LE SUEUR, MN - A federal inspection at Ridgeview Lesueur Long Term Care and Rehab Center revealed a severe staffing crisis that left residents waiting up to nearly two hours for basic care needs, according to a January 16, 2025 Centers for Medicare & Medicaid Services report.
Dangerous Call Light Response Times
The most concerning findings involved extended delays in responding to resident call lights. During continuous observation on January 13, 2025, inspectors documented alarming wait times for three residents who needed immediate assistance. One resident with amyotrophic lateral sclerosis (ALS) waited one hour and 46 minutes for help using a urinal, while two other residents experienced delays of one hour and 14 minutes and one hour and 32 minutes respectively.
The resident with ALS explained he had been waiting for over an hour to use the urinal and expressed concern about potential incontinence if staff took too long. His son ultimately arrived to provide the assistance that nursing staff could not deliver in a timely manner.
Another resident reported that extended response times were routine, stating that call lights "always took a long time" and sometimes up to two hours for staff to respond. The resident noted that staff appeared rushed when they finally arrived due to being overwhelmed with responsibilities.
Severe Understaffing Pattern
Documentation revealed systematic understaffing that compromised resident care quality. Nursing assistant records showed the facility operated significantly below required staffing levels on multiple days between December 15, 2024 and January 14, 2025. On some occasions, only two nursing assistants covered the entire facility, with one staff member reporting working alone for periods of time.
The facility's assessment indicated that 13 of 25 residents required two-person assistance for transfers and toileting, creating additional strain on limited staff resources. One nursing assistant explained that when multiple residents needed two-person care, it kept both available staff occupied in single rooms for extended periods, leaving other residents unable to receive timely assistance.
Documented Care Failures
The staffing shortage resulted in multiple missed scheduled services. Three residents who were scheduled for baths on January 13, 2025 did not receive them because staff reported being "too busy." One nursing assistant acknowledged documenting that a bath was completed when it actually was not, stating this occurred because "they had not been able to get baths done and had gotten in trouble for not giving baths."
Residents expressed disappointment about missed care services. One resident stated he did not receive his scheduled bath and was told staff were too busy, adding that he likely would not get a bath until his next scheduled day. Another resident similarly reported missing his scheduled bath without it being offered or rescheduled.
The inspection revealed that residents who missed baths on January 13 had still not received makeup baths by January 16, despite facility policy expectations for timely rescheduling.
Food Service Temperature Violations
Temperature monitoring during meal service revealed significant food safety concerns. When inspectors measured food temperatures on a test tray that had been sitting on the unit for 45 minutes, mashed potatoes registered 129.7 degrees Fahrenheit and mixed vegetables measured 125 degrees Fahrenheit - both below optimal serving temperatures.
Residents consistently reported receiving cold meals, particularly breakfast items. One resident with ALS stated his meals were "always late and always cold," explaining he had become accustomed to eating cold food. Another resident reported receiving cold breakfast items but eating them anyway due to lack of alternatives.
The facility's dietary manager acknowledged the temperature problems and stated they would return to using regular plates with warmers instead of Styrofoam containers to better maintain food temperatures.
Medical Protocol Failures
Medication monitoring violations compromised patient safety protocols. The facility failed to follow through on consulting pharmacist recommendations for a resident taking antipsychotic medication. The pharmacist had recommended monthly blood pressure monitoring for a resident prescribed quetiapine, but the facility incorrectly entered the order, causing the monitoring requirement to lapse.
This type of monitoring is essential for residents taking antipsychotic medications to detect potential side effects that could affect cardiovascular function and overall health stability.
Infection Control Breakdown
During an influenza outbreak affecting 11 residents, the facility failed to implement proper isolation protocols. Residents with confirmed or suspected influenza did not have appropriate signage posted on their doors to alert staff about necessary protective equipment requirements.
Staff members wore the same masks when moving between resident rooms, contrary to infection control standards that require mask changes to prevent cross-contamination. One nursing assistant acknowledged being unsure which rooms required gown use and was unaware of which residents had influenza.
The facility's infection prevention nurse was simultaneously working as floor nursing staff during the outbreak, preventing adequate time for implementing proper infection control measures.
Facility Maintenance Issues
Physical plant conditions presented additional health and safety concerns. Shower rooms used by 15 residents contained heavily soiled air filters, crumbling wall surfaces with rust-colored staining, and ceiling vents laden with debris. Shower floors showed permanent staining that could not be removed, and repairs were completed using inappropriate materials like zip ties.
The maintenance director acknowledged being unaware of multiple facility condition issues and stated that replacement filters ordered months earlier had not yet arrived.
Administrative Response
The facility administrator, who had been in position for approximately four weeks at the time of inspection, acknowledged the severity of staffing problems. She confirmed that agency staff were brought in starting January 14, 2025, specifically due to the outbreak situation and staffing crisis.
Management had not conducted performance reviews for any of the four nursing assistants whose files were reviewed, with some staff members having worked at the facility for several years without formal evaluation. The administrator attributed this to leadership turnover and stated plans to begin reviews once she became more familiar with staff capabilities.
Regulatory Standards and Implications
Federal regulations require nursing homes to maintain adequate staffing levels to meet resident care needs and ensure timely response to requests for assistance. The documented response times of up to nearly two hours for basic care needs represent significant departures from accepted care standards.
Professional care protocols typically expect call light responses within 5-15 minutes for non-emergency situations, with immediate response required for urgent needs like toileting assistance. Extended delays can result in resident dignity issues, increased fall risks, and potential medical complications.
The facility's own assessment policy established nursing assistant ratios of 1:10 during day and evening shifts, but actual staffing frequently fell well below these internal standards during the period reviewed.
This inspection highlights the critical importance of adequate staffing in maintaining basic care quality and resident safety in nursing home environments. The combination of staffing shortages, missed care services, and compromised infection control protocols created multiple risks for resident health and wellbeing at this Minnesota facility.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ridgeview Lesueur Long Term Care and Rehab Center from 2025-01-16 including all violations, facility responses, and corrective action plans.
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