Below 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 St Catherines Living Center during CMS and state inspections, most recent first.
A resident with mild vascular dementia, agitation, and a documented history of socially inappropriate and physically aggressive behaviors punched another cognitively impaired resident with traumatic brain injury and dementia in a common area. Staff heard yelling and then observed the aggressor standing over the injured resident with a raised fist after the punch. The aggressor admitted he intended to cause pain and expressed no remorse. The injured resident reported facial and headache pain, with redness noted on the left side of the face, and was evaluated in the ED before returning with mild residual redness and reduced pain.
Surveyors found that both the North and South Kitchens were not maintained in a clean and sanitary condition, with burnt and baked-on food debris in ovens, scattered food and debris on floors, dried food on cabinet surfaces, and mineral buildup and food debris under a handwashing sink. Debris, dust, and mineralization were also observed on top of the mechanical warewashing machine, and these conditions persisted across multiple observations, with additional debris created during oven cleaning. Two dietary staff members did not perform hand hygiene and handled the rims of beverage cups with bare hands while removing covers and arranging them on resident meal plates, contrary to FDA Food Code standards for preventing contamination of cleaned and sanitized utensils and lip-contact surfaces.
Surveyors found that two residents sharing a bathroom were exposed to persistent fecal soiling in the toilet bowl and on the toilet seat, along with an unlined trash can containing soiled wipes, despite a facility policy requiring regular cleaning of toilet surfaces and lined trash containers. Over repeated observations on multiple days, bowel movement residue remained present even after staff completed toileting care, and a resident reported that housekeeping had not cleaned the room or bathroom. Housekeeping staff reported being on-site daily, and administration stated that staff are expected to notify housekeeping or use sanitizing wipes after care, yet the bathroom remained unclean, failing to provide a safe, clean, and homelike environment.
Surveyors identified that a resident’s insulin pen label indicated a 10‑unit Lantus Solostar dose while nursing staff prepared and administered 12 units based on the eMAR, and an administrative nurse confirmed the label did not match the physician’s order. Facility policy stated that pharmacy should provide updated labels or a “see MAR for orders” label after dose changes, and that staff should follow the electronic order if pharmacy has not yet updated the label. In addition, a medication cart was observed unlocked and unattended on multiple occasions, despite facility policy requiring carts to remain locked when unattended, and an administrative nurse acknowledged the expectation that staff keep the cart locked.
Surveyors found that staff failed to follow the facility’s hand hygiene and glove use policy during personal care and wound care for two residents. A CNA removed a wet brief, changed briefs, and performed perineal care without appropriate glove use or performing hand hygiene before, between glove changes, or after care. In a separate incident, a nurse provided wound care to a resident on enhanced barrier precautions for a chronic ulcer and suspected MRSA carrier status, entering and exiting the room without hand hygiene and performing the entire dressing change with the same soiled gloves, including handling clean dressings and supplies. An administrative nurse reported that staff were expected to perform hand hygiene with ABHR after resident care, between glove changes, and during dressing changes.
A resident with peripheral vascular disease and recent COVID isolation developed wounds on the toes that were not consistently assessed, monitored, or documented according to facility policy and physician orders. The lack of timely treatment initiation, incomplete documentation, and poor provider communication led to delayed care, resulting in hospitalization and amputation of two toes due to gangrene.
A resident in a long-term care facility was verbally threatened by a CNA, causing fear and anxiety. The resident, who was cognitively intact and required assistance with daily activities, reported the incident, which was corroborated by another resident. The facility failed to recognize and address the abuse, as well as to update the care plan or notify the interdisciplinary team, leading to an immediate jeopardy situation.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse when one resident with a known history of socially inappropriate and physically aggressive behaviors punched another resident in the face. The facility’s Abuse Prevention Plan policy required identification, correction, and intervention in situations where abuse occurs, assessment of residents whose behaviors might lead to conflict, and development of an individual abuse prevention plan that includes the resident’s risk of abusing others and specific measures to minimize that risk. Despite this policy, a resident with documented behaviors such as threatening harm to other residents, being verbally aggressive, and a history of becoming physically abusive toward other residents was able to physically assault another resident. The assaulted resident had diagnoses of traumatic brain injury and dementia with behaviors, with a Brief Interview for Mental Status (BIMS) score indicating moderately impaired cognition. On the day of the incident, staff heard hollering from the commons area and then observed the aggressive resident standing over the other resident with a raised fist after having already punched him in the face. The aggressive resident admitted to punching the other resident because he was upset about a comment made to his female companion and stated that he intended to cause pain and did not care about the consequences. Following the punch, the injured resident complained of pain in the left temporomandibular area, with redness noted and an increasing headache rated 7–8/10 and facial pain rated 2/10. The resident was sent to the emergency department for further evaluation. Later documentation indicated the resident returned with mild redness on the left side of the face, no bruising developing, and reported facial pain of 1/10 with denial of headache. The surveyor determined that this incident constituted verified abuse under the facility’s definitions and that the facility failed to ensure residents remained free from abuse as required by policy and regulation.
Unsanitary Kitchen Conditions and Improper Handling of Tableware
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to maintain clean and sanitary conditions in both the North and South Kitchens, as required by the 2022 FDA Food Code. In the North Kitchen, observations showed burnt loose and baked-on debris in two ovens located under a stove, as well as scattered food and debris on the floors throughout the kitchen and in the mechanical warewashing room. On a subsequent observation, loose debris, dust, and mineralization were found accumulated on top of the mechanical warewashing machine, and the scattered food and debris remained on the floors in the kitchen and warewashing room. In the South Kitchen, surveyors observed burnt loose and baked-on debris in the double ovens, an approximately 14-inch linear area of dried food on the side of a silver lower cabinet, scattered food and debris on the floors throughout the kitchen, and mineral buildup and food debris under the handwashing sink. On later observations, the dried food on the cabinet and scattered food and debris on the floors and under the handwashing sink remained, with new debris present on the floor from cleaning the double ovens. Additionally, two unidentified dietary staff members failed to perform hand hygiene and touched the rims of water, juice, milk, and coffee cups with their bare hands when removing covers and arranging them onto resident meal plates, contrary to FDA Food Code requirements for preventing contamination of cleaned and sanitized utensils and lip-contact surfaces.
Failure to Maintain Clean and Homelike Shared Bathroom Environment
Penalty
Summary
The deficiency involves the facility’s failure to maintain a clean, sanitary, and homelike bathroom environment for two residents who shared a bathroom. The facility’s environmental services policy, dated 2020, required that the community be maintained in a clean and hygienic condition and that surfaces such as toilet seats be cleaned according to a schedule established by the environmental services supervisor, with community trash containers lined. Despite this policy, surveyors observed bowel movement (BM) splattered throughout the inside of the toilet bowl and smeared on the back and top of the toilet seat, as well as a trash can without a liner containing several soiled wipes next to the toilet. One of the residents reported that housekeeping had not cleaned the bathroom yet that day. Subsequent observations on multiple occasions over two days showed that BM remained in the toilet bowl and on the toilet seat, even after staff had reportedly completed toileting care for one of the residents in that same bathroom. The resident continued to report that housekeeping had not been in to clean the room or bathroom on either day. A housekeeping staff member stated that housekeeping staff are present seven days a week, and an administrative staff member stated she expects staff to notify housekeeping to address bathroom cleanliness or to clean areas with sanitizing wipes after care is provided. Nonetheless, the bathroom remained soiled over repeated observations, demonstrating a failure to ensure a clean and homelike environment as required by facility policy.
Medication Labeling Inconsistencies and Unsecured Medication Cart
Penalty
Summary
The deficiency involves failure to ensure accurate medication labeling and secure storage of medications. Surveyors observed that an insulin pen for Resident #3 was labeled for Lantus Solostar at 10 units in the morning, while a nurse prepared and administered 12 units, stating the provider had changed the order and that the correct 12‑unit dose was reflected in the electronic medication administration record (eMAR). Review of the eMAR confirmed a 12‑unit Lantus Solostar order with a start date of 11/17/2025. An administrative nurse later confirmed that the insulin pen label did not match the physician’s order in the eMAR and stated that insulin pen labels typically indicate “See MAR for dose,” and she expects staff to follow the eMAR. Facility policy on labeling of medications indicated that when a dose change occurs, pharmacy either sends a “see MAR for orders” label or a new label, and if pharmacy has not yet complied, nursing staff are to continue to administer the correct dose per the physician’s orders in the electronic record. The deficiency also includes failure to keep a medication cart locked when unattended. Surveyors observed a medication cart identified as #700 unlocked and unattended while a staff nurse was down the hallway. On another observation, the same medication cart was again found unlocked and unattended, and it remained so for eight minutes until an administrative nurse walked by and locked it. Review of the facility’s medication administration policy showed that the medication cart is required to be locked at all times when unattended. During interview, an administrative nurse stated she expects staff to lock the medication cart when it is not being attended.
Failure to Follow Hand Hygiene and Glove Use Standards During Personal and Wound Care
Penalty
Summary
Surveyors identified a failure to follow the facility’s hand hygiene policy and infection prevention standards during personal care for one resident. Observation showed a CNA transferring a resident to the toilet using a stand lift and removing the resident’s wet brief without wearing gloves. The CNA then applied gloves without performing hand hygiene, placed a clean brief on the resident, removed the gloves, and wiped her hands on her pants. Without completing hand hygiene, the CNA applied new gloves, performed perineal care, removed the gloves, assisted the resident back to bed, and exited the room without performing hand hygiene. The facility’s hand hygiene policy required hand hygiene before and after direct resident contact, when assisting with personal care and toileting, and after removing gloves. Surveyors also identified infection control failures during wound care for another resident who required enhanced barrier precautions due to a chronic right thigh ulcer, colostomy, and suspected MRSA carrier status. Observation showed a nurse donning a gown and gloves and entering the resident’s room without performing hand hygiene. The nurse obtained supplies from a dresser, placed them on the bedside table, removed the existing dressing from the right hip wound, and cleaned drainage from the wound. Without removing the soiled gloves, the nurse opened clean dressings, cleansed the wound with normal saline, patted it dry with gauze, and applied and taped a new dressing. The nurse then removed the gown and soiled gloves and exited the room without performing hand hygiene before entering or after exiting the room, and without changing gloves and performing hand hygiene between the soiled and clean portions of the dressing change. An administrative nurse stated she expected staff to perform hand hygiene with alcohol-based hand sanitizer after resident care, between glove changes, and during dressing changes.
Failure to Assess, Monitor, and Treat Foot Wounds Resulting in Amputation
Penalty
Summary
The facility failed to provide necessary care and treatment for a resident with impaired skin integrity on the feet and toes. Despite the resident's history of peripheral vascular disease and recent isolation for COVID, staff did not consistently assess, monitor, or document the resident's skin condition as required by facility policy. A physician's order was in place to monitor the wound every seven days and notify the physician if there was no change in two weeks, but the treatment administration record lacked documentation of skin assessment and treatment. Additionally, the electronic health record did not contain the dressing change orders referenced in the progress notes, and a weekly skin check failed to identify or assess the impaired skin integrity on the resident's toes. The facility also did not ensure timely initiation of treatment for the toe wounds, daily documentation of abnormal skin conditions, or proper communication with the provider regarding treatment. There was a lack of documentation from the physician assistant's in-house visit, and the administrative nurse confirmed that no assessment or orders were recorded from that visit. These failures resulted in a delay of treatment, and the resident was ultimately hospitalized for amputation of the fourth and fifth toes due to gangrene.
Failure to Prevent Verbal Abuse in LTC Facility
Penalty
Summary
The facility failed to provide an environment free of verbal abuse for a resident, leading to an immediate jeopardy situation. The incident involved a certified nursing assistant (CNA) who allegedly threatened a resident by saying, "If you don't stop talking about me, I'm going to put a pillow over your head and kill you." This statement was made after the resident had been put to bed, causing the resident to feel scared. The resident was cognitively intact and capable of making decisions, as indicated by a Brief Interview for Mental Status (BIMS) score of 15. The resident required assistance with activities of daily living, transfers, and had vision impairment and communication difficulties. The facility's investigation into the incident was initially deemed unsubstantiated, although it was acknowledged that a verbal altercation likely occurred. Another resident across the hall confirmed hearing yelling between the involved resident and the CNA. Additionally, other CNAs recalled conversations where the threatening statement was mentioned, but they did not report it to management. The facility failed to recognize the abuse, assess the resident physically and mentally, notify the interdisciplinary team, update the care plan, and inform the resident's provider. The facility's policy on abuse prevention, dated 2017, defines abuse as the willful infliction of intimidation resulting in mental anguish, including verbal and mental abuse. Despite this policy, the facility did not take appropriate action to prevent or address the verbal abuse incident, leading to fear, anxiety, and psychosocial harm for the resident involved.
Removal Plan
- CNA's file was updated to include do not rehire.
- All staff were retrained on definitions of abuse and how to identify abuse.
- Remaining facility staff were re-educated.
- The facility's regional registered nurse re-educated administrative staff members on definitions of abuse and how to identify abuse.
- Remaining administrative staff to be educated by administrative staff members.
- An automated notification was sent to all staff regarding the mandatory re-education.
- An education packet will be put in the employee newsletter for reference.
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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 Wahpeton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St Francis Home | 1.2 mi | ★★★★★ | 7 | 0 |
| St Gerard's Community Of Care | 20.3 mi | ★★★★★ | 0 | 0 |
| Mn Veterans Home Fergus Falls | 25.5 mi | ★★★★★ | 8 | 1 |
| Lb Broen Home | 25.9 mi | ★★★★★ | 5 | 0 |
| Pioneer Care Center | 26.2 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.