Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Sleepy Eye Rehabilitati Center during CMS and state inspections, most recent first.
A resident’s MDS was coded inaccurately for hospice status. The resident had diagnoses including dementia, sarcoidosis, and right breast cancer, and the chart included a hospice order and a note that the resident was admitted to hospice with Alzheimer’s disease. Even so, the significant change MDS marked hospice as “no” and also marked prognosis as “no” for a condition that may result in a life expectancy of less than 6 months. The RN/MDS coordinator acknowledged hospice should have been coded as “yes,” and the DON stated the MDS should be coded accurately.
Staff did not follow Enhanced Barrier Precautions when providing care to a resident with an indwelling catheter, despite clear care plan instructions and available supplies. Multiple staff members, including a nursing assistant, an LPN, and an RN, entered the room and performed high-contact care activities without donning required protective equipment or properly sanitizing equipment connections, contrary to facility policy.
A resident with COPD required oxygen therapy, and an LPN was observed carrying an oxygen tank unsafely, posing a risk of explosion or injury. The LPN was unaware of the proper handling procedures, despite having received training that did not specifically address this issue. The facility's policy requires oxygen tanks to be transported in a cart or holder, which was not followed.
The facility did not ensure that the most recent survey results were accessible for residents or visitors. A binder labeled 'Survey Results' was found to contain outdated information, missing the latest federal recertification survey results. The administrator confirmed the oversight and no policy for posting survey results was available.
A non-English speaking resident in an LTC facility experienced loneliness and depression due to inadequate communication methods. Despite a care plan indicating the need for translation services, staff were not trained or informed about the resident's language needs. The resident, who spoke Spanish and had moderate cognitive impairment, was unable to participate in activities or convey critical information, leading to isolation. Observations showed staff communicated in English, and translation tools were not utilized, resulting in the resident's distress and desire to transfer.
The facility did not follow the manufacturer's instructions for cleaning and sanitizing an ice machine used for resident consumption, potentially affecting all 53 residents. The maintenance director cleaned the machine annually using distilled water, contrary to the recommended six-month interval and specific cleaning solutions. The corporate maintenance director acknowledged the issue and planned to assist in implementing proper procedures.
The facility failed to maintain proper infection control practices, including not sanitizing a mechanical lift after use, improper glove use, and inadequate hand hygiene. A resident with multiple diagnoses was transferred using a lift that was not cleaned afterward. Housekeeping staff sorted soiled laundry without a gown and failed to perform hand hygiene. A nursing assistant wore the same gloves across multiple rooms without washing hands, violating the facility's infection control policies.
The facility failed to provide adequate staffing, resulting in delayed care and assistance for residents, particularly those on Hall 2. Residents and their families reported long wait times for call light responses, leading to incidents of incontinence due to lack of timely help. Staff interviews confirmed reliance on agency staff unfamiliar with resident care plans, causing further delays. Management acknowledged staffing issues, attributing delays to inconsistent staff familiar with resident routines.
The facility failed to provide substantial snacks to residents on the memory care unit and one resident on hallway 2, resulting in a lapse of more than 14 hours between dinner and breakfast. Observations showed that snacks offered lacked protein, and a resident with cognitive impairment experienced a delay in breakfast service. The facility's policy of no more than 14 hours between meals was not followed.
The facility failed to implement a comprehensive antibiotic stewardship program, leading to incomplete tracking of antibiotic use and infection details for several residents. The Director of Nursing, also the infection preventionist, admitted that logs were incomplete due to personnel changes, and culture reports were not timely scanned, affecting proper tracking and analysis.
A non-English speaking resident with moderate cognitive impairment and depression was not provided with individualized activities or appropriate communication tools, leading to social isolation. The resident primarily speaks Spanish, but the facility failed to offer activities in Spanish or train staff to use translation services effectively. As a result, the resident spent most of the time in the room without meaningful interaction, contributing to feelings of loneliness and isolation.
A facility failed to conduct weekly comprehensive skin assessments for a resident with a stage II pressure ulcer. Despite having a care plan with interventions like repositioning and pressure-reducing devices, the facility did not perform required assessments, leading to incomplete documentation of the wound's condition. The LPN responsible for assessments cited being occupied with other duties, and the DON acknowledged the deficiency, which was contrary to the facility's policy.
The facility failed to maintain or prevent the loss of range of motion for two residents with limited mobility. Despite therapy referrals for daily walking programs, there was no documentation or implementation of these programs. Interviews revealed staff were unaware of the walking programs, and the facility lacked a policy for restorative nursing or PT referrals. The DON acknowledged challenges with staff compliance and the absence of documentation for the residents' walking activities.
A resident with dementia and severe malnutrition did not receive a mechanically altered diet as ordered by the physician. Observations revealed the resident struggled to eat meals that were not appropriately prepared, despite having dentures that fit well. The dietary director acknowledged the oversight, and the director of nursing was informed of the issue, highlighting a failure to adhere to the facility's diet policy.
A resident with obstructive sleep apnea and other respiratory conditions did not receive prescribed BiPAP therapy due to the facility's failure to provide an oxygen adapter for the machine. Despite the presence of the BiPAP machine in the resident's room, staff did not apply it, and documentation inaccurately indicated its use. The resident's medical doctor was not informed of the issue, and facility policies on treatment orders and change of condition were not followed.
A facility failed to implement care-planned interventions for a Spanish-speaking resident, leading to communication barriers and social isolation. Despite the resident's care plan requiring Spanish-speaking staff or translation services, staff frequently communicated in English, which the resident did not understand. The facility had a computer translator, but it was not consistently used, and many staff were not trained to use it, resulting in unmet needs and feelings of loneliness for the resident.
Inaccurate MDS Coding for Hospice Status
Penalty
Summary
The facility failed to ensure that one resident’s status was accurately identified in the Minimum Data Set (MDS) assessment. R38’s face sheet listed diagnoses of dementia, sarcoidosis, and right breast cancer. However, the resident’s significant change MDS indicated “no” for hospice in section O and “no” for section J1400 regarding prognosis for conditions or chronic diseases that may result in a life expectancy of less than 6 months. The record also included a physician order for hospice and a progress note stating that R38 was admitted to hospice care with a diagnosis of Alzheimer’s disease. During interview, the RN who was also the MDS coordinator reviewed the assessment and stated hospice should have been coded as “yes” because that was the reason for the significant change MDS submission. The DON stated she expected the MDS to be coded accurately and resubmitted accurately.
Failure to Apply Enhanced Barrier Precautions During Resident Care
Penalty
Summary
Staff failed to apply Enhanced Barrier Precautions (EBP) while providing care to a resident with an indwelling catheter. The resident had diagnoses of acute pyelonephritis and malignant neoplasm of the endometrium, and her care plan specified the use of EBP due to the chronic Foley catheter. During observation, a nursing assistant entered the resident's room without donning EBP, despite signage and supplies being available. The nursing assistant performed high-contact care activities, including washing the resident and changing the urinary collection bag, without using appropriate EBP or sanitizing the catheter connection. Additionally, an LPN and an RN entered the room and provided direct care, such as assessing for edema, changing a dressing, and listening to lung sounds, without donning EBP. Interviews with staff revealed inconsistent understanding and application of EBP requirements, with some staff acknowledging the need for EBP and others incorrectly believing it was unnecessary. The facility's policy required gown and gloves for high-contact care for residents with indwelling medical devices, but this was not followed during the observed care activities.
Unsafe Handling of Oxygen Tank Poses Safety Hazard
Penalty
Summary
The facility failed to ensure the safe handling of an oxygen tank for a resident diagnosed with acute exacerbation of chronic obstructive pulmonary disease (COPD). The resident had physician orders for oxygen delivery via nasal cannula at 3-4 liters per minute every shift. During an observation, an LPN was seen carrying an E-sized metal oxygen tank by holding it to her chest with both arms wrapped around it, as she walked down a hallway. This action was identified as a safety hazard because if dropped, the oxygen tank could explode or become a projectile, posing a risk to residents and staff. Interviews revealed that the LPN was unaware that carrying an oxygen tank in such a manner was unsafe, although she could verbalize the potential dangers. The director of nursing confirmed that staff should not travel with an oxygen tank due to the safety risk. It was noted that the LPN had received training on oxygen use, but the training did not specifically cover the safe handling of oxygen tanks. The facility's policy indicated that oxygen tanks must be transported in an oxygen cart or placed in an approved holder on a wheelchair, but this was not adhered to in this instance.
Failure to Provide Access to Recent Survey Results
Penalty
Summary
The facility failed to ensure that the most recent survey results were readily accessible for residents or visitors to view. During an observation on February 24, 2025, a three-ring binder labeled 'Survey Results' was found in an acrylic wall mount in the hallway leading to the chapel, across from the vending machines. The binder contained survey results dated April 20, 2023, but did not include the results of the most recent federal recertification survey dated May 15, 2024. There was no posted information indicating the availability of any other survey results. On February 25, 2025, the administrator confirmed that he was responsible for placing the most recent survey results in the binder and acknowledged that the results from May 15, 2024, were not included as expected. Additionally, no policy regarding the posting of survey results was provided.
Failure to Provide Effective Communication for Non-English Speaking Resident
Penalty
Summary
The facility failed to provide effective communication methods for a non-English speaking resident, resulting in harm due to loneliness, depression, and isolation. The resident, who primarily spoke Spanish and had moderate cognitive impairment, was not provided with adequate tools or staff training to facilitate meaningful communication. Despite the resident's care plan indicating the need for translation services and the use of a translator, these measures were not consistently implemented, leaving the resident unable to convey critical information or participate in activities. Observations and interviews revealed that staff, including temporary and agency staff, were not informed or trained on the resident's communication needs. The resident's care plan and mood assessments indicated a need for social interaction and activities that catered to his language preferences, yet these were not provided. Staff often communicated in English, which the resident did not understand, and failed to use available translation tools. The resident expressed feelings of being ignored and isolated due to the language barrier, and staff confirmed the lack of individualized activities or communication tools. The facility's failure to ensure staff were trained and equipped to communicate with the resident led to a lack of meaningful social interaction and activities. The resident's mood and behavior were not adequately monitored or addressed, despite documented signs of depression and loneliness. The facility's assessment and policies highlighted the importance of cultural competency and language access, yet these were not effectively implemented, contributing to the resident's distress and desire to transfer to another facility.
Failure to Follow Manufacturer's Instructions for Ice Machine Cleaning
Penalty
Summary
The facility failed to adhere to the manufacturer's instructions for cleaning and sanitizing an ice machine used for resident consumption, which had the potential to affect all 53 residents in the facility. During an interview, the maintenance director (MD-A) revealed that the ice machine, located near the dining room, was cleaned only once a year using distilled water, contrary to the manufacturer's recommendation of a minimum of six months between cleanings. The manufacturer's manual for the Scotsman brand ice machine, model HID540, specified the use of hot water and a solution of ice machine scale remover for cleaning, and a sanitizing solution with a concentration of 100 parts per million for sanitization. Upon further investigation, it was found that MD-A had been in his role for about three years and had been instructed by his former supervisor to clean the ice machine annually, which did not align with the manufacturer's guidelines. The corporate maintenance director (CMD-G) acknowledged the discrepancy and indicated plans to assist MD-A in implementing the correct cleaning and sanitization procedures. The facility's sanitization policy, revised in October 2008, also required that ice machines and storage containers be cleaned and sanitized per the manufacturer's instructions, which was not being followed.
Infection Control Deficiencies in Equipment Sanitization and Hand Hygiene
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices in several instances. During an observation, a nursing assistant used a mechanical lift to transfer a resident diagnosed with right humerus fracture, diabetes mellitus, and heart failure, from her bed to a chair. After the transfer, the lift was parked in the hallway without being sanitized, which was confirmed by the nursing assistant and a registered nurse as a breach of protocol. Additionally, the facility's infection prevention and control program mandates that all lifts should be sanitized after each use, especially before being placed in common areas like hallways. In another observation, a housekeeping staff member was seen sorting soiled laundry without wearing a gown and failed to perform hand hygiene throughout the process. The staff member handled dirty laundry with gloves but touched her clothing multiple times, and transported unbagged laundry, which contradicts the facility's infection control policies. Furthermore, a nursing assistant was observed wearing the same gloves while moving from room to room without performing hand hygiene, which was acknowledged as incorrect practice by the staff and the director of nursing. The facility's handwashing policy requires hand hygiene before and after glove use and when handling soiled linen.
Staffing Deficiencies Lead to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient staffing to ensure residents received timely care and assistance with activities of daily living (ADLs) and prompt response to call lights. This deficiency affected multiple residents, particularly those on Hall 2, who required substantial assistance due to cognitive impairments and mobility issues. Interviews with residents and their families revealed consistent delays in staff responding to call lights, with some residents waiting up to an hour for assistance, leading to incidents where residents had to urinate or have bowel movements in their clothing due to the lack of timely help. Staff interviews corroborated these findings, indicating that the facility frequently relied on agency staff who were unfamiliar with the residents' care plans and routines, causing further delays in care. The facility's staffing schedules showed consistent shortages, particularly on weekends, with agency staff often filling in but lacking the necessary familiarity with resident needs. This inconsistency in staffing led to delays in morning care, meals, and other essential services, as agency staff required more guidance and time to perform their duties. The facility's management acknowledged the staffing issues, attributing delays in care to the use of agency staff and the inconsistency of staff familiar with resident routines. Despite the facility's assessment indicating a commitment to providing individualized care and maintaining adequate staffing levels based on resident acuity, the actual staffing practices fell short, resulting in unmet resident needs and prolonged wait times for assistance.
Failure to Provide Substantial Snacks Between Meals
Penalty
Summary
The facility failed to ensure that residents on the memory care unit and one resident on hallway 2 were provided with nutrient and calorie substantive snacks after the evening meal and before breakfast, resulting in a lapse of more than 14 hours between meals. Observations revealed that residents on the memory care unit went 15 hours between dinner and breakfast, with dinner served at 6:00 p.m. and breakfast at 9:00 a.m. The dietary director confirmed that while residents received a snack in the evening, it consisted only of carbohydrates without protein, which did not meet the definition of a substantial snack as stated by the registered dietician. Additionally, a resident with moderate cognitive impairment and requiring substantial assistance with eating was not offered a snack after dinner and experienced a delay in receiving breakfast the following day. The resident expressed confusion and concern about not having eaten since the previous evening. The director of nursing confirmed that the resident was not offered a snack as they were already asleep and acknowledged the delay in breakfast service. The facility's Meal Times policy specifies no more than 14 hours between the evening meal and breakfast, which was not adhered to in this instance.
Inadequate Antibiotic Stewardship Program
Penalty
Summary
The facility failed to develop and implement a comprehensive antibiotic stewardship program, which is essential for monitoring and reducing unnecessary antibiotic use and potential drug resistance. This deficiency was identified during an interview and document review, where it was found that the facility's infection and antibiotic tracking log was incomplete. The Director of Nursing (DON), who also served as the infection preventionist, admitted that the logs for January and March 2024 were not completed due to a transition in personnel. The logs for February and April 2024 were reviewed and found to be lacking critical information such as the resolution of symptoms, culture results, and complete antibiotic details for several residents. Specific cases highlighted in the report include residents with urinary tract infections and upper respiratory infections, where essential details like the onset date, culture results, and symptom resolution were missing. For instance, one resident was listed with a urinary tract infection but lacked documentation on the antibiotic name, dose, and resolution date. Another resident with an upper respiratory infection had incomplete antibiotic information. The DON acknowledged that culture reports were not always scanned in a timely manner, hindering proper tracking and analysis. The facility's policy on antibiotic stewardship outlined the need for comprehensive monitoring, but the implementation was found to be inadequate.
Failure to Provide Individualized Activities for Non-English Speaking Resident
Penalty
Summary
The facility failed to provide individualized activities and appropriate communication tools for a non-English speaking resident, leading to social isolation and unmet psychosocial needs. The resident, who primarily speaks Spanish and has moderate cognitive impairment, was observed to feel down, depressed, and lonely nearly every day. Despite the resident's care plan indicating the need for Spanish-speaking staff and translation services, these were not consistently provided, resulting in the resident spending most of the time in the room watching TV without meaningful interaction or activities. Interviews with staff revealed that the resident was not offered activities in Spanish or those that did not require verbal communication, such as word puzzles or church services, which were conducted in English. The activity staff admitted to using gestures and broken English to communicate with the resident, which often led to confusion and frustration. The facility had a translator computer, but it was not readily accessible, and staff were not trained to use it effectively. As a result, the resident was not engaged in activities that matched personal preferences or provided socialization. The lack of communication tools and individualized activities contributed to the resident's feelings of loneliness and isolation. Staff acknowledged the language barrier as a significant factor preventing the resident from participating in activities and interacting with others. Despite the resident's expressed desire to move to a facility closer to friends and Spanish-speaking individuals, the facility had not provided adequate interventions to address the resident's mood and behavior concerns, as identified in the depression screening.
Failure to Conduct Weekly Comprehensive Skin Assessments
Penalty
Summary
The facility failed to ensure weekly comprehensive skin assessments with measurements for a resident with a stage II pressure ulcer. The resident, who had moderate cognitive impairment and was dependent on staff for various activities, returned from the hospital with an open area on the coccyx. Despite having a care plan that included interventions such as repositioning, pressure-reducing devices, and dietary interventions, the facility did not conduct weekly skin assessments as required. The resident's medical record lacked evidence of comprehensive skin assessments, including measurements of the wound's width, length, depth, type of tissue, and exudate. The resident's condition had declined significantly, and she was frequently incontinent, requiring substantial assistance with mobility. The facility's documentation showed inconsistencies in recording the resident's skin condition, with some entries missing measurements and comprehensive descriptions. The licensed practical nurse responsible for the assessments confirmed that measurements were not completed as expected and that the next wound assessment after a certain date was delayed. The nurse cited being occupied with other duties as a reason for not completing the assessments. The director of nursing acknowledged that pressure ulcers should be measured weekly with a comprehensive assessment. However, the facility's policy on skin assessment and wound management was not followed, as evidenced by the lack of weekly skin inspections and comprehensive wound evaluations. The facility's failure to adhere to its policy and ensure timely and thorough assessments contributed to the deficiency in pressure ulcer care for the resident.
Failure to Maintain Residents' Range of Motion
Penalty
Summary
The facility failed to provide services to maintain or prevent the loss of range of motion (ROM) for two residents, R4 and R32, who were reviewed for limited ROM. R4, who had diagnoses of psychosis and blindness, was dependent on staff for toileting and could walk with assistance. Despite a therapy referral to nursing to walk R4 daily, there was no physician order for a walking program, and R4 expressed that she was not being walked as desired. Interviews with staff revealed a lack of awareness and documentation regarding R4's walking program, and the physical therapist confirmed that the referral instructions were not effectively communicated or implemented. R32, diagnosed with stroke and post-polio syndrome, required substantial assistance for mobility and was supposed to walk daily according to a therapy referral. However, R32 reported not being walked as expected, and staff interviews indicated confusion about the walking program's implementation. The physical therapist noted that the referral instructions were not added to R32's care plan, and there was no follow-up to ensure the program was carried out. The DON acknowledged the lack of documentation and expressed challenges with staff compliance on the memory care unit. The facility did not have a policy defining the process for restorative nursing or PT referrals for a walking program, contributing to the deficiency. The DON and regional nurse consultant were unable to provide documentation of the residents being walked or any refusals documented. The absence of a structured restorative nursing program and clear communication of therapy referrals led to the failure in maintaining the residents' ROM as prescribed.
Failure to Provide Mechanically Altered Diet
Penalty
Summary
The facility failed to provide a mechanically altered diet to a resident with specific dietary needs, as per physician orders. The resident, who had diagnoses of dementia, adult failure to thrive, and severe protein-calorie malnutrition, was observed receiving meals that were not mechanically altered, despite having a diet order for a regular diet with mechanical soft texture. During meal observations, the resident struggled to eat a whole hamburger, chicken strips, and potato wedges due to the food's hardness, even though the resident wore dentures that fit well. The dietary director acknowledged that the resident was on a mechanically altered diet and that the kitchen staff should have prepared the food accordingly. However, the food was not cut up as required, and the dietary director could not explain the oversight. The director of nursing was informed of the issue, indicating a lack of adherence to the facility's Diet Manual and Diet Orders policy, which mandates that food requiring cutting should be prepared by nursing or designated staff before serving.
Failure to Provide Appropriate BiPAP Therapy
Penalty
Summary
The facility failed to ensure that a resident's BiPAP machine was utilized in accordance with physician orders, which was necessary to meet the resident's respiratory care needs. The resident, who had diagnoses of obstructive sleep apnea, pulmonary fibrosis, COPD, and recent pneumonia, was cognitively intact and required the use of a BiPAP machine at night as per physician orders. However, the resident reported that she had not been able to use her BiPAP machine since her admission to the facility because it lacked an adapter for oxygen, which she now required. Despite the presence of the BiPAP machine in the resident's room, staff did not apply or offer it to her, and documentation inaccurately indicated that the machine was being used. Interviews with various staff members, including a trained medication assistant, a licensed practical nurse, and a registered nurse, revealed a lack of awareness and understanding regarding the resident's BiPAP machine and its use. The resident's medical doctor was also not informed about the issue with the BiPAP machine's compatibility with oxygen therapy, which was a critical oversight given the resident's respiratory needs. The director of nursing later confirmed that the staff should have notified the provider or her about the lack of an adapter for dual oxygen therapy. The facility's policies on medication and treatment orders, as well as change of condition, were not adhered to, as the necessary communication and actions to address the resident's respiratory care needs were not taken. This resulted in the resident not receiving the prescribed BiPAP therapy, which was essential for her condition.
Failure to Implement Communication Plan for Spanish-Speaking Resident
Penalty
Summary
The facility failed to consistently implement care-planned interventions for communication with a Spanish-speaking resident, identified as R12, which led to an alteration in psychosocial wellbeing, risk of isolation, and communication barriers. R12's care plan indicated the need for Spanish-speaking staff or translation services to communicate effectively, as R12 did not speak or understand English. Despite this, observations and interviews revealed that staff frequently communicated with R12 in English, which he did not understand, and failed to use available translation tools. R12 was observed to be socially isolated, expressing feelings of loneliness and a lack of activities due to the language barrier. The facility had a computer translator intended for use with non-English speaking residents, but it was not consistently available or utilized by staff. Many staff members, including agency staff and those unfamiliar with R12, were not trained to use the translator and were unaware of R12's language needs, leading to ineffective communication and unmet needs. Interviews with staff and observations indicated a lack of training and awareness regarding the use of translation services and communication tools. The facility's assessment claimed to provide person-centered care and cultural competency, yet the deficiency highlighted a significant gap in meeting the linguistic needs of R12. The failure to implement the care plan and provide adequate communication support contributed to R12's feelings of isolation and dissatisfaction with the facility's services.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 49 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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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) |
|---|---|---|---|---|
| Divine Providence Community Home | 1.4 mi | ★★★★★ | 11 | 0 |
| St John Lutheran Home | 12.4 mi | ★★★★★ | 10 | 0 |
| Oak Hills Living Center | 12.4 mi | ★★★★★ | 9 | 0 |
| Gil-mor Manor | 12.9 mi | ★★★★★ | 3 | 0 |
| Franklin Restorative Care Center | 17.9 mi | ★★★★★ | 13 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Sleepy Eye Rehabilitati Center.
100% money-back within 48 hours.
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.