Cura of Willmar

In the surveyor’s words

From the most serious findings on record at Cura of Willmar, in the surveyor’s own words.

• Actual harm, isolatedF600Mar 25, 2026

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

• Actual harm, isolatedF684May 5, 2022

  Based on observation, interview and document review, the facility failed to investigate the cause of a skin injury and assess for appropriate treatment for 1 of 1 resident (R1) who sustained a burn from hot liquids served at the facility. This deficient practice resulted in actual harm for R1. Findings include: A Nursing Home Incident Report (NHIR) dated 4/28/22, indicated R1 had sustained a burn on her right thigh. R1 had told the staff member she had spilt her coffee. The burn was noted to be irregular shaped 1st degree (A mild burn injury of the outermost layer that make up the skin. Usually heals without scarring the skin) and had three small areas. The lateral area measured 6 centimeters (cm) by 3 cm wide. The middle area was 3 cm wide x 2.5 cm long. […]

• No harm, potential for more than minimal, widespreadF880Aug 25, 2022

  Based on observation, interview and document review, the facility failed to disinfect a mechanical lift after used by a resident (R24) with COVID-19 and had the potential to be used for other residents on isolation precautions. In addition, the facility failed to perform hand hygiene and change gloves appropriately appropriately for 1 of 3 residents (R9) observed for incontinence care. In addition, the facility failed to develop a trending and tracking program system for monitoring residents who showed signs of illness, but were not on an antibiotic and failed to ensure laundry was handled to prevent contamination of clean laundry, these practices had the potential to affect all 59 residents currently residing in the facility. Findings include: During observation on 8/22/22 at 1:32 p.m. […]

• No harm, potential for more than minimal, patternF684Oct 5, 2023

  Based on interview and document review, the facility failed to monitor for signs and symptoms of aspiration for 2 of 4 residents (R1, R2) reviewed who were not provided thickened liquid as ordered. Findings include: R1's quarterly minimal data set (MDS) dated [DATE], indicated R1 had diagnoses which included stroke, dysphagia, hemiplegia/hemiparesis, and moderately impaired cognition. Further, R1's MDS identified R1 was independent with eating after setting up. R1's Physician Order Report, revealed R1's diet order dated 6/26/23, was mildly thick liquids. Review of facility report number 353673 to the State Agency (SA) dated 9/3/23, indicated R1 had reported choking on her old tea, and nursing assistant (NA) noted the tea was not thickened. […]

• No harm, potential for more than minimal, isolatedF686Jul 15, 2026

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