Ridgeview Lesueur Long Term Care And Rehab Center

F-F676: Based on observation, interview and document review the facility failed to ensure residents received assistance with meals for 3 of 3 residents (Resident R1, Resident R2, and Resident R10) reviewed for dining who required staff assistance and/or supervision with meals.

Refer to

F-F684: Based on interview and document review, the facility failed to monitor weights per physician order for 1 of 1 resident (Resident R10) reviewed for edema and 2 of 2 residents reviewed for nutrition (Resident R20 and Resident R23).

Refer to

F-F686: Based on observation, interview and document review, the facility failed to ensure weekly comprehensive skin assessments (including measurements) were completed for 2 of 2 residents (Resident R16 and Resident R20) reviewed for pressure ulcers.

Refer to

F-F688: Based 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 (Resident R20, Resident R22) reviewed for restorative services.

Refer to

F-F804: Based 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 (Resident R22 and Resident R16) reviewed for dining.

Resident R16's facesheet printed 1/15/25, indicated diagnosis of osteomyelitis (bone infection).

Resident R16's admission Minimum Data Set (MDS) assessment dated [DATE REDACTED], indicated intact cognition, no behaviors, independent with eating, dependent on staff for toileting hygiene, and partial assistance with personal hygiene.

Resident R22's facesheet printed on 1/15/25, indicated diagnoses of amyotrophic lateral sclerosis (ALS) and repeated falls.

Resident R22's significant change MDS assessment dated [DATE REDACTED], indicated intact cognition, no behaviors, use of a walker and wheelchair, and dependent on staff for eating, dressing, bathing, and personal hygiene.

Resident R22's care plan revised on 9/18/24, indicated a self-care deficit and dependent on staff for his activities of daily living with intervention of one staff assist for bathing.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 49 245416 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245416 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cura of Le Sueur 621 South 4th Street Le Sueur, MN 56058

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Resident R3's facesheet printed 1/15/25, indicated diagnoses of anemia, type 2 diabetes mellitus, chronic pain, and muscle weakness. Level of Harm - Minimal harm or potential for actual harm Resident R3's admission MDS assessment dated [DATE REDACTED], indicated intact cognition, no behaviors, use of a wheelchair, set up assistance for eating, and substantial assistance with personal hygiene. Residents Affected - Many Resident R2's facesheet printed 1/15/25, indicated diagnoses of heart failure, pain syndrome, and kidney disease.

Resident R2's significant change MDS assessment dated [DATE REDACTED], indicated intact cognition, no behaviors, and dependent on staff for personal hygiene and transfers.

Resident R2's care plan printed 1/15/25, indicated self-care deficit and dependent on staff for bathing assistance.

Resident R21's facesheet printed 1/15/25, indicated diagnoses of dementia, failure to thrive, and anxiety.

Resident R21's quarterly MDS assessment dated [DATE REDACTED], indicated severely impaired cognition, physical and verbal behaviors, and dependent on staff for personal hygiene and bathing.

Resident R21's care plan revised 1/3/25, indicated self care deficit, resident will appear clean, neat, and well kept, and bathing assist of one staff on Monday AM.

Call light observations/ staffing interviews

During continuous observation on 1/13/25, from 11:40 a.m. to 1:35 p.m., extended call light times were observed for Resident R16, Resident R22, and Resident R3. At 11:40 a.m., Resident R16, Resident R22, and Resident R3 all had their call lights on indicating the need for assistance. Resident R3's call light was answered at 12:54 p.m., Resident R16's call light was answered at 1:12 p.m., and Resident R22's call light was answered at 1:26 p.m. Resident R3's call light was on for one hour and 14 minutes, Resident R16's call light was on for one hour and 32 minutes, and Resident R22's call light was on for one hour and 46 minutes.

During interview on 1/13/25, at 12:49 p.m., Resident R22 stated he had been waiting for over an hour to use the urinal. Resident R22 further stated it took up to two hours for his call light to be answered some days and he would be uncomfortable and incontinent if it took too long. Resident R22 stated his son was coming to help him use the urinal due to the long wait time. Resident R22 stated the staff were good, there just were not enough of them to help everyone. Resident R22's son was observed arriving at Resident R22's room and assisting with urinal use.

During interview on 1/13/25 at 3:45 p.m., Resident R16 stated it always took a long time for staff to answer his call light, sometimes up to two hours. Resident R16 stated it was a common situation and the facility needed more staff so

they could help him sooner and not be so rushed when they did come to help him.

During interview on 1/13/25 at 11:46 a.m., nursing assistant (NA)-A stated they did not have enough staff to take care of the residents and it had been happening a lot lately. NA-A stated they got busy after breakfast and were still trying to catch up. NA-A further stated they were not able to answer call lights because so many residents required assistance of two staff and kept them in a residents room for over and hour, and

they only had two staff working for the whole building.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 49 245416 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245416 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cura of Le Sueur 621 South 4th Street Le Sueur, MN 56058

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 During interview on 1/14/25 at 8:59 a.m., NA-B stated today had been a better day because state was here so they had started using agency staff so it looked like they had more staff. NA-B further stated they never Level of Harm - Minimal harm or had four NA's working, but today they were letting four NA's work and were letting people get overtime and potential for actual harm stay longer to help, and were offering bonuses, but that never happened.

Residents Affected - Many During an interview on 1/14/25 at 9:30 a.m., NA-E stated she had worked at the facility for over a year and had never seen it this bad. Sometimes there were only two NA's on duty and sometimes she was the only NA on duty for a while for the entire facility. Agency NA's started today (1/14/25) and it was her understanding just for the outbreak.

During interview on 1/14/25 at 11:11 a.m., NA-E stated she had only worked with herself and one other NA for multiple days and at one time worked by herself. NA-E further stated it was hard to get her work done,

she could not get her baths done, and even with three NA's it was hard to take care of the residents because so many residents required two NA's to assist them. NA-E stated she did not get baths done again this morning, could not get walking or range of motion done, and at times residents who were not usually incontinent would be incontinent because she could not get to them in time.

On 1/14/25 at 2:26 p.m., NA-E stated resident vitals, weights, baths, and range of motion was not done as expected due to shortage of staff and the length of time some the residents require to assist with their cares.

A facility document titled Residents needing assist of two for transferring printed on 1/14/25, indicated 13 of 25 residents required two staff assist for transfers and toileting.

Facility call light response logs were requested and not received.

Baths

During observation on 1/13/25 at 7:00 p.m., no baths were observed completed. Review of the facility bath schedule indicated Resident R22, Resident R2, and Resident R21 were scheduled for baths on 1/13/25. The facility bath schedule printed 1/14/25, indicated Resident R2 and Resident R21 had weekly scheduled baths on Monday and Resident R22 had a scheduled bath twice per week on Monday and Thursday.

During interview on 1/14/25 at 9:47 a.m., Resident R2 stated he had not had his bath yesterday because staff told him

they were too busy. Resident R2 further stated he would not get a bath until his next bath because staff didn't have time for extra baths.

During interview on 1/14/25 at 2:29 p.m., Resident R22 stated he did not get his scheduled bath and it was not offered to him. Resident R22 further stated staff try, but they can't get it all done. Resident R22 stated he didn't think he would get his bath until his next scheduled bath day, but wanted his bath.

During interview on 1/14/25 at 2:16 p.m., nursing assistant (NA)-F stated they did not get any baths done yesterday (1/13/25) due to being too busy. NA-F stated she documented that Resident R2 had a bath, but he did not have a bath, and she did that because they had not been able to get baths done and had gotten in trouble for not giving baths so staff document was done so not get in trouble. NA-F stated she was unsure if the baths were rescheduled.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 49 245416 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245416 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cura of Le Sueur 621 South 4th Street Le Sueur, MN 56058

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 During interview on 1/15/25 at 8:20 a.m., NA-A stated if baths were missed was not sure how they were rescheduled, or if they just had to wait until the next scheduled bath. NA-A further stated she thought the Level of Harm - Minimal harm or next shift should do it, but they were busy too. potential for actual harm

During interview on 1/14/25 at 12:14 p.m., licensed practical nurse (LPN)-C stated she worked on 1/13/25, Residents Affected - Many and was not aware baths were not done. LPN-C further stated NA's were supposed to tell the nurse if baths were not completed.

During interview on 1/15/25 at 8:47 p.m., registered nurse (RN)-C, also known as regional clinical director, stated if residents missed their baths they should have a bath within the next 24 hours if they can. RN-D further stated she was not aware of a facility bath policy.

During interview on 1/16/25 at 12:09 p.m., RN-H, also know as regional clinical director, stated she would expect a bath that was missed on 1/13/25 to have happened by now, and should have happened within a reasonable time.

A review of facility electronic health record (EHR) task logs for bathing on 1/16/25, indicated Resident R22, Resident R2, and Resident R21 had not had a bath since missing their schedule baths on 1/13/25.

Meal assistance

On 1/13/25 at 1:47 p.m., the administrator stated she was asked by the nursing assistants to assist feeding Resident R22 his meal. The administrator stated residents were crying to go back to bed, and stated when we only have two NA's on the floor things don't function and we need three NA's to function. The administrator stated when the facility doesn't have three NA's during the day shift, its a bad day, stressful things might get put behind. The administrator stated the nurse managers help when they are present at the facility, however RN-A and RN-B had to go home so they can can work evening and overnight shift. The administrator stated due to the staffing shortage and situation she had opened shifts to agency staff starting tomorrow (1/14/25).

On 1/14/25 12:48 p.m., activities aide (AA)-B stated all the food had been delivered to resident, expect for Resident R19's food as he required staff assistance with eating.

On 1/14/25 12:53 p.m., NA-C stated Resident R19 required staff assistance with eating and there were not staff available to help him eat yet.

On 1/14/25 at 12:56 p.m., the administrator stated Resident R19 was expected to have not had to wait for until now for staff assistance with eating.

Facility Assessment

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 49 245416 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245416 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cura of Le Sueur 621 South 4th Street Le Sueur, MN 56058

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Review of facility assessment dated ,d+[DATE REDACTED], indicated the facility reviewed acuity within their resident population and listed 15-25% of residents and clinically complex and 30-40% of residents with reduced Level of Harm - Minimal harm or physical function. The facility assessment listed 30-40% of residents dependent for transfers and 25-35% potential for actual harm dependent for toileting, and 87% of residents in a chair most of the time. The facility uses a comprehensive admission assessment process to identify individualized resident care needs and determine if the facility can Residents Affected - Many meet the resident's need. The facility staffing plan within the facility assessment indicated they used a resident based approach to staffing which was based on the resident population and adjusted as necessary based off of shift day, evening, and overnight.

Staffing Schedules

Review of facility's nursing schedules for 12/15/24 through 1/14/25 lacked the required nursing assistants and nurses for the following based on facility assessment:

12/15: NA 6 hours

12/16: NA 3 hours

12/17: NA 2 hours, Nurse/TMA 3.5 hours

12/19: NA 2 hours

12/23: NA 8 hours

12/25: NA 8 hours

12/26: NA 8 hours, Nurse/TMA 8 hours

12/27: Nurse/TMA 8 hours

12/28: NA 2 hours, Nurse/TMA 3.5 hours

12/29: NA 2 hours

12/30: NA 1.5 hours, Nurse/TMA 3.5 hours

01/02: NA 2 hours

01/03: NA 3 hours, Nurse/TMA 4.5 hours

01/04: Nurse/TMA 2.5 hours

01/06: NA 3.5 hours, Nurse/TMA 7 hours

01/07: NA 4.5 hours, Nurse/TMA 8 hours

01/08: NA 2 hours

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 49 245416 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245416 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cura of Le Sueur 621 South 4th Street Le Sueur, MN 56058

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 01/09: NA 18 hours

Level of Harm - Minimal harm or 01/11: NA 4 hours potential for actual harm 01/12: NA 16.5 hours, Nurse/TMA 8 hours Residents Affected - Many 01/13: NA 24 hours, Nurse/TMA 8 hours

01/14: NA 10 hours

44630

On 1/14/25 at 2:37 p.m., RN-A, known as the assistant director of nursing and infection prevention nurse, confirmed due to not enough staff NA's were not able to give scheduled baths, answer call lights timely, walk or complete ROM with residents. RN-A stated the information about not enough staff was shared with the administrator, and administrator educated nursing staff to have a positive attitude, and help the NA's. RN-A stated the administrator was helping on the floor with resident cares due to the shortage of staff, and the administrator had pulled the business office staff to help with resident cares.

The Le Sueur Facility Assessment policy revised 3/2024, indicated the below staffing ratios from the staffing plan: (ratios are staff/:residents)

Nurses/TMAs

Days and evenings:

2 licensed nurses 1:22-1:35 ratio

1 TMA 1:22-1:35 ratio

Nights:

1 licensed nurse 1:35 ratio

Nursing assistants:

Days and Evenings: 1:10 ratio

Nights: 1:22 ratio

42073

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 49 245416 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245416 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cura of Le Sueur 621 South 4th Street Le Sueur, MN 56058

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0730 Observe each nurse aide's job performance and give regular training.

Level of Harm - Minimal harm or 50764 potential for actual harm Based on interview and document review, the facility failed to ensure annual performance reviews were Residents Affected - Some 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.

Findings include:

The following nursing assistants (NA)'s personnel records were reviewed for annual performance reviews 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.

During interview on 1/15/25 at 8:10 a.m., administrative support stated she did not have any performance reviews for staff in personnel files. She further stated there had been too much leadership turnover and the performance reviews had not been completed.

During interview on 1/15/25 at 9:08 a.m., administrator stated she did not have any completed performance reviews that she was aware of. Administrator further stated they had not been done due to change in leadership but she planned to start doing them when she knew the staff better.

A policy on performance reviews was requested but not received.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 49 245416 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245416 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cura of Le Sueur 621 South 4th Street Le Sueur, MN 56058

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44630

Residents Affected - Few Based on interview and document review, the facility failed to ensure consulting pharmacist recommendations were addressed or acted upon for 1 of 5 residents (Resident R10) reviewed for unnecessary medications.

Findings include:

Resident R10's quarterly Minimum Data Set (MDS) assessment dated [DATE REDACTED], indicated severe cognitive impairment, no rejection of care, required setup or clean up assistance with eating, substantial staff assistance with personal hygiene and diagnoses included non-traumatic brain dysfunction, dementia, Parkinson's disease(progressive brain disorder that affects movement, balance, and coordination), anxiety, depression, and psychotic disorder, taking an antipsychotic.

Resident R10's care plan dated 11/20/24, indicated potential for drug interactions and adverse effects r/t (related to) polypharmacy interventions included administer medications as ordered, observe for effectiveness and adverse effects, update MD (medical doctor) PRN (as needed) monthly medication regime review by pharmacy consultant, forward recommendations to MD for review.

Resident R10's medication administration record dated 1/1/25-1/31/25, indicated start date 8/6/24, quetiapine fumarate (antipsychotic medication) oral tablet give 50 mg (milligrams) by mouth two times a day related to unspecified psychosis not due to a substance or known physiological condition, Parkinson's disease.

Resident R10's Pharmacist Recommendations to Nursing documented dated 10/11/24, consulting pharmacist (CP)-L indicated please add an order for monthly blood pressures or document why this not able to be completed.

On the document registered nurse (RN)-B dated 10/13/24, indicated order placed.

Resident R10's treatment administration record (TAR) dated 10/1/24-10/31/24, indicated start date 10/14/24, and end date 11/5/24, orthostatic blood pressure one time a day every one month(s) starting on the 14th for 28 day(s) related to anxiety disorder, after resident has been lying down for at least five minutes, measure resident's blood pressure and pulse.

Resident R10's record review indicated the last documented orthostatic blood pressure was dated 11/5/24, and Resident R10's

record review did not include an order for current monthly orthostatic blood pressures.

On 1/16/25 at 12:22 p.m., RN-D, known as the regional nurse specialist, stated Resident R10's order for monthly orthostatic blood pressures was entered incorrectly and the order fell off. RN-D confirmed there was not a correct order for Resident R10 to have monthly orthostatic blood pressures.

On 1/16/25 at 12:45 p.m., CP-L stated would expect monthly orthostatic blood pressures on resident on Seroquel, to monitor for side effects.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 49 245416 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245416 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cura of Le Sueur 621 South 4th Street Le Sueur, MN 56058

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 The facility Consultant Pharmacist Medication Regimen Review policy dated 1/2025, indicated evaluating response to drug therapy to assure that each resident receives optimal medication therapy. The residents Level of Harm - Minimal harm or response to drug treatment is evaluated through the use of lab, physical assessment, medication potential for actual harm administration record and other data to determine if the therapeutic goals are achieved. Side effects, adverse reactions and interactions lab test and drug disease. Medical condition and response to drug therapy are Residents Affected - Few used to evaluate medication regime for unnecessary medications.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 49 245416 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245416 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cura of Le Sueur 621 South 4th Street Le Sueur, MN 56058

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42073 potential for actual harm Based on observation and interview, the facility failed to ensure meals were served at a warm and palatable Residents Affected - Few temperature to promote quality of life and nutritional intake for 2 of 2 residents (Resident R22 and Resident R16) reviewed for dining. This had the potential to affect all 25 residents who resided in the facility.

Findings include:

Resident R22's facesheet printed on 1/16/25, included a diagnosis of amyotrophic lateral sclerosis (ALS), commonly known as Lou Gehrigsdisease (a progressive disease that weakens muscles and impacts physical function).

Resident R22's significant change Minimum Data Set (MDS) assessment dated [DATE REDACTED], indicated Resident R22 was cognitively intact, had clear speech, could understand and be understood. Resident R22 required substantial assistance or was dependent upon staff for activities of daily living (ADL) including eating. Resident R22 did not walk independently.

Resident R22's physician orders dated 9/19/24, indicated a regular diet and assistance with eating meals.

Resident R22's care plan dated 9/18/24, indicated Resident R22 had a potential nutritional problem related to diagnosis of ALS, was unable to feed himself and needed total staff assistance at meals. Care plan with revised date of 12/15/24, indicated to serve diet as ordered. Regular diet. Total staff assist with meals in his room.

Resident R16's admission MDS dated [DATE REDACTED], indicated Resident R16 was cognitively intact, no rejection of care, required partial/moderate assistance with personal hygiene, dependent on staff for toileting, shower/bathe, lower body dressing, and transfers; diagnoses included unstageable pressure ulcer of the right heel, and osteomyelitis (infection of the bone).

Resident R16's care plan printed on 1/14/25, indicated Resident R16 provide and serve diet as ordered, regular diet, provide and serve supplements as ordered, ensure with meals for nutritional support and to promote wound healing, provide, serve diet as ordered, monitor intake and record meal.

Prairie wing/ Kitchen

During an observation on 1/13/25 at 12:12 p.m., observed meal trays for Prairie unit left in the hallway on a tall, multi-tiered, open-sided cart on wheels.

During an interview on 1/13/25 at 12:18 p.m., Resident R22 stated his meals were always late and his food was always cold - particularly breakfast. Resident R22 stated he always ate in his room. Resident R22 stated this morning (1/13/25),

he received a cold fried egg with toast, stating he forced it down and was used to it (cold food).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 49 245416 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245416 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cura of Le Sueur 621 South 4th Street Le Sueur, MN 56058

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 During an observation on 1/14/25 at 8:44 a.m., activity director (AD)-A and activity aide (AA)-B were observed passing breakfast trays. AD-A stated they only set-up meal trays for residents who were awake, Level of Harm - Minimal harm or otherwise they just left the trays in the residents' rooms. In Resident R22's room, observed Resident R22 was sleeping, and his potential for actual harm breakfast tray was setting on his overbed table.

Residents Affected - Few During an interview on 1/14/25 at 10:50 a.m., Resident R22 stated his breakfast that morning - a breakfast sandwich - had been cold, but he ate it anyway.

During an observation on 1/14/25 at 10:58 a.m., observed cook (C)-A measure the temperature (temp) of food on the steam table:

--Turkey and wild rice casserole - 200 degrees Fahrenheit (F)

--Mashed potatoes (instant) - 180 degrees F

--Mixed vegetables - 194 degrees F

During observation on 1/14/25 at 11:30 a.m., in the kitchen, observed staff dish up room trays. (The facility was in influenza outbreak and all residents received meals in their room during the survey period). C-A dished up food onto Styrofoam plates, set the plate on a plastic thermal base (not heated), and covered it with a plastic dome (not heated). Other dietary staff set the plates on trays that were on a tall, multi-tiered, open-sided cart on wheels.

Lunch tray delivery observations and interview on 1/14/25:

--At 11:42 a.m., the cart on wheels arrived from the kitchen to Prairie unit and was left in the middle of the hallway by the nurse's station.

--At 11:47 a.m., the first tray was delivered.

--At 12:10 p.m., only two nursing assistants passing meal trays, despite other staff walking past the cart.

--At 12:13 p.m., social worker (SW)-A began helping deliver trays.

--At 12:26 p.m., requested AD-A to remove the last tray not yet delivered and take it to the dining room off

the kitchen to measure temperatures. AD-A was accompanied to the dining room and both the administrator and dietary manager were requested to be present.

On 1/14/25 at 12:31 p.m., dietary manager (DM)-F measured the food temps with a digital thermometer as follows:

--Mashed potatoes - 129.7 degrees F (approximately five degrees below optimal serving temp)

--Mixed vegetables - 125 degrees F (approximately 10 degrees below optimal serving temp)

The administrator and surveyor tasted the food for the purpose of assessing the temperature. The administrator stated the potatoes and vegetables were lukewarm. Surveyor concurred.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 49 245416 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245416 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cura of Le Sueur 621 South 4th Street Le Sueur, MN 56058

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 During an interview on 1/14/25 at 12:43 p.m., the administrator stated lunch was supposed to be served to residents at 11:35 a.m. The administrator was informed that the last tray on Prairie unit was still on the cart at Level of Harm - Minimal harm or 12:26 p.m., after standing in the hallway for approximately 45 minutes before all residents received their potential for actual harm trays. The administrator stated her expectation was for meal trays to be delivered right away. The administrator stated they would probably go back to using regular plates with warmers instead of Styrofoam Residents Affected - Few plates to retain the heat better. The administrator stated she expected nurses, activities staff and the social worker to help pass trays too. The administrator did not know why more staff didn't assist with meal tray delivery today.

On 1/14/25 at 2:01 p.m., (C)-A stated dietary was going back to regular dishes and warmers to keep resident food warm until served.

During a telephone interview on 1/14/25 p.m. at 4:37 p.m., registered dietician (RD)-E stated the preferred food temperature for meal service was 140 degrees F, but 135 degrees F was acceptable. RD-E was informed of findings from the lunch meal service, e.g., trays left standing on the unit for 45 minutes, and the temperatures obtained on a test tray. RD-E stated proper food temperatures were important for palatability and for residents to enjoy their food.

During an observation on 1/15/25 at 8:01 a.m., C-A and DM-F were passing breakfast trays. C-A stated they had a meeting to figure out how they could help get the food out faster and as a result, dietary staff would help pass room trays during the outbreak. In addition, DM-F stated they are not going to deliver all breakfast trays right away - they are going to see which residents were awake first before bringing a tray to their room.

44630

Meadow wing

On 1/13/25 at 12:49 p.m., Resident R16 was lying in bed with a meal tray in front of him. Resident R16 stated his meal tray and food was delivered at 12:45 p.m,. and the food was cold and did not eat because of the cold food.

On 1/14/25 a 9:32 a.m., Resident R16 was lying in bed and stated his breakfast was cold. Resident R16 stated he did drink his protein drink, but could not eat the rest of the breakfast meal because the food was cold.

On 1/14/25 at 11:38 a.m., observed meal trays located on a cart in the meadow wing hallway.

-11:50 a.m., meal tray delivery started on meadow wing.

-12:11 p.m., social services (SS)-A delivered Resident R16's meal tray to his room

The facility Assisting the impaired Resident with In-Room Meals policy dated 1/2025, indicated staff were to check that hot foods were hot and cold foods were cold. To minimize the risk of foodborne illness, the time that potentially hazardous foods remained in the danger zone (41 degrees F and 135 degrees F) would be kept to a minimum. Foods left on trays without a source of heat (for hot foods) or refrigeration (for cold foods) longer than two hours would be discarded.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 49 245416 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245416 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cura of Le Sueur 621 South 4th Street Le Sueur, MN 56058

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Level of Harm - Minimal harm or 44630 potential for actual harm Based on document review and interview, the facility failed to ensure Quality Assurance Performance Residents Affected - Few Improvement (QAPI) meetings were held on a quarterly basis.

Findings include:

Review of the QAPI meeting minutes and agenda identified QAPI meetings held 12/19/24, 7/11/24, 4/11/24. There was no additional documentation of a QAPI meeting provided between 7/11/24-12/19/24.

On 1/16/25 at 1:14 p.m., the administrator stated she had worked at the facility approximately four weeks.

The administrator stated she did not know if the facility had previously had a QAPI meeting between 7/11/24-12/19/24 , and confirmed she was not able to provide any documentation of any other meetings that had occurred. The administrator stated QAPI meetings were expected quarterly with attendance.

The facility Quality Assurance and Performance Improvement (QAPI) policy dated 2/2024, indicated: The QAA committee will meet quarterly. QAPI activities and outcomes will be on the agenda of every staff meeting and shared with residents and family members through their respective councils and monthly newsletter. The minutes from all meetings will be posted throughout the organization. The QAA committee will report all activities to the board of directors during their regularly scheduled meetings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 49 245416 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245416 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cura of Le Sueur 621 South 4th Street Le Sueur, MN 56058

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50764 potential for actual harm Based on observation, interview and document review, the facility failed to follow Centers for Medicare and Residents Affected - Many 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 (Resident R2, Resident R9, Resident R10, Resident R79, Resident R12, Resident R4, Resident R16, Resident R1, Resident R18, Resident R22, Resident 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, (Resident R16). This had the potential to affect all residents who resided at the facility.

Findings include:

Resident R2's facesheet printed 1/15/25, indicated diagnoses of heart failure, pain syndrome, and kidney disease.

Resident R2's significant change Minimum Data Set (MDS) assessment dated [DATE REDACTED], indicated intact cognition, no behaviors, and dependent on staff for personal hygiene and transfers.

Facility outbreak tracking spreadsheet dated 1/14/25, indicated Resident R2 had symptoms of influenza A that included malaise and fatigue which developed on 1/11/25.

Resident R9's facesheet printed 1/15/25, indicated diagnoses of peptic ulcer and septic shock.

Resident R9's admission MDS assessment dated [DATE REDACTED], indicated intact cognition, no behaviors, setup assistance for eating, substantial assistance for dressing and personal hygiene.

Facility outbreak tracking spreadsheet dated 1/14/25, indicated Resident R9 had symptoms of influenza A that included malaise and fatigue which developed on 1/11/25.

Resident R10's facesheet printed 1/15/25, indicated diagnoses of Parkinson's disease, and neurocognitive disorder with lewy bodies.

Resident R10's quarterly MDS assessment dated [DATE REDACTED], indicated severe cognitive impairment, use of a wheelchair, substantial assistance for upper body dressing, dependence on staff for bathing and personal hygiene.

Facility outbreak tracking spreadsheet dated 1/14/25, indicated Resident R10 had symptoms of influenza A that included malaise which developed on 1/11/25.

Resident R79's facesheet printed 1/15/25, indicated diagnoses of cardiac pacemaker presence, anemia, and dementia.

Resident R79's admission MDS assessment dated [DATE REDACTED], indicated moderate cognitive impairment, behavioral symptoms not directed towards others, use of a walker and wheelchair, set up assistance for eating, and substantial assistance with personal hygiene.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 49 245416 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245416 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cura of Le Sueur 621 South 4th Street Le Sueur, MN 56058

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Facility outbreak tracking spreadsheet dated 1/14/25, indicated Resident R79 had symptoms of influenza A that included malaise and body aches which developed on 1/11/25. Level of Harm - Minimal harm or potential for actual harm Resident R12's facesheet printed 1/15/25, indicated diagnoses of type 2 diabetes mellitus, obesity, and vascular dementia. Residents Affected - Many Resident R12's annual MDS assessment dated [DATE REDACTED], indicated use of a wheelchair, setup assistance for eating, dependent on staff for personal hygiene, bathing, and dressing.

Facility outbreak tracking spreadsheet dated 1/14/25, indicated Resident R12 had symptoms of influenza A that included cough and fatigue which developed on 1/11/25.

Resident R4's facesheet printed 1/15/25, indicated diagnoses of heart failure, kidney disease, and chronic respiratory failure.

Resident R4's quarterly MDS assessment dated [DATE REDACTED], indicated intact cognition, verbal behaviors directed towards others, use of a wheelchair, setup assistance for personal hygiene, and partial assistance for upper body dressing.

Facility outbreak tracking spreadsheet dated 1/14/25, indicated Resident R4 developed symptoms of influenza A that included chills, malaise, and cough which developed on 1/10/25, and tested positive for influenza A on 1/10/25.

Resident R16's facesheet printed 1/15/25, indicated diagnosis of osteomyelitis (bone infection).

Resident R16's admission MDS assessment dated [DATE REDACTED], indicated intact cognition, no behaviors, independent with eating, dependent on staff for toileting hygiene, and partial assistance with personal hygiene.

Facility outbreak tracking spreadsheet dated 1/14/25, indicated Resident R16 had symptoms of influenza A that included cough and malaise which developed on 1/9/25, and tested positive for influenza A on 1/10/25.

Resident R1's facesheet printed 1/15/25, indicated diagnoses of alcohol-induced dementia, hypertension (high blood pressure), and weakness.

Resident R1's quarterly MDS assessment dated [DATE REDACTED], indicated moderately impaired cognition, no behaviors, use of a wheelchair, substantial assistance with bathing and personal hygiene.

Facility outbreak tracking spreadsheet dated 1/14/25, indicated Resident R1 had symptoms of influenza A that included cough which developed on 1/12/25.

Resident R18's facesheet printed 1/15/25, indicated diagnoses of pressure injury of left heel, chronic respiratory failure, and history of cerebral infarction (stroke).

Resident R18's quarterly MDS assessment dated [DATE REDACTED], indicated severely impaired cognition, behavioral symptoms not directed towards others, use of a walker and wheelchair, setup assistance for eating, dependent on staff for bathing, and partial assistance with personal hygiene.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 49 245416 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245416 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cura of Le Sueur 621 South 4th Street Le Sueur, MN 56058

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Facility outbreak tracking spreadsheet dated 1/14/25, indicated Resident R18 had symptoms of influenza A that included malaise, cough, and shortness of breath which developed on 1/9/25, and tested positive for Level of Harm - Minimal harm or influenza A on 1/12/25. potential for actual harm Resident R22's facesheet printed on 1/15/25, indicated diagnoses of amyotrophic lateral sclerosis (ALS) and repeated Residents Affected - Many falls.

Resident R22's significant change MDS assessment dated [DATE REDACTED], indicated intact cognition, no behaviors, use of a walker and wheelchair, and dependent on staff for eating, dressing, bathing, and personal hygiene.

Facility outbreak tracking spreadsheet dated 1/14/25, indicated Resident R22 had symptoms of influenza A that included diarrhea and cough which developed on 1/9/25.

Resident R3's facesheet printed 1/15/25, indicated diagnoses of anemia, type 2 diabetes mellitus, chronic pain, and muscle weakness.

Resident R3's admission MDS assessment dated [DATE REDACTED], indicated intact cognition, no behaviors, use of a wheelchair, set up assistance for eating, and substantial assistance with personal hygiene.

Facility outbreak tracking spreadsheet dated 1/14/25, indicated Resident R3 had symptoms of influenza A that included cough, malaise, and diarrhea which developed on 1/9/25, and tested positive for influenza A on 1/10/25.

During observation on 1/13/24 at 11:15 a.m., a sign was near the entrance of the facility stating the facility was currently experiencing an influenza outbreak and masks should be worn in the facility.

During observation on 1/13/24 at 11:39 a.m., resident rooms of Resident R2, Resident R9, Resident R10, Resident R79, Resident R12, Resident R4, Resident R16, Resident R1, Resident R18, Resident R22, Resident R3 did not have droplet precaution signage to indicate droplet precautions should have been used due to positive or suspected influenza A.

Signs on resident room doors at the time of initial observation on 1/13/24 at 11:39 a.m., indicated enhanced barrier precautions (EBP) for the rooms of Resident R9, Resident R10, and Resident R16, but did not indicate the need for further droplet precautions due to influenza A.

PPE

During observation on 1/13/24 at 11:30 a.m., a large, uncovered garbage bin was in the center of the Meadows hallway with soiled gowns present in the bin.

During observation on 1/13/25 at 12:22 p.m., nursing assistant (NA)-A, who was wearing a mask throughout

the facility, donned a gown and entered Resident R16's room. During interview on 1/13/25 at 12:39 p.m., NA-A stated

she was unsure which rooms to wear a gown in, was not aware which residents had influenza A, and was not told she could not wear the same mask resident room to resident room.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 49 245416 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245416 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cura of Le Sueur 621 South 4th Street Le Sueur, MN 56058

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 On 1/13/25 at 3:19 p.m., NA-F stated resident rooms were not posted on who had influenza or residents who had signs or symptoms of influenza. NA-F stated the same mask was worn from room to room regardless if a Level of Harm - Minimal harm or resident had influenza. potential for actual harm

On 1/13/25 at 3:21 p.m., NA-B stated the facility did not post precautions signs on resident doors that Residents Affected - Many indicated what PPE was needed worn into the resident rooms, or specific reason the resident was on precautions. NA-B confirmed the mask worn into resident rooms was not changed or removed going from room to room of residents.

On 1/13/25 at 3:25 p.m., NA-E stated a mask was worn at all times at the facility due to the influenza outbreak. NA-E confirmed the mask was not removed or changed going from room to room.

On 1/13/25 at 3:31 p.m., registered nurse (RN)-A, known as the assistant director of nursing and infection preventionist, stated facility was currently in an influenza outbreak as of 1/10/25. RN-A stated there are residents with confirmed positive influenza tests and residents presumed positive due to signs and symptoms. RN-A stated there were also staff with confirmed influenza and staff with signs and symptoms. RN-A stated an electronic message went to all staff on 1/10/25, educating staff the facility needed to follow droplet precautions for all residents. RN-A stated PPE was spread throughout the facility that included gowns, eye protection, masks and hand disinfectant. RN-A further stated stated community dining and activities were stopped and residents have been eating and participating in activities in their rooms. RN-A stated staff were not educated to change masks from room to room and confirmed staff were expected to change masks from room to room. RN-A stated the residents with confirmed influenza and presumed influenza based off signs and symptoms did not have precautions signs posted to make staff, residents, and visitors aware of the specific isolation and PPE needed to be worn entering the rooms.

On 1/13/25 at 4:09 p.m., during a follow up interview RN-A stated he arrived this morning for work and then was told he needed to leave and come back to cover the nursing shift for evenings as the there was staffing shortage for evenings and overnights. RN-A stated had not had time to get signs posted, PPE carts readily available and garbage's placed inside and outside resident rooms. RN-A stated the director of nursing was not at the facility due to influenza.

During interview on 1/13/25 at 4:29 p.m., RN-A stated he had not had time to work on infection control for

this outbreak because he had been working the floor so much and was not allowed any infection control hours. RN-A stated he discussed the first positive cases with the medical director on 1/10/25 and was told to treat anyone with symptoms as if they were positive with influenza A, and to implement appropriate precautions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 49 245416 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245416 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cura of Le Sueur 621 South 4th Street Le Sueur, MN 56058

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 On 1/13/25 at 4:42 p.m., the administrator stated she became aware of the influenza outbreak on 1/10/25 at 9:20 a.m., via an email from RN-A. The medical director was made aware the same day at 9:51 a.m., and Level of Harm - Minimal harm or RN-A sent a electronic message to all staff masks were required throughout the facility. The administrator potential for actual harm stated RN-A was also the infection prevention nurse, and was working as a floor nurse during the outbreak.

The administrator stated RN-A was not designated time or hours while the outbreak was going on to ensure Residents Affected - Many the correct PPE was available, signs were posted or staff received education. The administrator stated RN-A was expected to delegate tasks if needed, however RN-A was responsible to ensure staff were following correct procedures for the influenza outbreak and was responsible to ensure PPE was available to the staff.

The administrator confirmed signs were not posted on the resident doors presumed positive ( signs or symptoms of influenza) or the residents with confirmed positive influenza. The administrator stated the signs were expected for residents, staff and visitors to be aware of the isolation precautions and the PPE that was expected worn into the rooms. The administrator stated signs was important to prevent the spread of the influenza, and the administrator was not aware the same mask could not be worn from room to room.

During observation on 1/13/25 at 5:53 p.m., RN-D was observed putting droplet precaution signs on the doors of the rooms of Resident R2, Resident R9, Resident R10, Resident R79, Resident R12, Resident R4, Resident R16, Resident R1, Resident R18, Resident R22, Resident R2.

During observation and interview on 1/13/25 at 6:07 p.m., NA-F was observed exiting Resident R9's room with a gown on, doffing the gown in the hallway, and disposing of the gown in the large garbage bin located in the meadows hallway. NA-F stated she sometimes wore her gown in the hallway if the garbage in the room was full. NA-F further stated she should remove her gown in the room, rather than in the hallway to prevent the spread of infection.

44630

During observation on 1/14/25 at 8:53 a.m., LPN-C was observed exiting Resident R12's room with a soiled gown in her hands and disposing of it in the large hallway garbage bin across the hall. LPN-C and NA-E both exited

the room without doffing their masks. NA-E then exited the meadows hallway with her same mask on. LPN-C also continued on with the same mask on.

During interview on 1/14/25 at 9:03 a.m., NA-E stated she was not aware of any training on how to don/doff PPE other than online training and would have liked to have had in-person training or a demonstration. NA-E further stated she was told she could wear her mask room to room.

On 1/14/25 at 9:18 a.m., medical doctor (MD)-G stated signs posted on resident doors with influenza were expected o ensure staff, visitors and residents followed transmission based precautions to prevent the spread of influenza.

During interview on 1/14/25 at 12:42 p.m., RN-A stated he would expect that gowns be removed before exiting positive or suspected influenza A rooms and masks should be removed immediately upon exiting the room and not worn room to room to prevent the spread of infection. RN-A further stated that contaminated gowns should be disposed of in the room or should be bagged prior to being brought to the large garbage in

the hallway. RN-A stated droplet precaution signs had been put on the door of residents with confirmed or suspected influenza A yesterday 1/13/25, but should have been put in place when the outbreak started on 1/9/25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 49 245416 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245416 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cura of Le Sueur 621 South 4th Street Le Sueur, MN 56058

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During interview on 1/14/25 at 6:15 p.m., RN-D, regional nurse specialist, stated she would expect gowns be removed in the room or bagged and sealed if brought in the hallway. RN-D stated masks should not be worn Level of Harm - Minimal harm or room to room. RN-D further stated proper signage and PPE use should have been in place to prevent the potential for actual harm spread of infection to other residents, staff, and visitors.

Residents Affected - Many The facility Policies and Practice- Infection Control policy effective 12/2024, stated the objectives of our infection control policies and practices are to:

a. Prevent, detect, investigate, and control infections in the facility

b. Maintain a safe, sanitary, and comfortable environment

c. Establish guidelines for implementing Isolation Precautions, including standard and transmission based

d. Establish guidelines for the availability and accessibility of supplies and equipment

e. Maintain records of incidents and corrective actions relate to infections

f. Provide guidelines for the safe cleaning and reprocessing of reusable resident-care equipment

g. The facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections.

Glove use/hand hygiene with wound care

Resident R16's admission MDS dated [DATE REDACTED], indicated Resident R16 was admitted to the facility on [DATE REDACTED], cognitively intact, no rejection of care, required partial/moderate assistance with personal hygiene, dependent on staff for toileting, shower/bathe, lower body dressing, and transfers; diagnoses included unstageable pressure ulcer of the right heel, and osteomyelitis (infection of the bone); skin conditions indicated Resident R16 was at risk of developing pressure ulcers/injuries, no unhealed pressure ulcers/injuries, had infection of the foot, other open lesion on the foot, surgical wounds; skin treatments included pressure reducing device for chair and bed, surgical wound care, application of ointments/medications other than to feet, application of dressings to feet.

Resident R16's care plan printed on 1/14/25, indicated Resident R16 had self care deficit related to morbid obesity and decreased functional ability due to bilateral pressure injury to heels, needed assist with ADL's (activities of daily living), alteration in skin integrity r/t (related to) pressure ulcer to bilateral heels and interventions included administer treatments as ordered and observe for effectiveness, assist/encourage to float heels while in bed, measure wound weekly; update MD (medical doctor) PRN (as needed) with change, observe for s/sx (signs/symptoms) of infection, and wound vac in place.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 49 245416 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245416 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cura of Le Sueur 621 South 4th Street Le Sueur, MN 56058

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 On 1/14/25 at 9:19 a.m., LPN-A and medical doctor (MD)-G entered Resident R16's room with gloves, gown, and mask. LPN-A with gloved hands, removed the old dressing from Resident R16's left heel, used same gloved hands Level of Harm - Minimal harm or and opened a betadine gauze package and used the betadine swab on the wound. LPN-A, with same potential for actual harm gloves, applied a foam dressing on the left heel and while the dressing was placed the same gloves touched

the inside foam of the clean dressing. LPN-C removed gloves and exited the room with a gown on. LPN-A Residents Affected - Many after exiting Resident R16's room removed the gown and placed in opened garbage across the hallway from Resident R16's room.

On 1/14/25 at 10:37 a.m., LPN-A confirmed gloves were not changed during Resident R16's wound care and stated

she was expected to change gloves and complete hand hygiene after removing the old dressing and place new clean gloves on prior to applying the new dressing. LPN-A confirmed the gown was not removed prior to exiting Resident R16's room, and stated the gown was expected to removed prior to exiting Resident R16's room and stated there were not a garbage available to dispose of the gown at the time.

On 1/14/25 at 11:12 a.m., RN-D, known as the regional nurse specialist, stated staff were expected to change gloves after old dressing was removed, wash hands and place new gloves prior to the clean dressing applied.

The facility Wound Care policy dated 12/2025, indicated;

Don gloves. [NAME] other personal protective equipment as applicable.

Remove and discard used dressing, remove and discard soiled gloves.

Performa hang hygiene

Don gloves

Cleanse the wound

Discard disposable items remove and discard soiled gloves

Perform hand hygiene

Don gloves

Proceed with dressing the wound as ordered, remove and discard soiled gloves

Perform hand hygiene.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 49 245416 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245416 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cura of Le Sueur 621 South 4th Street Le Sueur, MN 56058

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Level of Harm - Minimal harm or potential for actual harm 42073

Residents Affected - Some Based 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.

Finding include:

Prairie Unit - East

During an observation on 1/14/25 at 2:15 p.m., the tub/shower room on the east Prairie unit was observed to have a large tub and separate walk-in shower, toilet, and vanity with sink and cupboards.

A furnace filter measuring approximately two feet by eight inches was observed laying on the floor half-way under the wall-mounted heater. The filter was heavily laden with gray fuzzy material. On top of the heater where air came out where small square grates that had an accumulation of dust and webs on them.

Next to the heater was a corner wall where sheetrock was missing on the lower one - two feet. The material exposed resembled cement - white and porous, and was crumbling. These open areas were discolored rust and brown.

A ceiling vent, approximately 12 inches x 12 inches was heavily laden with gray fuzzy debris with some of it hanging down like a web.

The floor of the walk-in shower was worn looking and stained a tan/rusty color. In addition, the hand-held shower head was attached to the shower with black zip ties.

Prairie Unit North

The floor of the walk-in shower was worn looking and stained with a tan/rusty color. In addition, the floor seemed to have tiny black marks resembling sand until closer inspection revealed the black marks did not come off.

During an interview and observation on 1/15/25 at 1:17 p.m., together with maintenance director (MD)-A, viewed both tub/shower rooms on the Prairie unit. In the tub/shower room on Prairie east, MD-A pulled out and examined the filter and stated it looked pretty bad. MD-A stated he had ordered filters a couple of months ago, but they had not come in yet. MD-A stated he was not aware of the other concerns: crumbling wall, ceiling vent, zip ties and floor of the shower. In the tub/shower room on Prairie north, MD-A tried to scratch off the black marks on the floor of the shower with his fingernail, but it didn't come off. MD-A was not aware of this either and acknowledged these findings did not provide a home-like, nor sanitary environment for residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 49 245416 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245416 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cura of Le Sueur 621 South 4th Street Le Sueur, MN 56058

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 On 1/15/25 at 4:01 p.m., with the administrator, looked at areas of concern in each of the Prairie tub/shower rooms. She had been aware of the filters after MD-A reported it to her, but unaware of other issues. The Level of Harm - Minimal harm or administrator stated she would expect the tub/shower rooms to be clean and in good repair. potential for actual harm

A policy on physical maintenance of the building, upkeep, and cleanliness was requested. The facility Residents Affected - Some Maintenance - Plumbing, HVAC and Related Systems policy dated 1/2025, was received. The policy indicated to clean or discard filters in individual air-conditioning units in resident rooms at least monthly

during the summer. Clear air vents and air handling units at least annually.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 49 245416 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245416 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cura of Le Sueur 621 South 4th Street Le Sueur, MN 56058

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0947 Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Level of Harm - Minimal harm or potential for actual harm 50764

Residents Affected - Some Based 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.

Review of online training transcripts for NA-A, NA-F, NA-B, and NA-E included online trainings on abuse prevention, behavioral health, workplace injury, cultural competency, dementia, dining and food safety, Elder Justice Act, emergency preparedness, fall prevention, HIPAA, infection control, infectious disease, Medicare, OSHA, resident privacy, QAPI, resident rights, substance abuse, trauma informed care, and vulnerable adult. All training logs were the same with no individualized training based on performance reviews.

During interview on 1/14/25 at 8:59 a.m., NA-B stated she was not aware of a recent performance review or individualized training. She further stated she did the annual computer training completed by all employees, but was not aware of any other training.

During interview on 1/14/25 at 11:11 a.m., NA-E stated she had not had any specific training and had only done the computer training she had to do yearly.

During interview on 1/15/25 at 8:20 a.m., NA-A stated she had not had a performance review and did not know she should have had training based on a performance review. NA-A stated she did complete the yearly required computer classes.

During interview on 1/16/25 at 12:12 p.m., registered nurse (RN)-A stated he was not aware of any training based off of performance reviews since he had started and further stated he did not know of any individual education provided to NA's.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 49 245416 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245416 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cura of Le Sueur 621 South 4th Street Le Sueur, MN 56058

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0947 During interview on 1/15/25 at 9:08 a.m., administrator stated she was not aware of any completed performance reviews and was too new to be sure on training processes. Level of Harm - Minimal harm or potential for actual harm A policy on performance reviews and training was requested but not received.

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 49 245416