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 October 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.
A resident with multiple diagnoses including malnutrition and hemiplegia had a care plan for fluid volume deficit and hydration problems, but it was not revised after ED visits and a hospitalization for dehydration. The record did not reflect hospital discharge instructions for hourly fluids while awake, strict I&O, and water with repositioning, and staff confirmed the care plan lacked updated fluid intake interventions.
Failure to Monitor Ordered Fluid Restriction: A resident with hyponatremia-related diagnoses and mild cognitive impairment was ordered a 1,200 mL/day fluid restriction, but nursing and dietary kept separate paper intake records without calculating a combined daily total or assessing whether the restriction was met. On several reviewed days, the documented combined intake exceeded the ordered limit, while staff were unsure whether the resident also obtained additional fluids from a water fountain or faucet. Interviews showed the resident often wanted more water, and staff acknowledged no one was reviewing the records together to monitor the restriction.
A resident with malnutrition, cognitive impairment, and a chronic Foley catheter had repeated care plan directions for fluids, dehydration monitoring, and urine assessment, but the record did not show daily fluid intake monitoring, hydration assessments, or consistent urine characterization. The resident developed dark urine, hematuria, fever, sepsis, and AKI, required ED visits and IV fluids, and later had documentation of dehydration from low water intake overnight. Intake and output records were incomplete or not analyzed to determine whether hydration was adequate.
Hand Hygiene Not Performed During Toileting Care: A resident with hemiplegia/hemiparesis, an indwelling urinary catheter, and frequent bowel incontinence required substantial to maximum assistance with toileting hygiene. During observed care, an NA donned gloves without first performing hand hygiene, handled soiled and clean brief care with the same contaminated gloves, wiped stool from the resident, and continued touching the resident, wheelchair, and gait belt without removing gloves or performing hand hygiene.
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 Update Hydration Care Plan After Hospitalization
Penalty
Summary
The facility failed to revise R1’s person-centered care plan after significant changes in condition related to hydration status and after hospital discharge instructions were received. R1’s record identified diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, obstructive and reflux uropathy, nutritional deficiency, moderate protein-calorie malnutrition, and hemiplegia/hemiparesis affecting the left non-dominant side. The nutrition assessment documented R1’s weight as 114.2 pounds, need for nectar-thick liquids, and fluid needs were not documented. The existing care plan identified potential for fluid volume deficit and hydration problems, with interventions to observe for dehydration and encourage or assist with fluids, but the record did not show revision after R1’s two ED visits and hospitalization for dehydration. R1’s ED and hospital records documented dehydration-related events and discharge instructions that included offering fluids every hour while awake, monitoring strict intake and output, offering water with every two-hour repositioning, and monitoring changes in output. The record review from 5/4/26 through 5/10/26 showed no indication that the care plan was updated to reflect these instructions. The significant change MDS identified moderate cognitive impairment and triggered dehydration/fluid maintenance, and the CAA stated R1 was at risk for dehydration due to poor intake and need for nectar fluids and that a care plan would be developed, but the care plan had not been updated. During interviews, LPN-A and LPN-B stated there were no interventions in the care plan for fluid intake after the hospital return, and the DON stated R1 should have had the care plan revised after hospitalization and when he returned to baseline.
Failure to Monitor and Assess Fluid Intake for Ordered Restriction
Penalty
Summary
The facility failed to monitor and assess a resident’s fluid intake to ensure a physician-ordered 1,200 mL/24-hour fluid restriction was implemented as prescribed. The resident had diagnoses including hypokalemia, hypo-osmolality, and hyponatremia, and the annual MDS identified mild cognitive impairment, impaired mobility, and use of a walker and wheelchair. The resident’s care plans identified a potential for fluid volume deficit and later directed staff to monitor the fluid restriction per doctor order, encourage fluid intake per order, and report changes in ability. The nutrition care plan also identified a 1,200 mL/24-hour fluid restriction with extra fluids offered between meals, during activities, in common areas, and in the room. The resident’s physician visit note identified that the resident was on a prescribed fluid restriction and the plan was to continue monitoring hydration status with a 1,200 mL/day restriction. Paper Daily Fluid Intake Tracker records from nursing and dietary were maintained separately, with handwritten instructions dividing fluids between meals, supplements, and water pitcher amounts. However, neither form identified a calculated daily fluid total or documented the total amount consumed each day from both nursing and dietary, and there was no indication the resident’s fluid intake was evaluated or assessed to ensure the 1,200 mL goal was met. On multiple reviewed dates, the combined nursing and dietary totals exceeded the ordered restriction, including totals of 1,844 mL, 1,860 mL, 1,590 mL, and 1,800 mL. Laboratory results in June showed elevated BUN values, low GFR values, low chloride on some dates, and sodium values of 135 on two occasions. During observation, the resident had a 16 oz water pitcher and 5 oz cups in the room, and staff observed that the pitcher appeared to contain more than the daily allotment. Staff interviews showed uncertainty about whether the resident obtained additional fluids from the water fountain or bathroom faucet. The resident stated staff did not give much water and that if extra water was requested, staff sometimes did not return. Nursing and dietary staff stated that dietary documented fluid intake unless the resident was on a fluid restriction, that nursing and dietary each recorded portions of the intake separately, and that no one was reviewing the nursing and dietary records together to determine the resident’s total daily intake or whether the resident met or exceeded the prescribed restriction.
Failure to Monitor Hydration and Fluid Intake
Penalty
Summary
The facility failed to assess, monitor, and implement interventions to maintain adequate hydration for a resident with nutritional deficiency, moderate protein-calorie malnutrition, hemiplegia/hemiparesis, moderate cognitive impairment, and a chronic indwelling Foley catheter. The resident’s care plans repeatedly identified risks for fluid volume deficit, dehydration, constipation, altered renal function, and urinary issues, and directed staff to encourage and assist with fluids, offer extra fluids, observe for signs and symptoms of dehydration, and report changes in condition. A nutrition assessment documented estimated calorie and protein needs, but the fluid needs section was left blank and no daily fluid requirement was documented. From 4/29/26 through 5/4/26, the record did not identify documentation of daily fluid intake, nursing assessments of whether the resident was receiving adequate hydration, or monitoring for signs and symptoms of dehydration. Although catheter output was documented each shift, the record did not consistently document urine characteristics such as color or concentration, and there was no assessment of whether the urine output was adequate in relation to intake. On 5/4/26, the resident’s Foley catheter was changed and dark urine was noted. Shortly after, the resident developed bloody urine, fever, tachycardia, and was transferred to the ED. The ED evaluated the resident for hematuria after the catheter change and found UTI, sepsis, chronic Foley catheter, and acute kidney injury. The resident received IV fluids and antibiotics and was discharged with instructions to encourage more water and monitor the catheter. After returning to the facility, the record did not identify whether the resident consumed more fluid or whether symptoms worsened. The resident later had a critical lactate level, continued hematuria, and was sent back to the ED, where dehydration from low water intake overnight was documented along with sepsis and acute kidney injury. Subsequent records showed intermittent intake and output documentation, but the facility did not total, compare, or otherwise assess the amounts to determine whether hydration was adequate, and later notes continued to identify poor oral intake, weight loss, and ongoing risk for dehydration.
Hand Hygiene Not Performed During Toileting Care
Penalty
Summary
The facility failed to complete hand hygiene for one resident during toileting care. The resident had diagnoses of hemiplegia and hemiparesis affecting the left non-dominant side, and the quarterly MDS identified a urinary indwelling catheter, frequent bowel incontinence, and the need for substantial to maximum assistance from staff for toileting hygiene. During an observation, a nursing assistant transferred the resident to a wheelchair, took him to the bathroom, and donned gloves without first performing hand hygiene. The nursing assistant removed the resident’s soiled brief, handled and applied a clean brief while still wearing the same gloves, and wiped the resident’s buttocks, where stool was observed on the wipe. Without removing the contaminated gloves or performing hand hygiene, the nursing assistant pulled up the resident’s clean brief and pants, tied the pants, touched the wheelchair arm, placed a gloved hand on the resident’s gait belt, released the wheelchair brakes, propelled the resident out of the bathroom, and removed the gait belt. The facility’s handwashing/hand hygiene policy stated that hand hygiene is the primary means to prevent the spread of infections and required hand hygiene before moving from a contaminated body site to a clean body site, after contact with blood or body fluids, after contact with objects in the resident’s immediate vicinity, and after removing gloves.
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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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 | ★★★★★ | 5 | 0 |
| Truman Senior Living | 14.9 mi | ★★★★★ | 15 | 0 |
| Oak Hills Living Center | 18.9 mi | ★★★★★ | 9 | 0 |
| Hillcrest Health Care, Llc | 20 mi | ★★★★★ | 6 | 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 October 2026) and official state health department websites.