Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cura Of Sauk Centre during CMS and state inspections, most recent first.
A resident with cognitive impairment and multiple health conditions was given another resident's medications after a nurse pre-prepared and mislabeled medication cups. The error resulted in the resident experiencing a fall, minor head injury, tachycardia, and hypertension, requiring emergency department evaluation and monitoring. The incident was attributed to the nurse's failure to follow policy by preparing medications for more than one resident at a time.
The facility did not accurately post required daily nurse staffing information, with postings missing the facility name, current census, and containing inaccuracies such as listing TMAs under LPN sections. Staff confirmed that postings were made for multiple days at a time and did not meet regulatory requirements.
A resident with severe cognitive impairment and a documented history of recurrent UTIs did not have their UTI history, treatment goals, or preventive interventions included in their care plan. Staff interviews confirmed that this information should have been documented to ensure appropriate monitoring and response, in accordance with facility policy.
The facility failed to provide timely x-ray results for three residents, leading to delayed medical interventions. A resident with Alzheimer's disease experienced a fall and had a fracture identified only after a six-day delay. Another resident with brain dysfunction had a foot x-ray delayed by seven days, and a third resident with heart and respiratory failure had a chest x-ray delayed by eleven days. The delays were due to a shortage of radiologists and a lack of a formal process for timely x-ray result expectations.
A resident with a deep tissue pressure ulcer on the coccyx did not receive proper documentation of wound assessments during dressing changes. Despite the LPN observing worsening conditions and notifying the RN and DON, there was no formal reassessment or documentation in the medical record. The facility's policy required such documentation and physician notification for wound changes, which was not followed, leading to a deficiency.
A resident with a history of depression and cognitive impairment attempted self-harm using a nasal cannula. Despite the severity, the facility staff failed to notify the resident's physician or family about the incident in a timely manner. The LPN documented the event but did not take further immediate action or disclose the full details to the family. The facility's documentation lacked evidence of interventions until the following morning when social services assessed the resident and contacted the physician.
Medication Error Leads to Resident Harm Due to Pre-Prepared Medications
Penalty
Summary
A resident with moderate cognitive impairment and multiple medical diagnoses, including hypertension, diabetes, and dementia, was administered another resident's medications during a morning medication pass. The nurse responsible for medication administration had prepared multiple residents' medications in advance, labeling the medication cups with initials and storing them in the medication cart drawer. Due to a mislabeling error, the nurse gave the resident the wrong set of medications. Following the administration of the incorrect medications, the resident experienced an unwitnessed fall, resulting in a laceration above the left eyebrow. The resident was subsequently sent to the emergency department for evaluation. Clinical documentation indicated that the resident developed tachycardia and hypertension after receiving the wrong medications, which included high doses of blood pressure and seizure medications not prescribed for her. The emergency department performed diagnostic tests and provided monitoring instructions due to the risk of adverse effects from the medications ingested. The nurse involved acknowledged the error, stating that she had pre-prepared medications for multiple residents, which was not in accordance with facility policy. The consultant pharmacist reviewed the incident and confirmed that the combination and dosage of medications administered in error were significant and likely contributed to the resident's fall and subsequent symptoms. The facility's policy required medications to be prepared for one resident at a time and prohibited pre-pouring or pre-setting medications.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that required nurse staffing information was accurately posted each day, as observed and documented over a three-day review period. On each day, the posted staffing information was either outdated, missing required elements such as the facility name and current census, or contained inaccurate information. Specifically, trained medication aides (TMAs) were incorrectly listed under sections designated for LPNs, and postings were made for two days at a time rather than daily. These postings were located inside the facility entrance but did not meet regulatory requirements for content and accuracy. Interviews with the business office manager and the director of nursing confirmed these deficiencies. The business office manager acknowledged posting two days at a time, omitting the facility name and census, and misclassifying TMAs under LPN sections. The director of nursing also confirmed that TMAs should not be listed under LPN sections and that the postings lacked required information. The facility's own policy required daily posting of accurate staffing data, including the facility name, current date, and actual hours worked by each category of nursing staff, which was not followed during the review period.
Failure to Include Recurrent UTI Management in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with a significant history of urinary tract infections (UTIs). The resident, who had severe cognitive impairment and required assistance with all activities of daily living, had multiple diagnoses including hypertension, renal insufficiency, non-Alzheimer's dementia, and morbid obesity. The resident's medical record documented several episodes of UTIs over a period of months, with corresponding antibiotic and preventive treatments ordered by the physician. Despite this documented history and ongoing risk, the resident's care plan did not include any mention of UTIs, the history of recurrent infections, goals of treatment, or interventions to monitor, prevent, or address UTIs. Interviews with facility staff, including a registered nurse clinical coordinator and the director of nursing, confirmed that the care plan should have included the resident's history of UTIs and related interventions. Both staff members acknowledged the importance of documenting such information to ensure staff awareness and timely response to symptoms. The facility's own policy required comprehensive, person-centered care plans that incorporate measurable objectives, timetables, identified problem areas, and risk factors, none of which were present in the resident's care plan regarding UTIs.
Delayed X-ray Results Lead to Deficiency in Timely Diagnostic Services
Penalty
Summary
The facility failed to provide timely x-ray results for three residents, leading to delayed medical interventions. Resident 1, diagnosed with Alzheimer's disease and severe cognitive impairment, experienced an unwitnessed fall resulting in a head laceration and later developed swelling and bruising on her left arm. An x-ray was ordered on January 9, 2025, but the results were not reviewed until January 15, 2025, when the resident's physician personally checked the x-ray and identified a fracture, prompting an emergency room evaluation. Similarly, Resident 2, with a diagnosis of non-traumatic brain dysfunction and dementia, had an x-ray ordered on January 16, 2025, but the formal results were not available until January 23, 2025. Resident 3, diagnosed with debility, heart failure, and respiratory failure, had a chest x-ray ordered on November 21, 2024, with results not available until December 2, 2024. The delays in receiving x-ray results were attributed to a shortage of radiologists, as stated by the Director of Nursing and the Director of Regional Hospital Imaging Department. The facility lacked a formal process for timely x-ray result expectations, and the Contract for Radiology Services required timely completion of medical records. The Assistant Director of Nursing and the facility administrator expressed concerns about the delays, emphasizing the need for x-ray results within a couple of hours to ensure prompt medical care. The facility did not have a diagnostic testing policy, contributing to the deficiency in providing timely diagnostic services.
Failure to Document Pressure Ulcer Assessments
Penalty
Summary
The facility failed to document assessments during pressure ulcer dressing changes for a resident with a deep tissue pressure ulcer on the coccyx. The resident had multiple diagnoses, including osteomyelitis of the vertebra, extradural and subdural abscess, severe protein-calorie malnutrition, acute infarction of the spinal cord, and a pressure ulcer. The care plan included specific interventions such as administering pain medications, using an air mattress, and repositioning the resident every two hours. However, it did not include instructions for documenting findings during dressing changes. The resident's wound was noted to have worsened, with changes in the wound bed observed by an LPN, who notified the RN and DON via email. Despite this notification, there was no evidence of a formal reassessment or documentation of the wound's characteristics in the resident's medical record. The facility's policy required staff to document wound assessments, including measurements and visual data, and notify the physician if the wound showed signs of infection or deterioration. Interviews with facility staff revealed that the LPN observed changes in the wound but did not document these findings in the medical record. The DON confirmed the lack of documentation and reassessment following the LPN's notification. The facility's failure to document wound assessments and follow up on identified changes led to a deficiency in providing necessary treatment and services to promote healing and prevent infection, as outlined in their policy.
Failure to Notify Physician and Family of Resident's Self-Harm Attempt
Penalty
Summary
The facility failed to ensure timely notification of a resident's physician and responsible parties when the resident, who had increasing depression, attempted to harm herself. The incident involved a resident with a history of major depression, cognitive impairment, and several chronic health conditions, including COPD and liver cirrhosis. On the evening of the incident, the resident expressed suicidal thoughts and attempted to strangle herself with her nasal cannula. Despite the severity of the situation, the facility staff did not immediately contact the resident's primary physician or any on-call physicians, nor did they inform the resident's family about the specific details of the incident. The report highlights that the LPN on duty documented the resident's suicidal statement and the removal of the cannula but failed to take further immediate action to ensure the resident's safety or notify the necessary parties. The LPN suggested moving the resident to a more observable area and called a family member to sit with the resident, but did not disclose the full extent of the incident. The facility's documentation lacked evidence of any interventions or safety measures implemented between the time of the incident and the following morning when social services assessed the resident and contacted the physician and family. Interviews with facility staff, including the DON and social work designee, confirmed the lack of appropriate documentation and communication regarding the incident. The resident's primary physician was not informed until the next morning, at which point the resident was transferred to the emergency room for further assessment. The physician noted that elevated liver function and ammonia levels could have contributed to the resident's mental disturbance. The facility's policy on suicide prevention was not adequately followed, as staff did not notify the appropriate parties or document the incident thoroughly.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Sauk Centre
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cura Of Melrose | 8 mi | — | 13 | 0 |
| Galeon | 13 mi | — | 7 | 0 |
| Cura Of Long Prairie | 16.6 mi | — | 1 | 0 |
| Benedictine Living Community | Mother Of Mercy | 19.7 mi | — | 7 | 0 |
| Belgrade Nursing Home | 20.7 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.