Cura of Willmar

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure timely assistance with repositioning occurred for 1 of 2 residents (R29) reviewed for pressure ulcers. Findings Include: R29's quarterly Minimum Data Set (MDS) dated [DATE], identified R29 was cognitively intact and had diagnosis which included; diabetes mellitus, coranary artery disease, and hypertension. R29's MDS identified R29 was dependent for dressing lower half, transfer, toileting and required substantial/maximal assistance with rolling in bed side to side. R29 had one stage 4 pressure ulcer (full-thickness skin and tissue loss with exposed or with directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer). [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to implement care planned interventions to prevent further falls for 1 of 2 resident (R22) reviewed for falls.

Inspectors wroteBased on interview, observations, and document review, the facility failed to provide nursing rehab services as ordered for 1 of 1 resident (R44) reviewed for rehab services. R44's Quarterly Minimum Data Set (MDS) dated [DATE], indicated R44 had intact cognition, did not reject care that is necessary to achieve the resident's goals for health and well-being. R44's diagnoses included hemiplegia (left side weakness), hypertension (high blood pressure), and diabetes. R44's care plan revised on 6/10/26, directing staff to the nursing rehab program as noted in tasks; the program is overseen by a nurse and periodically reviewed. R44's discharge recommendations, signed 11/26/25, identified range of motion program; [...]

Inspectors wroteBased on observation, interview and document review the facility failed to ensure infection prevention practices including hand hygiene were followed during wound cares for 1 of 1 residents (R29) observed for wound cares. Findings Include: R29's quarterly Minimum Data Set (MDS) dated [DATE], identified R29 was cognitively intact and had diagnosis which included; diabetes mellitus, coranary artery disease, and hypertension. R29's MDS identified R29 was dependent for dressing lower half, transfer, toileting and required substantial/maximal assistance with rolling in bed side to side. R29 had one stage 4 pressure ulcer (full-thickness skin and tissue loss with exposed or with directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer). [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure grievance forms and procedures were posted in prominent locations throughout the facility for residents and resident representatives to file grievances, and anonymously if desired for 3 of 3 (R10, R28, R42) resident council members interviewed. This had the potential to affect all 52 residents who resided in the facility.

Inspectors wroteBased on interview and document review the facility failed to protect 1 of 1 resident (R1) from neglect when R1 experienced a fall from the toilet on 3/7/26 and unidentified staff assisted R1 back to bed without notification to nurse and assessment. This resulted in actual harm when R1 was later identified to be in pain, required emergency medical attention, and was diagnosed with closed fracture of left hip. R1 required surgical repair of the fracture. The facility implemented corrective action, and the deficient practice was corrected on 3/08/26, prior to the survey, and was issued at past non-compliance.

Inspectors wroteBased on observation, interview and document review the facility failed to develop and implement a process to ensure the wander alert system was in working order. This had the potential to affect 2 of 2 residents (R1, R2) who utilized a wander alert device.

Inspectors wroteBased on observation and interview, the facility failed to ensure resident rights were maintained for 1 of 3 residents (R37) reviewed for dignity. Findings Include: R37's quarterly Minimum Data Set (MDS) dated [DATE], identified R37 had severe cognitive impairment and required assistance with activities of daily living (ADL)'s. R37's diagnoses included non-Alzheimer's dementia, weakness and localized edema. MDS also indicated R37 had an indwelling external catheter. During observation on 8/4/25 at 2:21 p.m., R37's urinary catheter drainage bag, which was approximately half full of dark amber colored liquid, was hanging on the left side of bed. Drainage bag was visible to all residents and staff who walked past. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to inform residents in the facility that all bird feeders, including personally owned bird feeders, were being removed, prior to doing so, for 1 of 1 residents (R34) in the sample.

Inspectors wroteBased on interview and document review, the facility failed to complete and implement a baseline care plan within 48 hours of admission for 1 of 2 residents (R22) reviewed for care plans.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure a wheeled walker was not used as a wheelchair for 1 of 1 residents (R10) which placed resident at increased risk for a fall.

Inspectors wroteBased on interview and document review the facility failed to ensure coordination of dialysis care for 2 of 2 resident (R3 and R22) who required dialysis (treatment to filter blood when kidneys are no longer able). Additionally, the facility failed to ensure post-dialysis assessment and monitoring was completed for 2 of 2 resident (R3 and R22) reviewed for dialysis.

Inspectors wroteBased on interview and document review, the facility failed to ensure tuberculosis (TB) testing was completed for 1 of 6 sampled residents (R68) reviewed for required baseline TB screening and testing.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure the nursing staff posting (which included number of nurses and nursing assistants and the hours they were scheduled) was posted and available for all residents. families and visitors. This potentially effected all 20 residents residing in [NAME] House, all 20 residents residing in [NAME] House and their families / visitors.

Inspectors wroteBased on interview and document review, the facility failed to ensure as needed (PRN) medications were administered per physician's order for 1 of 1 resident (R20) reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview and document review, the facility failed to perform hand hygiene after high contact direct cares for 1 of 3 residents (R114) reviewed for infection control.

Inspectors wroteBased on interview and document review, the facility failed to ensure 1 of the 5 residents (R55) reviewed for immunizations were offered and/or provided the pneumococcal vaccination series as recommended by the Centers for Disease Control (CDC) to help reduce the risk of associated infection(s).

Inspectors wroteBased on interview and document review, the facility failed to ensure education on benefits and potential side effects of COVID-19 booster vaccination and administration of the vaccination to 1 of 5 residents (R55) reviewed for COVID-19 vaccination status.

Inspectors wroteBased on interview and document review, the facility failed to monitor for signs and symptoms of aspiration for 2 of 4 residents (R1, R2) reviewed who were not provided thickened liquid as ordered.

Inspectors wroteBased on interview and document review, the facility failed to notify resident representative/physician timely following an incident where residents therapeutic dietary order was not followed with the potential for aspiration for 2 of 4 residents (R1, R2) reviewed. In addition, the facility failed to update the physician for 1 of 4 residents (R4), who had continuous low blood pressures.

Inspectors wroteBased on interview and document review the facility failed to administer blood pressure medications in accordance to physician's orders for 1 of 4 residents (R4) reviewed.