Below average — CMS composite of the measures below.
The next survey window likely opens around April 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 Lb Broen Home during CMS and state inspections, most recent first.
A resident who needed assist of one for ambulation and used O2 walked out alone to the pond area and sat in direct sun in 95-degree weather without water or a way to call for help. Staff saw him outside but did not physically check on him until he was found slumped over and unresponsive, with an empty O2 tank and severe hyperthermia. EMS and hospital records documented heat stroke, tachycardia, tachypnea, pneumonia, and acute kidney injury. Interviews showed staff were unclear about who was responsible for monitoring residents outside and there was no sign-out or tracking system for residents going to the pond.
Failure to preserve dignity occurred when staff placed a brief on a cognitively intact resident who was continent of bowel and bladder. The resident stated the brief made him feel like a baby, and a NA confirmed she applied it even though he was not incontinent; RN and DON both verified the resident was continent and that briefs should not be placed on continent residents.
The facility failed to implement proper infection control measures, as staff did not consistently use PPE or perform hand hygiene. Observations showed staff not wearing gowns and gloves for residents on enhanced barrier precautions and not sanitizing equipment between uses. An LPN administered medications without hand hygiene, contrary to facility policies. These lapses were confirmed by staff interviews, highlighting a breach in infection prevention protocols.
Failure to Supervise Resident Outside in Extreme Heat
Penalty
Summary
The facility failed to provide adequate supervision to a resident who required assistance with ambulation and used oxygen, while he was outside in extreme heat without protection. The resident had diagnoses including CHF, atrial fibrillation, HTN, renal insufficiency, insulin-dependent DM, asthma, macular degeneration, muscle weakness, and COPD, and his records showed he needed assistance of one staff with transfers and ambulation, prompt response to requests for assistance, and oxygen therapy. His care plan also directed staff to ensure he had access to cold water whenever possible and to provide a wheelchair if he required continuous oxygen use or had increased weakness. On the day of the incident, the resident told staff he was going outside and then walked out of the building alone with his walker and oxygen tank. He went to the pond area behind the facility, where he sat in direct sunlight in 95-degree weather wearing long sleeves and pants, with no water and no way to contact staff for help. Staff later reported seeing him outside but did not physically check on him, and no official checks were documented until he was found slumped over in a chair and unresponsive. When staff and EMS reached him, he was extremely hot and red in color, his oxygen was not properly applied, and his oxygen tank was empty. The resident was evaluated by EMS and transferred to the hospital with a temperature of 105.8 F, tachycardia, and tachypnea. Hospital records identified heat stroke, hyperthermia likely related to heatstroke, left lower lobe pneumonia, acute COPD exacerbation, and acute kidney injury. Interviews showed staff were unsure who was responsible for supervising residents outside, residents were not required to sign out when leaving, and there was no clear system in place to know when residents went to the pond area or to ensure they were checked while outside. The DON stated she was unaware of a facility policy or protocol addressing staff responsibility when a resident wanted to go outside independently.
Failure to Preserve Dignity by Placing a Brief on a Continent Resident
Penalty
Summary
The facility failed to provide services in a dignified manner for 1 resident who was cognitively intact and had diagnoses including renal insufficiency, DM, and hypertension. The resident’s MDS identified him as continent of bowel and bladder and needing staff assistance with ADLs including bed mobility, transfers, and toileting. A bowel and bladder assessment also identified the resident as continent, and the care plan stated he was aware of the need to void or defecate and would request to use the toilet as needed. During interview, the resident stated staff put diapers on him even though he was not incontinent and said it made him feel like a baby. During observation, a NA placed a brief on the resident, and the resident showed the surveyor the brief and stated it had just been put on him a few minutes earlier. The NA verified she placed a brief on the resident that morning even though he was not incontinent and said she was unsure why she did so. RN-A confirmed the resident was continent and stated staff put a brief on him out of habit. The DON stated staff should not place a brief on residents who are continent and that it was important to maintain the resident’s dignity.
Inadequate Infection Control Practices in PPE Use and Hand Hygiene
Penalty
Summary
The facility failed to implement appropriate infection prevention and control measures, specifically in the use of personal protective equipment (PPE) and hand hygiene practices. Observations revealed that staff did not consistently wear gowns and gloves when providing care to residents on enhanced barrier precautions (EBP) due to multidrug-resistant organisms. For instance, a registered nurse did not wear a gown or gloves while assisting a resident with a wound positive for MRSA, despite the requirement for such precautions. Similarly, another nursing assistant failed to wear a gown while assisting a resident with a Foley catheter, and the mechanical lift used was not sanitized between resident transfers. Additionally, the facility did not ensure proper hand hygiene during medication administration. An LPN was observed administering medications to multiple residents without performing hand hygiene between resident contacts or after handling medication equipment. This lack of hand hygiene was acknowledged by the LPN, who admitted it was not her usual practice to sanitize her hands during medication passes. The facility's policies on EBP and hand hygiene were not adhered to, as evidenced by the staff's failure to wear appropriate PPE and sanitize equipment between uses. Interviews with staff, including the infection preventionist and director of nursing, confirmed the expectations for PPE use and hand hygiene, which were not met during the observed incidents. The facility's policy required shared equipment to be disinfected between residents, but this was not consistently practiced, contributing to the potential spread of infections.
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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 Fergus Falls
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pioneer Care Center | 0.3 mi | ★★★★★ | 7 | 0 |
| Mn Veterans Home-fergus Falls | 1.9 mi | ★★★★★ | 8 | 1 |
| Good Samaritan Society - Battle Lake | 16.7 mi | ★★★★★ | 1 | 0 |
| Pelican Valley Health Center | 20.3 mi | ★★★★★ | 2 | 0 |
| St Francis Home | 24.9 mi | ★★★★★ | 7 | 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.