Cura Of Sauk Centre
Cura of Sauk Centre in SAUK CENTRE, MN — inspection on March 5, 2026.
Found 5 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During observation on 3/3/26 at 11:28 a.m., R26 was observed sitting in a wheelchair in the dining room. A mechanical lift sling remained under R26.
The leg straps of the sling were positioned upright between R26's legs and were visibly protruding upward.
The straps were visible to others in the dining room.
During observation on 3/3/26 at 4:12 p.m., R26 was observed in the chapel seated in a wheelchair with the mechanical lift sling still in place.
The sling leg straps were again observed sticking straight up between R26's legs and were visible to other residents and staff in the area. R26's comprehensive care plan, printed 3/5/26, indicated it was acceptable to leave the sling underneath R26 for safety and potential skin alteration; however, the care plan did not include instructions regarding positioning of the sling while R26 was seated in common areas.
During an interview on 3/05/26 at 8:31 a.m., nursing assistant (NA)-B stated the Hoyer sling was typically left under R26 while seated in the wheelchair. NA-B stated the sling should have been tucked in as much as possible around the sides, so it was not visible. NA-B further stated the leg straps should have been removed from between R26's legs and tucked in as much as possible so they were not noticeable in order to maintain R26's dignity.
During an interview on 3/05/26 at 8:34 a.m., registered nurse case manager (RN)-A stated the Hoyer sling was care planned to be left under R26, and staff should have ensured the sling was not folded or positioned off to the side. RN-A stated the sling should have been tucked in as much as possible. RN-A further stated the leg straps should have been removed from between R26's legs and tucked under the legs. RN-A confirmed the straps should not have been left between R26's legs or sticking up, as this would have been a dignity concern.
During an interview on 3/05/26 at 11:25 a.m., the director of nursing (DON) stated if the Hoyer sling was left under R26 while seated in the wheelchair it would typically be care planned, as removing the sling could cause more harm to R26 due to rigidity.
The DON stated staff were expected to tuck the sling in as much as possible, so it was not highly visible.
The DON further stated the leg straps should have been removed from between R26's legs and tucked in, or a lap blanket could have been placed across R26's lap to cover the sling.
The DON confirmed leaving the straps between R26's legs would have been a dignity concern.
Review of the facility policy titled Quality of Life - Dignity, dated 10/25, indicated each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality.
The policy further indicated that residents shall be treated with dignity and respect at all times.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
245341 03/05/2026
Cura of Sauk Centre 425 N Elm Street Sauk Centre, MN 56378
Review of R3's progress notes and incident documentation dated 8/28/25 through 11/30/25, indicated R3 experienced falls on 8/28/25, 9/2/25, 9/5/25, 9/7/25, 9/18/25, 9/23/25, 9/25/25, 10/5/25, 10/20/25, 10/22/25, 10/24/25, 10/28/25, and 11/3/25.
Documentation did not identify R3 sustained a major injury, such as a fracture, dislocation, closed head injury with altered consciousness, or another injury requiring extensive medical intervention as a result of any one of these falls.
During an interview on 3/4/26 at 3:41 p.m., the MDS Coordinator (MDS) confirmed the MDS indicated R3 experienced a fall with major injury and stated R3 did not sustain a major injury from the fall and that it must have been accidentally coded incorrectly.
During an interview on 3/4/26 at 3:52 p.m., the Director of Nursing (DON) stated R3 had not experienced a fall with a major injury since admission on [DATE].
The DON stated MDS assessments should always be double-checked to ensure they included accurate and correct information before submission.
Review of the facility policy titled Minimum Data Set, Management of, Long Term Care, dated 1/25, indicated the facility would ensure the MDS was accurately and comprehensively completed.
245341 03/05/2026
Cura of Sauk Centre 425 N Elm Street Sauk Centre, MN 56378
During interview on 3/04/26 at 12:51 p.m., care manager (RN)-A, after reviewing R48's care plan stated R48's care plan lacked documentation of resident's pain issues.
The MDS coordinator (RN)-B stated when R48 was admitted to the facility, he was on a different unit and assessed and care planned by a newer care manager. RN-A stated when R48 was transferred to her unit in January 2026, she should have reviewed R48's care plan more closely. RN-B stated R48's care plan did mention resident was on pain medications, however after further review, pain [medications] were mentioned was under R48's nutritional problem. In an interview on 3/5/26 at 9:27 a.m., director of nursing (DON) stated it was the expectation, when residents have been comprehensively assessed, all areas of concerned identified, would be comprehensively care planned, so that facility staff would be aware of the issues of each resident. In review of the facility policy, entitled: Care Plans, Comprehensive Person-Centered (effective date 02/2025) indicated the following in section 8:8.
The Comprehensive, person-centered care plan will:a. include measurable objectives and timeframes;b. describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being;c. describe services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment;d. describe any specialized services to be provided as a result of PASARR [Preadmission Screening and Resident Review] recommendations;e. include the resident's stated goals upon admission and desired outcomes;f. include the resident's stated preference and potential for future discharge, including his or her desire to return to the community and any referrals made to local agencies or other entities to support such desire;g. incorporate identified problem areas;h. incorporate risk factors associated with identified problems;i. build of the resident's strengths; j. reflect the resident's expressed wishes regarding care and treatment goals;k. reflect treatment goals, timetables and objectives in measurable outcomes;l. identify the professional services that are responsible for each element of care;m. aid in preventing or reducing decline in the resident's functional status and/or functional level;n. enhance the optimal functioning of the resident by focusing on a rehabilitative program; [NAME]. reflect currently recognized standards of practice for problem areas and condition.
245341 03/05/2026
Cura of Sauk Centre 425 N Elm Street Sauk Centre, MN 56378
Review of R13's electronic medical record (EMR) identified R13 previously had wounds to the right and left ischial tuberosities, which had resolved on 1/8/26.
However, review of the comprehensive care plan revealed continued inclusion of interventions for enhanced barrier precautions (EBP) related to wound care, despite the wounds being resolved and EBP no longer being implemented.
During observation on 3/2/26 at 1:16 p.m., no EBP precautions were in place for R13, including no signage posted outside the resident's room and no personal protective equipment (PPE) cart present.
During an interview on 3/3/26 at 12:52 p.m., R13 stated prior sores to the buttocks had healed approximately one month earlier and confirmed no current open areas.
During a joint interview on 3/4/26 at 3:37 p.m., the registered nurse case manager (RNCM) and infection preventionist (IP) stated R13 had no current wounds and confirmed the wounds had resolved on 2/5/26.
They further stated R13 was no longer on EBP precautions and acknowledged the care plan should have been updated to remove these interventions.
They indicated it was important for the care plan to accurately reflect current interventions to ensure staff followed appropriate care and understood the resident's overall needs.
During an interview on 3/4/26 at 3:49 p.m., the Director of Nursing (DON) stated care plans were to be updated with any changes in a resident's condition or care needs.
The MDS process, including quarterly assessments, should prompt review and revision of the care plan.
The DON further stated updates should be reflected in the care plan and any related signage should be removed immediately when no longer applicable.
The DON indicated the care plan was an ongoing document intended to guide staff in providing appropriate care based on the residents' current needs.
Review of the facility policy titled Care Plans, Comprehensive Person-Centered, dated 2/2025, indicated a comprehensive, person-centered care plan with measurable objectives and timelines was to be developed and implemented for each resident.
The policy further indicated resident assessments were ongoing and care plans were to be revised as the residents' condition changed.
245341 03/05/2026
Cura of Sauk Centre 425 N Elm Street Sauk Centre, MN 56378
During observation and interview on 3/02/26 at 2:42 p.m., R3 stated she wore oxygen only at nighttime and required staff assistance to apply and remove the nasal cannula.
The nasal cannula was observed lying on the floor with the prongs, which are inserted into the resident's nose when in use, touching the floor.
During observation on 3/03/26 at 11:14 a.m., oxygen tubing was observed on the floor at the end of R3's bed with the nasal cannula prongs touching the floor.
During observation on 3/03/26 at 2:15 p.m., oxygen tubing remained on the floor at the end of R3's bed next to the oxygen concentrator with the nasal cannula prongs touching the floor.
During observation on 3/04/26 at 8:30 a.m., oxygen tubing noted on the floor at the end of R3's bed next to the oxygen concentrator with the nasal cannula prongs touching the floor.
During observation on 3/04/26 at 12:16 p.m., oxygen tubing remained on the floor at the end of R3's bed next to the oxygen concentrator with the nasal cannula prongs touching the floor. R3's order summary report, dated 3/5/26, indicated an order initiated on 12/10/25 for supplemental oxygen at 2 liters per minute (LPM) at NOC (bedtime) for nocturnal hypoxia identified during a sleep study.
During interview on 3/04/26 at 1:46 p.m., nursing assistant (NA)-A stated R3 required assistance removing the oxygen in the mornings as R3 only wore oxygen at night. NA-A stated the nasal cannula should be draped over the end of the bed or the oxygen concentrator when not in use and should not touch the floor.
During interview on 3/04/26 at 2:50 p.m., licensed practical nurse (LPN)-A stated oxygen tubing should never touch the floor due to infection control concerns.
During a joint interview on 3/04/26 at 3:41 p.m., registered nurse case manager (RN)-A and MDS registered nurse (RN)-B stated R3 wore oxygen at night, and the oxygen tubing should not be on the floor. RN-A and RN-B stated allowing oxygen tubing to touch the floor was an infection control concern.
During interview on 3/04/26 at 3:52 p.m., the director of nursing (DON) stated oxygen tubing should not be placed on the floor when not in use due to infection control concerns.
Review of the facility policy titled Infection Prevention and Control, dated 1/2026, indicated the facility was to maintain equipment in a sanitary condition and implement appropriate infection control practices to prevent contamination and the spread of infection.