Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens 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 St Johns On Fountain Lake during CMS and state inspections, most recent first.
A resident was not protected from a significant medication error, as required, with no further details provided about the circumstances or the resident's condition.
A resident with significant cardiac and liver conditions experienced a medication error involving Torsemide. After the error was discovered, the DON destroyed the unused medication but failed to document the prescription numbers, quantity, and date of destruction as required by facility policy. The medication destruction log and the resident's medical record did not reflect the proper disposition of the medication.
A facility failed to follow infection control practices when a resident's urinary drainage bag was found on the floor, and loose laundry was sent down a chute unbagged. Staff interviews revealed awareness of proper procedures, but these were not consistently followed, posing infection risks.
The facility failed to maintain proper holding temperatures for hot foods, with cheese quesadillas and bacon observed below the required 135°F. Additionally, infection control practices were not followed, as a cook handled food without gloves and did not wash hands after handling broken glass. The DON acknowledged the need for re-education on infection control.
A resident with a history of fractures and other conditions experienced a fall and later complained of neck pain, which was not immediately reported to the physician. The resident's condition worsened, leading to an eventual transfer to the emergency department where additional fractures were diagnosed. Staff interviews confirmed the oversight in communication, and the facility's policy on physician notification was not provided.
A resident with a history of diabetes and other health issues developed pressure ulcers on both heels while in a facility. Despite the care plan requiring weekly comprehensive skin assessments, the facility failed to conduct these assessments consistently. The resident's condition and the facility's documentation practices contributed to the deficiency, as confirmed by staff interviews.
The facility failed to address the consultant pharmacist's recommendations for two residents, leading to medication management deficiencies. One resident with diabetes and chronic kidney disease did not receive recommended follow-up for ACEI/ARB therapy, and another was prescribed duloxetine with an inappropriate indication. Despite receiving the recommendations, the DON did not ensure they were acted upon, resulting in medication irregularities.
The facility failed to implement enhanced barrier precautions (EBP) for two residents during high-contact care activities, despite CDC guidelines and care plan instructions. One resident with bullous pemphigoid and another with a urostomy were observed receiving care without EBP. Staff interviews revealed a lack of adherence to EBP protocols, despite education and audits by the infection preventionist.
A resident with quadriplegia fell from a mechanical lift due to improper use and lack of comprehensive assessments for sling size, resulting in ongoing pain. The facility failed to ensure staff followed manufacturer's recommendations, and there was no system in place for determining appropriate sling sizes. Interviews revealed staff were unaware of proper sling size determination, and the facility's investigation did not address sling size or type used during the transfer.
A facility failed to update a resident's care plan after a significant decline in health status, resulting in inaccurate care instructions for mobility and activities of daily living. Despite the resident's return from the hospital with new needs, no comprehensive assessment or care plan update was completed.
The facility failed to administer medication per physician order and did not evaluate and address medication errors to prevent recurrence for a resident with moderate cognitive impairment and a life expectancy of less than six months. The resident received double doses of Ativan on multiple occasions, and the facility did not document monitoring for overdose response or complete a causal analysis to prevent similar errors.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident received a significant medication error, but does not provide further details regarding the specific actions, inactions, or events that led to the error. No additional information about the residents involved or their medical conditions at the time of the deficiency is included in the report.
Failure to Document Medication Disposition for a Resident
Penalty
Summary
The facility failed to maintain proper documentation regarding the disposition of medications for a resident with multiple complex medical conditions, including hypertensive heart disease with heart failure, atrial fibrillation, a prosthetic heart valve, a defibrillator, and chronic liver disease. Specifically, after a medication error was identified in which the resident received an incorrect dosage of Torsemide, the Director of Nursing (DON) destroyed four prescription cards of the medication but did not document the prescription numbers, quantity, or date of destruction as required. The medication destruction log did not include the destroyed Torsemide, and the resident's medical record lacked evidence of the medication's proper disposition. Interviews with facility staff and review of the facility's Medication Destruction Policy confirmed that all medications delivered to the facility are considered the property of the resident and that a log must be completed for any medication disposed of, including specific details such as resident name, prescription number, quantity, date, and staff signature. The consulting pharmacist and registered nurse both acknowledged that the required documentation was missing for the destroyed Torsemide, and the DON admitted to not recording the necessary information at the time of destruction.
Infection Control Lapses in Catheter and Laundry Handling
Penalty
Summary
The facility failed to ensure proper infection control practices were followed for a resident with an indwelling urinary catheter. The resident's urinary drainage bag was observed laying on the floor, which is against the facility's infection control policy. The Licensed Practical Nurse (LPN) who administered medication to the resident did not initially address the issue, and upon inquiry, acknowledged that the catheter bag should not be on the floor as it could lead to a urinary tract infection (UTI). The facility's policy on catheter care did not specify the proper positioning of the urinary drainage bag to prevent such occurrences. Additionally, the facility did not adhere to proper procedures for handling soiled linens. Observations revealed that loose and contaminated laundry was sent down the laundry chute without being secured in a plastic bag, contrary to the facility's policy. Staff interviews confirmed that linens were sometimes thrown down the chute unbagged due to haste, and there was no signage to remind staff of the proper procedure. The facility's policy on soiled linen handling required linens to be bagged to prevent contamination, but it did not include specific instructions for using the laundry chute. Interviews with the Director of Nursing (DON) and other staff members indicated awareness of the proper procedures, yet these were not consistently followed. The DON acknowledged that placing catheter bags on the floor and sending loose linens down the chute posed infection control concerns. Despite staff training, these lapses in protocol were observed, highlighting a need for reinforcement of infection prevention practices within the facility.
Failure to Maintain Food Safety and Infection Control
Penalty
Summary
The facility failed to maintain proper holding temperatures for hot foods, specifically cheese quesadillas and bacon, which were observed to be below the required 135 degrees Fahrenheit. The cheese quesadillas were initially removed from the oven at 136 degrees Fahrenheit but dropped to 127 degrees Fahrenheit after being left partially uncovered on the stove. Similarly, bacon was observed on a warm burner without a lid, with a holding temperature of 119.9 degrees Fahrenheit. The Culinary Services Manager acknowledged the failure to maintain adequate holding temperatures, which contradicted the facility's policy requiring hot foods to be held at a minimum of 135 degrees Fahrenheit. Additionally, the facility failed to ensure proper infection control practices during food preparation and service. A cook was observed handling food without gloves and touching food contact surfaces without washing hands. After a collision in the kitchen, the same cook handled broken glass and peaches without washing hands before returning to food preparation tasks. The Director of Nursing recognized the need for immediate re-education on infection control, as these practices have the potential to affect all residents on the unit. The facility's hand hygiene policy emphasizes the importance of hand hygiene in preventing the spread of infection, which was not adhered to in these instances.
Failure to Notify Physician of Neck Pain After Fall
Penalty
Summary
The facility failed to notify the physician of a resident's neck pain following a fall, which was a deficiency identified during the survey. The resident, who had a history of Parkinsonism, pneumonia, atrial fibrillation, and fractures, experienced an unwitnessed fall while reaching for an item. Although the resident initially complained of mild foot pain, later in the day, he began to experience neck pain, which was not immediately communicated to the physician. The nursing staff documented the resident's complaints of neck pain and offered pain relief, but the physician was not notified until the following morning when the resident's condition worsened. The resident was eventually transferred to the emergency department, where further fractures were diagnosed. Interviews with the medical staff, including the resident's doctor and nurses, confirmed that the physician should have been notified immediately when the resident began complaining of neck pain. The director of nursing and other staff members acknowledged the oversight in communication, noting that the physician was initially contacted after the fall but not when the neck pain developed. The facility's policy on physician notification was requested but not provided, indicating a possible gap in procedural adherence or documentation.
Failure to Conduct Weekly Skin Assessments for Pressure Ulcers
Penalty
Summary
The facility failed to ensure weekly comprehensive skin assessments with measurements were completed for a resident reviewed for pressure ulcers. The resident, who was cognitively intact and required substantial assistance with daily activities, had a history of type one diabetes, cancer, hypertension, renal insufficiency, and chronic kidney disease, making them at risk for developing pressure ulcers. Despite having two unstageable pressure injuries on both heels, the facility did not conduct the required weekly skin assessments after the initial discovery of the ulcers on October 10, 2024, until October 24, 2024. The resident's care plan included interventions such as pressure-relieving devices and weekly documentation of the skin injuries' measurements and characteristics. However, the facility's documentation was inconsistent, with missing entries for the required weekly assessments. The resident's treatment administration record indicated a lack of comprehensive skin checks, and the facility's staff confirmed that the assessments were not completed as expected. The resident's condition, including diabetes and poor perfusion, was noted to contribute to the risk of skin breakdown, but the facility did not adhere to its policy of weekly wound assessments. Interviews with facility staff, including the nurse manager and consulting wound nurse, revealed that the resident's pressure ulcers were acquired in-house and were not documented with the necessary measurements and comprehensive descriptions. The facility's pressure injury policy required weekly wound assessments and documentation, but this was not followed, leading to a deficiency in the care provided to the resident. The facility's director of nursing and administrator acknowledged the lapse in completing the weekly skin checks and the need for comprehensive assessments.
Failure to Address Pharmacist Recommendations for Medication Management
Penalty
Summary
The facility failed to act upon the consultant pharmacist's recommendations for two residents, leading to deficiencies in medication management. For one resident, identified as R59, the consultant pharmacist recommended a follow-up on the potential need for ACEI/ARB therapy due to the resident's diabetes and chronic kidney disease. Additionally, there was a lack of indication for the use of aspirin. Despite these recommendations being documented in the resident's chart, the facility did not address them, as confirmed by the Director of Nursing (DON) and the nurse manager. The DON acknowledged receiving the recommendations but failed to ensure they were acted upon by the provider. Another resident, identified as R55, was prescribed duloxetine with an inappropriate indication of cognitive impairment. The consultant pharmacist issued multiple notices requesting clarification or an appropriate indication for the medication, but these were not addressed. The DON admitted to receiving an email about the duloxetine recommendation but had not taken action. The nurse manager, who was not involved in the pharmacy review process, confirmed the lack of action on the recommendations. The facility's policy requires the consultant pharmacist to perform a medication regimen review for each resident and report any irregularities to the attending physicians. However, in these cases, the facility did not follow through on the pharmacist's recommendations, resulting in medication irregularities for the residents. The DON was responsible for ensuring these recommendations were addressed but failed to do so, leading to the deficiencies noted in the report.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to utilize enhanced barrier precautions (EBP) for two residents during high-contact care activities, as observed by surveyors. The Centers for Disease Control (CDC) guidelines indicate that EBP should be used during high-contact care activities for residents with infections or colonization with multi-drug resistant organisms (MDRO), or for those with chronic wounds or indwelling medical devices. Despite these guidelines, staff did not implement EBP for two residents, R1 and R2, who required such precautions due to their medical conditions. Resident R1, diagnosed with bullous pemphigoid, had severe cognitive impairment and required assistance with dressing, bathing, and hygiene. R1 had a left foot ulceration and underwent wound debridement. Despite the care plan indicating the need for EBP during high-contact care activities, staff were observed transferring R1 and assisting with toileting without using EBP. Similarly, Resident R2, who had a urostomy and severe cognitive impairment, required assistance with transfers and care. Staff were observed transferring R2 without using EBP, despite the care plan's instructions. Interviews with staff revealed a lack of adherence to EBP protocols, with some staff unaware of the need to use EBP during high-contact care activities. The infection preventionist stated that education on EBP was provided at meetings, and audits were conducted, but the deficiency persisted. The Director of Nursing expected EBP to be followed and accessible, yet observations indicated otherwise. The facility's EBP policy outlined the need for gloves and gowns during close contact care for residents with MDRO history or colonization, but this was not consistently implemented.
Improper Use of Mechanical Lift Leads to Resident Injury
Penalty
Summary
The facility failed to safely use a full body mechanical lift according to the manufacturer's recommendations, resulting in harm to a resident (R1) who fell from the lift. R1, who was diagnosed with quadriplegia and had bilateral range of motion impairment, was dependent on staff for all activities of daily living except eating. The incident occurred when nursing assistants were transferring R1 from a wheelchair to a bed, and the right shoulder sling loop/strap detached from the lift, causing R1 to fall approximately three feet to the floor. This fall resulted in ongoing pain in R1's shoulders and neck region. The facility also failed to ensure comprehensive assessments were completed to determine the proper sling size for residents requiring transfers with a mechanical lift. R1's care plan and nursing assessments did not specify the sling size or type, and staff used whatever sling was available in the room without a clear process for determining the appropriate size. Interviews with staff revealed a lack of awareness and training on how to properly determine sling sizes, and the facility did not have a system in place for sling assessments. Additionally, the facility's investigation into the fall did not address whether the appropriate sling size and type were used during R1's transfer. Maintenance logs indicated that the lifts were not inspected immediately following the incident, and the facility was using a different brand of lifts than documented. The lack of proper sling size determination and failure to follow safety protocols contributed to the deficiency, as staff did not check the tension of the sling loops/straps before moving the resident, leading to the fall.
Failure to Update Care Plan After Resident's Health Decline
Penalty
Summary
The facility failed to ensure a comprehensive care plan was developed and maintained for a resident with moderately impaired cognition and a terminal illness. The resident's care plan initially included interventions for mobility assistance, but after a significant decline in health status, the care plan was not updated to reflect the resident's new needs. The resident experienced a decline in mobility and communication abilities, was sent to the emergency room, and returned with a new diagnosis and treatment plan, but no comprehensive assessment or updated care plan was completed upon their return to the facility. Interviews with the clinical manager and the director of nursing revealed that the resident's care plan was not accurate for their level of care related to mobility and activities of daily living after the change in condition. The clinical manager acknowledged that a mobility assessment had not been completed, and the director of nursing confirmed that a comprehensive assessment should have been conducted to re-establish the resident's baseline and update the care plan accordingly. Both staff members recognized the deficiency in the care planning process. The facility's policy on care planning indicated that the interdisciplinary team is responsible for developing resident care plans based on assessments and that these plans should be updated following significant changes in a resident's condition. Despite this policy, the facility did not complete the necessary assessments or update the care plan for the resident after their return from the hospital, leading to a failure in providing appropriate care for the resident's needs.
Failure to Administer Medication Per Physician Order and Address Medication Errors
Penalty
Summary
The facility failed to administer medication per physician order and did not evaluate and address medication errors to prevent recurrence for a resident with moderate cognitive impairment and a life expectancy of less than six months. The resident's medication administration record (MAR) showed discrepancies in the administration of Ativan, with doses given incorrectly on multiple occasions. A medication error report indicated that the resident received double doses of Ativan, but the facility did not document monitoring of the resident for overdose response or vital signs before the next dose. Additionally, the facility did not complete a causal analysis to prevent similar errors in the future. The Director of Nursing (DON) was informed of the medication error but had not investigated or provided education to prevent further errors. The DON confirmed that the resident's record lacked documentation of monitoring and assessing after the error. The facility's Medication Error Policy required a medication error report to be completed and signed by the responsible person, with follow-up actions as needed. However, the DON had not yet implemented any measures to prevent recurrence. The administrator expected nurses to follow the medication administration policy and refer errors to the DON for follow-up.
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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 Albert Lea
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Thorne Crest Retirement Center | 2 mi | — | 25 | 0 |
| Good Samaritan Society - Albert Lea | 2.6 mi | — | 5 | 0 |
| New Richland Care Center | 16.2 mi | — | 2 | 0 |
| Parkview Care Center | 17.3 mi | — | 8 | 0 |
| Lutheran Retirement Home | 17.5 mi | — | 8 | 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.