Above average — CMS composite of the measures below.
The next survey window likely opens around January 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 St Williams Living Center during CMS and state inspections, most recent first.
Failure to notify the provider of low blood sugars. A resident with DM, Alzheimer's disease, and PTSD had an order to update the provider if blood sugar was 70 or below or 400 or above. The record showed multiple blood sugar readings below 70 mg/dL, but there was no documentation that the PCP was notified. The RN supervisor said the facility usually only notified the provider if the blood sugar could not be corrected, while the NP confirmed the order required notification in the moment.
A resident with severe cognitive impairment and on anticoagulant therapy developed increased right hip pain and extensive bruising of unknown origin. Staff noted and treated the symptoms but did not promptly notify the physician or the resident's family, despite facility policy requiring such notifications for unexplained bruising and changes in condition. The physician and family only became aware after the resident was sent to the ER, resulting in a deficiency for delayed communication.
A resident with severe cognitive impairment and on anticoagulant therapy developed significant bruising and pain of unknown origin. Multiple staff observed and documented the injuries over several days, but failed to promptly notify the DON, administrator, or state authorities as required by policy. The delay in reporting and investigation did not meet regulatory requirements for timely response to potential abuse or neglect.
A resident with severe cognitive impairment and on anticoagulant therapy developed significant bruising and hip pain of unknown origin. Despite multiple staff observations and documentation of pain and bruising, there was a delay in reporting the injury to authorities and initiating an investigation. Staff interviews revealed incomplete documentation and lack of timely communication with the provider and DON, resulting in a deficiency for failure to respond appropriately to an alleged violation.
A resident with multiple medical conditions who required assistance with bed mobility became trapped between a newly installed air mattress and bed side rail after staff failed to assess entrapment zones as required by facility policy. The omission occurred when staff replaced the mattress but did not check for gaps, resulting in the resident sustaining injuries and requiring assistance to be freed.
The facility's infection control program was found deficient due to incomplete surveillance logs from September to December 2024. The logs lacked critical data such as signs and symptoms of infections, antibiotic start and stop dates, and antibiotic timeouts. Interviews with the IP and DON confirmed these deficiencies, which did not meet national standards for infection prevention and control.
The facility exhibited deficiencies in food handling and sanitation, including improper glove use by a dietary aide, unsanitary conditions of the ice machine, and failure to maintain proper food temperatures. These practices could potentially lead to foodborne illness among residents.
Failure to Notify Provider of Low Blood Sugars
Penalty
Summary
The facility failed to notify the physician for out-of-range blood sugars for 1 of 5 residents reviewed for unnecessary medications. The resident had cognitive impairment and diagnoses including diabetes mellitus, Alzheimer's disease, and PTSD. The resident's care plan included Accu-Checks as ordered, diet as ordered, medications as ordered, monitoring for signs of hyperglycemia and hypoglycemia, labs as ordered, and updating the provider as needed. A progress note order dated 1/24/26 directed blood sugar checks by Freestyle Libre with fingerstick PRN twice a day and to update the provider if blood sugar was less than or equal to 70 or greater than or equal to 400. Review of the treatment administration record from 2/11/26 through 2/22/26 showed blood sugar readings below 70 mg/dL on four occasions: 62 mg/dL, 57 mg/dL, 69 mg/dL, and 64 mg/dL. Review of the resident's progress notes for that period lacked documentation that the primary care provider was notified for those low blood sugars as ordered. During interview, the RN supervisor stated it was not the facility's standard practice to notify the provider if blood sugar could be brought back up, and said the provider was not notified at the time of the low readings. The NP verified the order required provider notification when blood sugar was below 70 or above 400, and the facility policy stated the physician should be notified if blood glucose was above or below normal range when indicated by symptoms or specific orders in the chart.
Failure to Notify Physician and Family of Resident's Increased Pain and Bruising
Penalty
Summary
The facility failed to ensure timely notification of a physician and a resident's representative regarding increased right hip pain and significant bruising in a resident with severe cognitive impairment and multiple comorbidities, including atrial fibrillation and use of anticoagulant medication. The resident, who was dependent for transfers and had a history of falls, began experiencing right hip pain and was observed with bruising of unknown origin. Documentation shows that pain and bruising were noted and treated with Tylenol, but there was a delay in reporting these changes to the physician and family. Staff interviews revealed that bruising was first identified and reported among staff, but not immediately communicated to the physician or family, and the size and extent of the bruising were not consistently documented at the time of discovery. Progress notes and staff interviews indicate that the resident's pain increased over several days, with pain scores reaching as high as eight or nine out of ten, and the bruising expanded in size and severity. Despite these changes, the physician was not notified until after the resident was sent to the emergency room at the request of the family, who was also not informed of the situation until the evening the resident was transferred. The medical director confirmed that he was not made aware of the bruising or pain until a follow-up visit days later, and the family expressed concern that they would have requested medical evaluation sooner had they been notified earlier. Facility policy required staff to notify the physician and family of unexplained bruising or changes in condition, especially for residents on anticoagulants. However, staff interviews and documentation review confirmed that these notifications did not occur promptly. The delay in communication and incomplete documentation of the resident's condition led to a deficiency in ensuring that significant changes in the resident's health status were reported as required.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
A deficiency occurred when the facility failed to report an allegation of potential abuse within the required two-hour timeframe for a resident with an injury of unknown origin. The resident, who was severely cognitively impaired and required substantial assistance for transfers, was observed to have multiple bruises and a scabbed scratch on the right hip and lower extremities over several days. Despite ongoing documentation of pain, bruising, and changes in condition, the initial bruising was not reported to the state agency as required, and an investigation was not promptly initiated. The resident had a complex medical history, including atrial fibrillation managed with anticoagulant therapy, dementia, arthritis, and a history of falls. Staff documented increasing right hip pain, grimacing, and significant bruising that expanded over time. Multiple staff members, including nursing assistants and LPNs, observed and documented the bruising and pain, but there was a delay in notifying the Director of Nursing, administrator, and state authorities. The resident was unable to recall the cause of the injuries due to cognitive impairment, and staff interviews confirmed that the bruises were of unknown origin and should have been reported immediately. Facility policy required that all allegations of abuse, neglect, or injuries of unknown origin be reported to the appropriate authorities within two hours. However, the report to the state agency was not made until several days after the initial identification of the bruising. Interviews with staff and review of documentation revealed that the required notifications and investigation were not initiated in a timely manner, resulting in a failure to protect the resident as outlined in facility policy and regulatory requirements.
Failure to Investigate and Report Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an allegation of potential resident abuse for a resident who was found to have an injury of unknown origin. The resident, who was severely cognitively impaired and dependent on staff for most activities of daily living, developed significant bruising and right hip pain over several days. Despite multiple observations and documentation of pain and bruising by nursing staff, there was a delay in reporting the injury to the appropriate authorities and in initiating an investigation into the cause of the bruising. Staff interviews revealed that bruising was observed and reported to nurses, but the injury was not measured, and documentation was incomplete. The resident's pain increased, and the bruising expanded before the incident was reported to the state and an investigation was started. The resident's medical history included atrial fibrillation, dementia, arthritis, and use of an anticoagulant, which increased the risk of bruising. Staff documented ongoing pain and bruising, with the resident at times unable to recall how the injury occurred. Despite these findings, there was a lack of timely communication with the medical provider, and the director of nursing was not notified promptly when the bruising and pain worsened. The facility's policy required immediate investigation and reporting of suspected abuse or unexplained injuries, but this was not followed in this case. Interviews with staff and the medical director confirmed that the resident's cognitive impairment made it difficult to obtain an accurate history, but staff were expected to report and investigate unexplained injuries immediately. The delay in reporting, incomplete documentation, and failure to initiate an immediate investigation resulted in a deficiency related to the facility's response to an alleged violation and potential abuse.
Failure to Assess Bed Rail Entrapment Risk After Mattress Replacement
Penalty
Summary
Facility staff failed to properly assess and ensure the safe use of bed rails for a resident who required assistance with bed mobility. The resident, who had diagnoses including wheezing, pneumonia, sleep apnea, and weakness, was assessed to use double half side rails for mobility and was able to use the rails to assist with turning and repositioning. However, the resident also required partial to moderate assistance to roll and extensive assistance from staff for bed mobility, as documented in the care plan. On the night of the incident, staff replaced the resident's mattress with an alternating pressure air mattress due to the previous mattress not holding air. The new mattress was installed on a bed with side rails attached, but staff did not assess the entrapment zones between the mattress and the side rails after the replacement. This omission was contrary to facility policy, which required assessment of bed rail and mattress compatibility to prevent gaps that could entrap a resident. The facility's policy also specifically prohibited the use of side rails with air mattresses due to entrapment risk. As a result of the failure to assess the entrapment zones, the resident was found with his head trapped between the mattress and the side rail, unable to free himself and experiencing pain and skin tears. Staff had difficulty removing the resident's head from the gap, and the incident was later confirmed by a bed rail gap test, which the bed did not pass. The entrapment assessment had not been performed when the mattress was swapped, leading directly to the resident's injury.
Removal Plan
- Updated policy to include side rails will not be used with air mattresses
- Licensed nurses were educated on the side rail policy, Side Rail Assessment, Bed Rail/Mattress Safety Assessment including how to measure for gaps that may cause entrapment
Inadequate Infection Control Surveillance
Penalty
Summary
The facility failed to establish an ongoing infection control program that included comprehensive surveillance of resident infections. The infection control surveillance log from September to December 2024 lacked critical data such as signs and symptoms for each infection, dates when cultures were obtained, and start and stop dates for antibiotics. This deficiency was identified through a review of the facility's infection control surveillance log, which showed incomplete documentation for various infections, including urinary tract infections, tooth infections, and respiratory conditions. During interviews, both the infection preventionist (IP) and the director of nursing (DON) confirmed the deficiencies in the surveillance log. The IP, responsible for overseeing the infection control program, acknowledged that the log did not include necessary data such as signs and symptoms, antibiotic timeouts, and resolution dates. The DON also confirmed these omissions and stated that the expectation was for the surveillance log to be completed according to national standards to prevent the spread of infectious diseases. The facility's infection prevention and control manual outlined essential elements of a surveillance system, including standardized definitions and symptoms of infections based on national standards. However, the facility's current practices did not align with these guidelines. The infection preventionist was expected to collect and review data on an ongoing basis, including signs and symptoms of infections, culture results, and antibiotic orders, but the surveillance log did not reflect this comprehensive data collection.
Deficiencies in Food Handling and Sanitation Practices
Penalty
Summary
The facility was observed to have several deficiencies in food service practices, which could potentially lead to foodborne illness among residents. During a dining service observation, a dietary aide was seen handling food items such as buns and baked potatoes with the same pair of gloves after touching non-food items like an iPad and kitchen drawers. The aide did not wash hands or change gloves between these actions, which was confirmed during an interview. The dietary manager verified that the expectation was for staff to wash hands and change gloves when touching non-food items to prevent the spread of germs. The ice machine in the north kitchen area was found to be unsanitary, with a white powder substance present on the spouts and drain plate. The dietary manager and maintenance staff confirmed the presence of the substance and acknowledged that there was no cleaning process in place for the ice machine. The maintenance staff mentioned that the machine was cleaned every three months, but no log was kept to verify this. The white powder substance was identified as potentially containing bacteria, which could lead to illness in residents. Additionally, the facility failed to maintain proper holding temperatures for cold food items. Egg salad sandwiches were observed to be at temperatures above the recommended safe range, with one sandwich measured at 55.7 degrees Fahrenheit. The cook confirmed that cold sandwiches were not placed on ice and that the holding temperature should be under 41 degrees Fahrenheit to prevent illness. The dietary manager and dietician both confirmed the importance of maintaining proper food temperatures to prevent foodborne illness and ensure food quality for residents.
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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 Parkers Prairie
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bethany On The Lake Llc | 19 mi | ★★★★★ | 14 | 0 |
| Knute Nelson Care Center | 19.1 mi | ★★★★★ | 7 | 0 |
| Evansville Care Center | 20.2 mi | ★★★★★ | 5 | 0 |
| Good Samaritan Society - Battle Lake | 20.8 mi | ★★★★★ | 1 | 0 |
| Galeon | 21.3 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 July 2026) and official state health department websites.