Above 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 Living Meadows At Luther - Madelia during CMS and state inspections, most recent first.
Staff did not consistently monitor or document dish machine chemical sanitization and kitchen freezer/refrigerator temperatures as required by policy, with logs showing infrequent or missing entries and staff acknowledging the lack of compliance. These failures had the potential to affect all residents by not ensuring proper dishware sanitization and safe food storage.
A resident with severe cognitive impairment and high risk for pressure ulcers was not repositioned according to her care plan, remaining on one side in bed for over three hours without staff intervention. Despite documented skin issues and a facility policy requiring repositioning every two hours, staff failed to check or reposition the resident, resulting in soiled dressings and unaddressed incontinence.
A resident with significant mobility limitations and pain did not receive staff-assisted range of motion (ROM) exercises as ordered in her care plan and therapy recommendations. Despite documentation indicating ROM was completed, interviews and observations revealed that staff believed the resident could perform the exercises independently, did not routinely assist her, and failed to document refusals or actual participation, resulting in unmet assessed needs.
A resident in a long-term care facility received a hydromorphone dose ten times greater than prescribed due to an LPN's error in reading the medication label and using an incorrect syringe size. The resident became unresponsive with decreased respiratory rate and oxygen saturation, requiring Narcan administration to reverse the overdose effects. The error was discovered during a review of medication supply and refills.
Failure to Monitor Dish Machine Sanitization and Food Storage Temperatures
Penalty
Summary
The facility failed to consistently monitor and document the chemical sanitization solution and temperatures of the dish machine, as well as the temperatures of kitchen freezers and refrigerators, as required by facility policy. During a kitchen tour, it was observed that chemical monitoring logs for the dish machine were not readily accessible and, upon review, showed infrequent documentation of chemical disinfectant and temperature checks over several months. Staff interviews confirmed awareness of the requirement to monitor and document these parameters with each meal service, but could not provide explanations for the lack of compliance. The dietary manager, new to the role, was unaware of the monitoring lapses. Additionally, a kitchen freezer was found without a thermometer until one was added during the survey, and temperature logs for both the freezer and a refrigerator had not been updated since January, despite policy requiring twice-daily checks. Staff acknowledged that required temperature documentation was not being performed. These failures had the potential to affect all residents in the facility by not ensuring proper sanitization of dishware and safe food storage.
Failure to Provide Timely Repositioning for High-Risk Resident
Penalty
Summary
A resident with diagnoses including Alzheimer's disease, osteoarthritis, and spasticity was identified as being at high risk for pressure ulcers, with a Braden Scale score of 12 and a care plan specifying the need for repositioning every two hours in bed and every hour when up in a chair. The resident was dependent on staff for all mobility and transfers, incontinent of bowel and bladder, and had no current skin issues at the time of the most recent MDS assessment, but had a history of pressure injuries and ongoing skin concerns documented in provider and nursing notes. Despite the care plan and facility policy requiring regular repositioning, direct observation revealed that the resident was left on her right side in bed for over three hours without repositioning or staff entering the room to provide care. During this period, no staff checked the resident’s incontinence pad or repositioned her, and the resident remained in the same position from 8:45 a.m. until after 12:00 p.m. When staff finally entered the room, stool was found smeared onto the sacral dressing, and the wound dressing was soiled, indicating that the resident had not been checked or repositioned as required. Interviews with staff confirmed a lack of awareness regarding the resident’s repositioning schedule and failure to follow the care plan. Documentation also showed ongoing issues with skin integrity, including abrasions and pressure injuries to the sacral and buttock areas, with provider notes detailing wound measurements, drainage, and treatment changes. The facility’s repositioning policy emphasized the importance of regular repositioning for residents at risk of skin breakdown, but this was not consistently implemented for the resident in question, as evidenced by both observation and staff interviews.
Failure to Provide and Document Required Range of Motion Services
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including heart failure, peripheral neuropathy, Parkinson's disease, and osteoarthritis, did not receive range of motion (ROM) services as assessed and ordered. The resident's care plan and therapy discharge summary specified that staff should assist with active assistive range of motion (AAROM) exercises to the bilateral upper extremities twice daily during morning and evening care. Despite these documented interventions and therapy recommendations, the resident reported that staff did not assist with the exercises, and she was unable to perform them independently due to pain and limited mobility. Observations and interviews revealed that staff, including nursing assistants and a registered nurse, believed the resident could perform the exercises on her own and did not routinely assist her as required. Staff also did not document whether ROM exercises were completed or refused, contrary to facility policy. The resident consistently stated that she needed help with the exercises and that staff rarely, if ever, provided the necessary assistance, even though the exercises were posted in her room and included in her care plan. Documentation on treatment records indicated that ROM was completed almost every time, but interviews with staff and the resident contradicted this, suggesting that documentation may not have reflected actual care provided. The facility's policy required staff to review care plans, provide gentle assistance, and document all aspects of ROM care, including refusals and resident participation, but these procedures were not followed, resulting in a failure to provide care according to the resident's assessed needs.
Significant Medication Error with Hydromorphone Administration
Penalty
Summary
The facility failed to ensure that hydromorphone was administered as prescribed, resulting in a significant medication error for a resident. The resident, who was cognitively intact and receiving palliative care, was prescribed a dose of 0.25 ml of hydromorphone for pain management. However, on the morning of the incident, an LPN administered a dose ten times greater than prescribed, giving 2.5 ml instead of 0.25 ml. This error led to the resident becoming unresponsive, with decreased respiratory rate and oxygen saturation levels. The error was discovered when the hospice RN and the LPN reviewed the medication supply and refills, realizing that the wrong dose had been administered. The resident exhibited symptoms of opioid overdose, including glossy eyes, very little responsiveness, and cyanotic lips. The hospice RN contacted the nurse practitioner, who ordered Narcan to reverse the effects of the overdose. The resident received two doses of Narcan, which eventually restored alertness and responsiveness. The LPN involved in the incident admitted to misreading the medication label and using an incorrect syringe size, which contributed to the error. The facility's policies on medication administration were not followed, as the LPN failed to verify the correct dosage and used a 3 ml syringe instead of the expected 1 ml syringe. This oversight led to the administration of a significantly higher dose of hydromorphone than prescribed, resulting in immediate jeopardy for the resident.
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Illustrative
What surveyors actually found near you
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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 Madelia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan Society - St James | 11.6 mi | ★★★★★ | 0 | 0 |
| Truman Senior Living | 14.9 mi | ★★★★★ | 13 | 0 |
| Oak Hills Living Center | 18.9 mi | ★★★★★ | 9 | 0 |
| Hillcrest Care & Rehabilitation Center | 20 mi | ★★★★★ | 5 | 0 |
| Pathstone Living | 21 mi | ★★★★★ | 25 | 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.