Cura of Le Sueur

Inspectors wroteBased on interview and document review the facility failed to ensure medications were administered according to physician orders which resulted in a significant medication error for 1 of 3 residents (R1) reviewed for medication administration. This resulted in actual harm for R1 when an increased dose of a diuretic (water pill) had been ordered but was later discontinued without a physician order. R1 did not receive an increased dose, nor any doses of prescribed diuretic for two days and subsequently developed shortness of breath, had to be sent to the emergency department (ED) where he received intravenous diuretic and needed to be hospitalized . The facility implemented immediate corrective action and corrected the deficient practice by 6/18/26, so the citation was issued at past non-compliance.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a resident was comprehensively assessed and appropriately monitored for fluid volume status after a reported significant increase in daily weight for 1 of 3 residents (R2) reviewed for change in condition.

Inspectors wroteBased on observation and interview, the facility failed to maintain 1 of 1 ice machine to prevent potential contamination and to ensure food and drinks were served in a safe and sanitary manner. This had the potential to affect all 21 residents who resided in the facility. Findings Include:On 2/23/26 at 10:45 a.m., during the initial tour of the kitchen with the dietary director (DD-D), a Manitowoc brand ice machine located in a hallway adjacent to the kitchen was observed with white/grey chalky, powdery, hard, crusty, rock-like, lumpy deposits present on: the inside lid of the ice machine, the outside lid, the front exterior surface, and both side exterior surfaces. The buildup appeared consistent with lime scale and mineral deposits. The DD-D stated the ice machine had lime scale buildup and that maintenance staff were responsible for cleaning the ice machine. [...]

Inspectors wroteBased on interview and document review, the facility failed to establish and maintain a system to ensure concerns voiced during resident council meetings were addressed and follow up with residents. This had potential to effect 6 of 6 residents (R1, R4, R5, R9, R18, R20) identified to have attended the meetings.

Inspectors wroteBased on interview and document review, the facility failed to submit accurate and/or complete data for staffing information, based on payroll and other verifiable and auditable data during 1 of 1 quarter reviewed (Quarter 4, 2025), to the Centers for Medicare and Medicaid Services (CMS), according to specifications established by CMS.

Inspectors wroteBased on interview and document review, the facility failed to ensure resident mail was delivered on Saturdays for 7 of 7 residents (R1, R4, R5, R13, R15, R18, R20) reviewed during resident council. This deficient practice had the potential to affect all 21 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to complete a comprehensive skin assessment and monitoring of impaired skin integrity for 1 of 3 residents (R1) reviewed for skin care.

Inspectors wroteBased on observation, interview, and document review, the facility failed to provide sufficient staffing to ensure residents received care and assistance as needed. These deficient practices had the potential to affect all residents who resided in the facility.

Inspectors wroteBased on observation, interview and document review, the facility failed to follow Centers for Medicare and Medicaid Services (CMS) and Centers for Disease Control (CDC) guidelines by appropriately implementing preventive measures to prevent the spread of influenza A, failed to post appropriate signage for 11 of 11 residents (R2, R9, R10, R79, R12, R4, R16, R1, R18, R22, R3) who exhibited symptoms of influenza A or had tested positive for influenza A, and further failed to ensure correct personal protective equipment (PPE) use. In addition; the facility failed to ensure correct use of gloves during wound care for 1 of 1 resident, (R16). This had the potential to affect all residents who resided at the facility.

Inspectors wroteBased on interview and document review, the facility failed to ensure annual performance reviews were completed for 4 of 4 nursing assistants (NA-A, NA-F, NA-B, NA-E) whose files were reviewed. This had potential to affect all residents who currently resided in the nursing home and who could receive care from these staff.

Inspectors wroteBased on observation and interview, the facility failed to ensure 2 of 3 tub/shower rooms were maintained in good repair and sanitary conditions for 15 residents who utilized two tub/shower rooms on the Prairie unit.

Inspectors wroteBased on interview and document review, the facility failed to ensure an annual performance review was conducted for 4 of 4 nursing assistants (NA-A, NA-F, NA-B, NA-E) and therefore failed to ensure annual training reflected the NA's areas of weaknesses identified on performance reviews. Findings Include: The following NA's personnel and training records were reviewed for annual performance reviews and training and identified the following: NA-A was hired on 6/14/23. NA-A's personnel record lacked evidence an annual performance review was ever completed. NA-F was hired on 11/7/23. NA-F's personnel record lacked evidence an annual performance review was ever completed. NA-B was hired on 7/16/18. NA-B's personnel record lacked evidence of a current annual performance review. NA-E was hired on 6/7/21. NA-E's personnel record lacked evidence an annual performance review was ever completed. [...]

Inspectors wroteBased on interview, observation and document review the facility failed to ensure the Minimum Data Set (MDS) was accurately coded for pressure ulcers for 1 of 2 residents (R16) reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview and document review the facility failed to develop a comprehensive person centered care plan to address falls and ensure the care plan was revised with the new fall interventions to prevent further falls for 1 of 2 residents (R79) reviewed for falls.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure residents received assistance with meals for 3 of 3 residents (R1, R2, and R10) reviewed for dining who requred staff assistance and/or supervison with meals.

Inspectors wroteBased on interview and document review, the facility failed to monitor weights as ordered for 1 of 1 resident (R10) reviewed for edema and 2 of 2 residents reviewed for nutrition (R20 and R23)

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure weekly comprehensive skin assessments (including measurements) were completed for 2 of 2 residents (R16 and R20) reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview and document review, the facility failed to provide services to maintain and prevent loss of range of motion (ROM) for 2 of 2 residents (R20, R22) reviewed for restorative services.

Inspectors wroteBased on observation, interview and document review, the facility failed to conduct a comprehensive reassessment after falls to identify root cause and ensure new interventions were implemented to prevent further falls for 1 of 2 residents (R79) reviewed for falls.

Inspectors wroteBased on interview and document review, the facility failed to ensure consulting pharmacist recommendations were addressed or acted upon for 1 of 5 residents (R10) reviewed for unnecessary medications.

Inspectors wroteBased on observation and interview, the facility failed to ensure meals were served at a warm and palatable temperature to promote quality of life and nutritional intake for 2 of 2 residents (R22 and R16) reviewed for dining. This had the potential to affect all 25 residents who resided in the facility.

Inspectors wroteBased on document review and interview, the facility failed to ensure Quality Assurance Performance Improvement (QAPI) meetings were held on a quarterly basis.

Inspectors wroteBased on interview and document review, the facility failed to ensure 12 of 25 residents (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, and R12) reviewed for drug diversion were free from misappropriation of their property when their medications were taken by a staff member. This resulted in diversion of 121 oxycodone tablets, one tramadol tablet and two doses of liquid lorazepam. The immediate jeopardy (IJ) began on 9/27/24, when registered nurse (RN)-A notified the director of nursing (DON) with her concerns that trained medication aide (TMA-A) had been signing controlled medications out of the narcotic logbook. However, TMA-A was not documenting medication in the medication administration record (MAR) as given. R1 and R2 notified RN-A and their provider they had not received as needed (PRN) medications. [...]

Inspectors wroteBased on interview and document review, the facility failed to ensure narcotic and controlled substances destruction was completed in accordance with established policies and procedures to reduce the risk of diversion and/or theft.

Inspectors wroteBased on observation, interview and document review the facility failed to complete a thorough investigation when 1 of 1 residents (R1) alleged staff to resident abuse and the care plan was not reviewed to ensure all provisions of care were being adequately implemented. This put R1 at risk for future accidents when, during review, it was determined staff were not implementing transfer interventions as care planned.

Inspectors wroteBased on observation, interview and document review the facility failed to implement Self Care plan interventions for 1 of 3 residents (R1) which put R1 at risk for falls during provisions of care.

Inspectors wroteBased on interview and document review, the facility failed to submit accurate and/or complete data for staffing information, including information for salaried nursing staff, based on payroll and other verifiable and auditable data during 1 of 1 quarter reviewed - Quarter 1, 2024, (October 1 - December 1), to the Centers for Medicare and Medicaid Services (CMS), according to specifications established by CMS.

Inspectors wroteBased on observation and interview staff failed to ensure mechanical transfer lifts were cleaned after resident use for 2 of 2 residents (R19 and R20) observed for infection control practices. Findings Include: R19's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R19 was cognitively intact, dependent on staff for toileting, required set up or clean up assistance with personal hygiene, substantial/maximal assistance with transfers, and used a wheelchair for mobility. R19's care plan dated 3/22/24, indicated R19 had self-care deficit related to hx (history) of right hip fx (fracture) interventions included locomotion off unit: total dependence in w/c (wheelchair), toileting: assist of two to commode, transfer: assist of two resident performs stand pivot transfers with four wheeled walker and is able to take 3-5 steps as needed, and non-ambulatory. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to assess for potential restraints for 2 of 2 residents (R12 and R20) who used weighted blankets.