Gundersen St. Elizabeth's: Infection Control Failure - MN
During a federal inspection on June 9, 2026, just before noon, the facility's director of nursing walked into a resident's room to help transfer him from his bed to a chair for lunch. The resident, identified in inspection records only as R54, had moderate cognitive impairment, used a walker, and depended on staff for most of his daily care. He also had kidney disease and relied on an indwelling urinary catheter, a tube inserted into the bladder to drain urine he could not pass on his own.
That catheter is precisely why the director was supposed to put on a gown and gloves before touching him. The facility's own enhanced barrier precautions policy, updated just three weeks earlier on May 20, 2026, spelled it out: any resident with an indwelling medical device requires that staff gear up before hands-on care activities, including transfers.
The director did not.
Four minutes after the observation, an inspector interviewed her. She acknowledged she should have been wearing the protective equipment. She said R54 required enhanced barrier precautions because of his catheter. She said the gear was important to stop infection from spreading between residents.
She knew. She just didn't do it.
Enhanced barrier precautions exist because urinary catheters create a direct pathway for bacteria to enter the body, and organisms picked up on bare hands or unprotected clothing during a transfer can travel from room to room on the next staff member who skips the same step.
Inspectors cited the violation at the minimal harm level, meaning no injury to R54 was documented. Whether the lapse was a single moment of inattention or something more routine, the inspection record does not say. What it does say is that the nurse who sets the standard for infection control in the building was the one caught not meeting it.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Gundersen St Elizabeth's Care Center from 2026-06-10 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
GUNDERSEN ST ELIZABETH'S CARE CENTER in WABASHA, MN was cited for violations during a health inspection on June 10, 2026.
The resident, identified in inspection records only as R54, had moderate cognitive impairment, used a walker, and depended on staff for most of his daily care.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.