Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
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 Willmar during CMS and state inspections, most recent first.
A resident with stroke-related hemiplegia, ESRD, diabetes, legal blindness, and a care plan requiring assist of two for transfers was transferred to the toilet by one staff member and left there with a call light. The resident reported sliding or tipping off the toilet while attempting to wipe, landing on the floor, and being lifted under the arms by two unidentified female staff and returned to bed without a nursing assessment. Throughout the day, the resident complained of left leg and hip pain, which was documented by PT and nursing, and repeatedly reported that he had fallen from the toilet, while multiple NAs denied witnessing or assisting with the fall and gave inconsistent accounts. Despite a facility policy requiring immediate reporting of all actual, suspected, or resident-reported falls to a nurse, the fall was not promptly reported or assessed at the time it occurred, and the resident was moved from the floor back to bed without evaluation, with a later ED visit revealing a left intertrochanteric femur fracture requiring surgery.
The facility failed to maintain a working wander alert system, resulting in two residents with cognitive impairments being able to exit the building on separate occasions. Despite alarms sounding, the doors did not lock as intended, and staff reported the malfunction had persisted for several weeks. Maintenance and testing procedures were inadequate, and the system was not properly checked according to manufacturer guidelines.
A resident with chronic diastolic congestive heart failure did not receive PRN Metolazone as ordered for significant weight gain on multiple occasions. Facility staff, including an LPN and RN, were unaware of the PRN order linked to the resident's daily weight task, leading to a failure in administering the medication. The DON confirmed the importance of following physician's orders, which was not done in this instance.
A facility failed to perform proper hand hygiene after caring for a resident on contact enteric precautions due to a C. Diff. infection. The resident had a history of end-stage renal disease, diabetes, and pressure ulcers, and required assistance for transfers. A nursing assistant did not wash or sanitize her hands after assisting with the resident's transfer and handling a meal tray. The DON confirmed the need for handwashing with soap and water, as hand sanitizer is ineffective against C. Diff.
A resident with moderately impaired cognition and multiple diagnoses was not offered the PCV20 vaccination as recommended by the CDC. Despite the facility's policy to verify immunizations upon admission and educate residents on vaccination benefits, the resident's record lacked evidence of shared clinical decision-making or an offer for the PCV20, highlighting a deficiency in following immunization guidelines.
A facility failed to educate and administer a COVID-19 booster to a resident with moderately impaired cognition and chronic conditions. The resident's last booster was in March 2023, with no further documentation or education provided. The DON admitted the oversight, acknowledging the lapse in following the facility's immunization policy.
Failure to Report and Assess Resident-Reported Fall From Toilet Resulting in Hip Fracture
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect when staff did not follow required fall reporting and assessment procedures after the resident fell from a toilet. The resident had multiple diagnoses including stroke, ESRD, diabetes, CVA with left-sided hemiplegia/hemiparesis, was legally blind, required assistance of two staff for transfers and toileting per the care plan, and used a wheelchair or walker for mobility. The admission MDS indicated the resident was cognitively intact, frequently incontinent, dependent for transfers, and had a prior fall history. The care plan and Kardex specified assistance of two staff for ambulation, transfers, and toileting due to left-sided weakness and fall risk. On the day of the incident, an activity assistant/nursing assistant (AA-A) reported that the resident requested to use the bathroom. AA-A stated she asked staff what level of assistance the resident required and was told he was assist of one with a transfer belt to the toilet. AA-A transferred the resident from bed to the toilet with assist of one, left him on the toilet with his call light, and reported she was told that other staff would transfer him off the toilet and back to bed while she went on break. Later, the resident reported that while sitting on the toilet he attempted to wipe himself, slid or tipped off the toilet, and fell forward onto the floor, landing on his left side. The resident, who was blind, stated that two female staff came into the room, lifted him under his arms from the floor, and put him back into bed, but he could not identify who they were. Following the fall, the resident complained of left leg and knee pain, including during a physical therapy session where the PTA documented that the resident reported a fall from the toilet while staff reported no fall had occurred. The PTA noted left lower extremity knee, hip, and intertrochanteric band area pain with all movement and that attempts at transfer training were unsuccessful due to pain, and nursing was informed of these findings. Later that day, the resident continued to complain of worsening left leg pain, and during an evening nursing assessment he yelled out in pain with repositioning, with swelling noted to the left hip area. The resident again reported he had fallen off the toilet earlier. Nursing review of the earlier shift report showed that the resident had reported tipping off the toilet, but staff stated they had not witnessed a fall. The facility’s own fall communication policy required that all fall events, including resident-reported or suspected falls, be reported immediately to a nurse for prompt assessment, and that staff must never fail to notify the nurse if they are aware a fall occurred. Despite the resident’s report of a fall and subsequent pain, the fall was not promptly reported or assessed at the time it occurred, and the resident was moved from the floor back to bed without a nursing assessment, leading to delayed identification of a left hip fracture that required emergency evaluation and surgical repair. Interviews with multiple nursing assistants revealed inconsistent accounts and denials of witnessing or assisting with the fall, even though the resident and his family member consistently reported that he fell from the toilet and was assisted from the floor by two staff. One NA reported receiving a social media message instructing her to "stick to the story" about the fall and that another NA had put the resident back into bed, though the message disappeared and could not be produced. Another NA acknowledged getting the resident up earlier in the day and later sending a message asking if anyone had called about the fall, but denied assisting him from the floor. The LPN on duty stated that when she was informed the resident wanted Tylenol and went to his room, the resident told her he had fallen from the toilet, but after interviewing the NAs, none admitted seeing a fall, and the nurse thought the resident was confused and simply passed the information to the next shift at the end of her shift. The facility’s investigation concluded that the resident had been transferred to the toilet by one employee despite a care plan requiring assistance of two, that the resident fell from the toilet, and that he was moved back into bed without assessment, constituting neglect as defined by regulation.
Failure to Ensure Functioning Wander Alert System
Penalty
Summary
The facility failed to develop and implement a process to ensure the wander alert system was functioning properly, affecting two residents who utilized wander alert devices. One resident, who had diagnoses including vascular dementia, Alzheimer's disease, and bilateral below-the-knee amputations, was identified as high risk for elopement and wore wander alert bracelets on both the left wrist and wheelchair. Despite these precautions, the resident was able to exit the facility on two separate occasions. In one incident, the wander guard did not work, allowing the resident to leave through the front entrance doors, which had not locked after being recently opened. In another incident, the resident was found outside in a culvert with the wheelchair on top of him after pushing and holding the exit door long enough for the emergency release to activate, despite wearing the wander alert device. Interviews with staff revealed ongoing issues with the door locking mechanism. Nursing assistants and an LPN reported that the doors would alarm when the resident was near but did not physically lock, and this issue had been occurring for several weeks. Staff stated that the malfunction had been reported to management, but the problem persisted. The administrator confirmed that the facility had been without a maintenance director for about two weeks and had relied on maintenance staff from another facility to inspect the doors. However, the inspections did not identify or resolve the underlying issue with the wander alert system and door locks. Further review of the facility's testing procedures and manufacturer recommendations indicated that the required weekly testing of the wander alert system was not being conducted as specified. The former maintenance director admitted to not testing whether the doors would unlock if a wander alert device was near and was unsure who to contact for technical issues. The regional director of operations and other staff used a handheld remote to test the doors, but this did not replicate the actual conditions under which the system failed. Documentation and interviews confirmed that the process for ensuring the wander alert system's functionality was inadequate, leading to repeated failures to prevent elopement.
Failure to Administer PRN Medication for Weight Gain
Penalty
Summary
The facility failed to administer as-needed (PRN) medications according to a physician's order for a resident with chronic diastolic congestive heart failure. The resident, who had moderate cognitive impairment and required assistance with all activities of daily living, had a physician's order for Metolazone 5 mg to be given by mouth as needed for fluid retention or weight gain. However, the electronic health record (EHR) lacked documentation of the administration of this PRN medication on several occasions when the resident's weight increased significantly overnight. The resident's weight documentation indicated multiple instances of weight gain exceeding the parameters set by the physician's order, yet the PRN medication was not administered. Interviews with facility staff, including a licensed practical nurse (LPN), a registered nurse care coordinator (RN), and the director of nursing (DON), revealed a lack of awareness and communication regarding the PRN order linked to the resident's daily weight task. The RN care coordinator acknowledged that the PRN order was not linked to the daily weight task, which should have prompted the nursing staff to administer the medication. The director of nursing confirmed that the PRN medication should have been administered with the increased weight gain, emphasizing the importance of following physician's orders for the management of the resident's congestive heart failure. The consultant pharmacist also stated that the medication should have been administered according to the provider's order. The facility's Medication Guidelines policy indicated that medications should be administered accurately and in a timely manner by qualified personnel, but this was not adhered to in this case.
Failure to Perform Hand Hygiene After Resident Care
Penalty
Summary
The facility failed to perform proper hand hygiene after high-contact direct care for a resident, identified as R114, who was on contact enteric precautions due to a Clostridium difficile (C. Diff.) infection. R114 had a history of end-stage renal disease, diabetes, pressure ulcers, and had recently been hospitalized for diabetic ketoacidosis and inflammation of the colon caused by C. Diff. The resident was frequently bowel incontinent, deconditioned, and dependent on staff for transfers and mobility. A sign indicating the need for transmission-based precautions was placed outside R114's room, instructing staff to wash hands or use hand sanitizer, don gown and gloves before entry, and wash hands upon leaving the room. During an observation, a nursing assistant (NA-A) failed to wash or sanitize her hands after assisting with R114's transfer and proceeded to handle a meal tray without performing hand hygiene. NA-A acknowledged the oversight during an interview, stating she was unaware of the specific precautions required for R114. The Director of Nursing (DON) confirmed that R114 was on contact enteric precautions due to C. Diff. and emphasized the importance of handwashing with soap and water, as hand sanitizer does not kill the C. Diff. organism. The facility's hand hygiene policy, dated January 2023, required washing hands with soap and water after contact with residents with infectious diarrhea, including C. Diff.
Failure to Offer Pneumococcal Vaccination
Penalty
Summary
The facility failed to ensure that a resident, identified as R55, was offered and/or provided the pneumococcal vaccination series as recommended by the CDC. R55, who had moderately impaired cognition and diagnoses of hypertension, peripheral vascular disease, and diabetes, was [AGE] years old. The resident's immunization record indicated that they had received a PPSV23 on 7/13/2017 and a PCV13 on 4/20/16. However, there was no evidence of shared clinical decision-making with the physician for a PCV20 at least five years after the last pneumococcal dose, nor was there evidence that R55 or their representative was offered or received a PCV20. During an interview, the DON, who also serves as the infection preventionist, confirmed that immunizations are verified upon admission through MIIC and resident medical records. The DON stated that residents and/or their representatives would be offered and educated on the risk/benefit of the PCV20, and consents are obtained if eligible. The DON also mentioned that the facility follows policies based on CDC recommendations for immunization guidelines. Despite these procedures, the DON verified that R55 had not been offered or provided education on PCV20, indicating a lapse in following the facility's policy on pneumococcal immunization.
Failure to Educate and Administer COVID-19 Booster
Penalty
Summary
The facility failed to ensure proper education and administration of the COVID-19 booster vaccination for one resident, identified as R55, who was reviewed for COVID-19 vaccination status. According to the report, R55 had moderately impaired cognition and diagnoses of hypertension, peripheral vascular disease, and diabetes. The resident's electronic medical record indicated that the last COVID-19 booster was administered on March 15, 2023. However, there was no documentation of any additional booster vaccination or evidence of education regarding the benefits and potential side effects of the booster. Furthermore, there was no indication of any contraindication to the COVID-19 vaccination in R55's records. During an interview, the Director of Nursing (DON), who also serves as the infection preventionist, acknowledged that the process of verifying immunizations and offering education on the COVID-19 booster was missed for R55. The DON explained that immunizations are typically verified upon admission through the Minnesota Immunization Information Connection and resident medical records. The facility's policy, dated October 2023, states that COVID-19 vaccinations should be offered to all staff and residents unless medically contraindicated or if the individual has already received all recommended doses. The DON admitted that the facility's process, which involves collaboration with the facility pharmacy and resident providers, was not followed in this instance.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 38 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Willmar
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bethesda | 1.7 mi | — | 14 | 0 |
| Glenoaks Senior Living Campus | 14.6 mi | — | 5 | 0 |
| Clara City Care Center | 18 mi | — | 9 | 1 |
| Olivia Restorative Care Center | 23.1 mi | — | 1 | 0 |
| Belgrade Nursing Home | 23.5 mi | — | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Cura Of Willmar.
100% money-back within 48 hours.
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.