infection data, including totals for UTIs, skin infections, and respiratory infections, but there was no indication that employee surveillance was reviewed or discussed in any quarter. The minutes also did not show benchmarks, goals, or analysis of the infection data, and Quarter 4 minutes documented only that resident infections were discussed in numbers without data review or analysis. During interview on 4/15/26 at 3:45 p.m., the administrator stated she was in charge of PIP and the DON was in charge of the rest of the QAPI discussion and documentation. The administrator agreed there was no evidence that the infection preventionist had brought employee surveillance to QAPI for oversight. Review of the February 2026 QAPI plan stated the committee would make quality improvement decisions based on data analysis and include representatives from all departments, and review of the January 2026 Infection Control Coordinator policy stated the infection control coordinator was to report compliance information to the Administrator and QA committee and maintain infection logs for staff and residents.
Failure to Implement Resident Walking Program
Penalty
Summary
The facility failed to provide a walking program to meet the assessed needs of a resident with chronic obstructive pulmonary disease, type two diabetes mellitus, chronic kidney disease, and heart failure. The resident's quarterly Minimum Data Set (MDS) assessment indicated the use of a walker, wheelchair, and limb prosthesis, with partial assistance required for various activities. Despite a care plan indicating the resident should walk with setup assistance and a therapy referral recommending a walking program three times daily, the resident reported not walking as much as desired due to staff unavailability. Observations and interviews revealed inconsistencies in the implementation of the walking program. Nursing assistants stated that both restorative nursing assistants and nursing assistants were responsible for walking residents, with completed walks documented in the electronic health record (EHR). However, a review of the EHR showed that the resident did not walk three times daily as recommended, with several days showing no walks at all. The director of nursing acknowledged the importance of walking to maintain the resident's function but noted that the walks were not completed as recommended.
Oxygen Administration Monitoring Deficiency
Penalty
Summary
The facility failed to ensure proper monitoring of oxygen administration for two residents, leading to deficiencies in care. One resident, diagnosed with multiple fractured ribs and congestive heart failure, required continuous oxygen therapy. However, during an observation, it was found that the resident's oxygen tank was empty while she was in the dining room. The LPN present acknowledged the empty tank and replaced it. The nursing assistant admitted to noticing the low oxygen level earlier but forgot to address it after the resident decided to eat in the dining room. The resident's care plan did not include oxygen therapy, which contributed to the oversight. Another resident, diagnosed with chronic obstructive pulmonary disease, was observed with an empty oxygen tank while seated in the dining room. The LPN verified the tank was empty and replaced it. The resident did not feel short of breath during the meal, as she was not exerting herself. The facility's policy on oxygen concentrators and cylinders did not include periodic checks of the oxygen level in tanks, which may have contributed to the oversight. The director of nursing stated that staff usually changed out portable oxygen tanks in the morning if needed, but the responsibility to check the oxygen level was on the staff member accompanying the resident.
Inappropriate Use of Mechanical Lift Sling Results in Resident Injury
Penalty
Summary
The facility failed to use the appropriate type of mechanical lift sling according to the care plan for a resident, resulting in harm. The resident, who had multiple diagnoses including osteoarthritis, chronic pain, and limited mobility, was transferred using a toileting sling instead of the prescribed full body sling. This inappropriate use of the toileting sling caused the resident significant pain, bruising, and a humeral fracture in the left arm. The care plan specifically directed staff to use a full body sling for transfers and not to use a sling that goes under the arms due to the resident's limited range of motion and shoulder issues. On the day of the incident, two nursing assistants used the toileting sling for the transfer, despite one of them questioning its appropriateness due to the difficulty in applying it and the resident's moaning during the process. The resident's increased pain and bruising were noted by various staff members over the following days, leading to an emergency department visit where a fracture was confirmed. Interviews with staff revealed that the resident had been using a full body sling for approximately 1.5 years and that the toileting sling was not suitable for her condition. The facility's policy required staff to follow care plans and caregiver worksheets for guidance on the level of assistance required by each resident. However, in this case, the staff did not adhere to the care plan, resulting in the resident's injury. The Director of Nursing and the administrator both acknowledged that the toileting sling was initially tried but found unsuitable, and it was expected that staff would follow the care plan to prevent such incidents.
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What surveyors actually found near you
We read the 54 citations issued within 25 miles in the last 12 months — 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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Nursing homes near Sleepy Eye
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sleepy Eye Rehabilitati Center | 1.4 mi | ★★★★★ | 8 | 0 |
| Gil-mor Manor | 12 mi | ★★★★★ | 3 | 0 |
| Oak Hills Living Center | 12.3 mi | ★★★★★ | 9 | 0 |
| St John Lutheran Home | 12.9 mi | ★★★★★ | 10 | 0 |
| Franklin Restorative Care Center | 16.7 mi | ★★★★★ | 13 | 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 July 2026) and official state health department websites.