Essentia Health Oak Crossing

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to consistently follow provider's orders for one of five residents (R1) investigated for unnecessary medication. Findings Include: R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 was cognitively intact and had diagnoses which included: heart failure, respiratory failure, anxiety and depression. R1's MDS identified R1 received diuretics (medication to help remove excess fluids). R1's care plan revised 12/3/25, identified R1 was at risk for cardiac complications related to history of respiratory failure and diagnoses of congestive heart failure (CHF), atrial fibrillation (A-Fib, irregular heart and often rapid heart rhythm) and hypertension (HTN, high blood pressure). Approaches identified R1 sometimes refused to have my weight obtained, monitor for signs and symptoms and monitor vital sign as per protocol or as ordered. R1's Physician Order Report signed 11/28/25, included the following:-Daily Weights for heart failure, start date…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to ensure appropriate hand hygiene was performed during personal cares for 1 of 1 residents (R3) reviewed for hand hygiene. Finding include: R3's care plan dated 6/3/25, identified he had an activities of daily living (ADLS) deficit related to impaired cognition, impaired mobility, and incontinence. Staff were directed to offer and assist with toilet upon rising, before and after meals, check on him every two hours at night and assist to toilet on 1:00 a.m. rounds. Stay with resident while in bathroom, do not leave alone. Transfer with assist of one and walker. He required assist of one for personal hygiene and toileting. History of urinary tract infection. R3's quarterly Minimum Data Set (MDS) dated [DATE], identified R3 had severe impaired cognition and no behaviors. R3 required partial/moderate assistance chair/bed to chair transfer and substantial/maximal assistance with personal hygiene, shower/bathe, upper and lower body dressing,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to maintain the water and ice machines in a sanitary manner to prevent potential contamination for 69 residents who currently received water and ice from the ice machines. In addition, the facility failed to maintain the coffee machine on the Meadow [NAME] unit in a sanitary manner to prevent potential contamination for the residents who currently used the coffee machine. Findings include: On 10/21/24 at 11:49 a.m., an initial tour was conducted on all units and the following concerns were identified: -The water and ice machine located outside the main dining room on the Meadow [NAME] unit was observed to have an encrusted hard white flaky substance build up under the ice and water dispenser. The tip of the ice dispenser had an encrusted hard white flaky substance around the inside and the outside of the ice dispenser. The grate inside of the tray of the ice machine had an encrusted hard white flaky substance build up on top of the grate…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure advanced directives for emergency care and treatment were accurately reflected in all areas of the resident's medical record to ensure residents wishes would be implemented correctly in an emergency for 3 of 25 residents (R10, R60, R68) reviewed for advanced directives. Findings Include: R10 R10's admission Minimum Data Set (MDS) dated [DATE], identified R10 was cognitively intact and had diagnoses which included: heart failure, diabetes mellitus, and respiratory failure. Review of R10's electronic medical record (EMR) identified the following: -R10's dashboard Profile (banner viewed on computer screen) identified Advance Directive: do not resuscitate (DNR). -R10's Physician Order Report identified Advance Directive: Full Code, order date [DATE]. -R10's scanned in Provider Orders For Life-Sustaining Treatment (POLST) signed [DATE], identified Attempt Resuscitation/Cardiopulmonary resuscitation (CPR). Review of R10's paper chart identified the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to appropriately implement identified pressure relieving interventions to promote healing for 1 of 3 resident (R1) reviewed with current, recurring, stage three (3) pressure ulcer on R1's left heel. Stage 3 pressure ulcer; full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling. Slough; non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had moderate cognitive impairment and had diagnoses which included aphasia (a disorder that could affect how a person communicated. It may impact speech, as well as the way a person may write and understand both spoken…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to identify the root cause of falls, implement appropriate interventions and follow care planned interventions for 2 of 3 residents (R 29, R127) who had multiple falls in the facility. Findings include: R29 R29's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified R29 had diagnoses that included hypertension, Diabetes Mellitus, and dementia. Indicated R29 had mildly impaired cognition. Indicated R29 required maximal assistance with toileting, moderate assistance with dressing and hygiene, and assistance with transfers. R29 utilized a walker and a wheelchair. Identified R29 had fallen since admission with injury. R29's significant change Care Area Assessment (CAA) dated 2/29/24, identified R29 had delusional disorder, alcohol abuse, and a history of falling. Indicated R29 was at risk for falls due to her impaired mobility, cognition, psychotropic medication use, and incontinence. Resident required one assist with transfers.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure residents were assessed for the ability to self administer medications for 2 of 7 residents (R21, R46) reviewed for medication administration. Findings include: R21 R21's annual Minimum Data Set (MDS) dated 10/23, identified R21 was independent with cognitive skills for daily decision making and had diagnoses which included: hypertension (high blood pressure), peripheral vascular disease (narrowing of blood vessels other than the heart), thyroid disorder (functioning of the thyroid gland) and depression. Indicated R21 required supervision to partial assistance with dressing and bathing. R21's care plan dated 12/12/23, identified R21 was unable to self-administer medications. R21's Physician Order Report dated 11/6/23, included: -Tylenol 325 milligram (mg) take two tablets three times a day. -Cetirizine 5 mg daily. -Vitamin D3 125 mcg (5,000 unit) take two tablets daily. -Levothyroxine 137 micrograms (mcg) daily. -Furosemide 40 mg…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to provide assistance with personal hygiene for 1 of 3 residents( R14) reviewed for activities of daily living (ADL)'s. Findings include: R14's significant change Minimum Data Set (MDS) dated [DATE], identified R14 had moderate cognitive impairment and had diagnosis which included cerebral Palsy, arthritis, and hypertension (elevated blood pressure). Identified R14 required moderate assistance with activities of daily living (ADL's) which included bed mobility, transfers, and personal hygiene. R14's current care plan last revised 10/17/23, indicated R14 had deficits with ADL's related to impaired cognition. Indicated staff were to assist R14 with shaving as needed. R14's comprehensive Care Area Assessment (CAA) dated 11/4/23, identified R14 required moderate assistance with ADL's. During an observation on 12/11/23 at 12:38 p.m , R14 was lying in bed and had several red one inch long facial hairs present on his cheeks, chin and above his…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to implement hand hygiene for 3 of 7 residents (R46, R48, and R16) observed during medication administration. Findings include: R46's quarterly Minimum Data Set (MDS) dated [DATE], identified R46 had severe cognitive impairment and diagnoses which included: cancer, renal insufficiency, dementia, and anxiety. Identified R46 required substantial/maximal assistance with dressing, personal hygiene and showering/bathing. R48's quarterly MDS dated [DATE], identified R48 had moderate cognitive impairment and diagnoses which included: hip and knee replacement, hypertension (high blood pressure), Alzheimer's dementia and depression. Identified R48 required substantial/maximal assistance with dressing, personal hygiene and showering/bathing. R16's quarterly MDS dated [DATE], indicated R16 was cognitively intact and diagnoses which included: heart failure, diabetes, hypertension. Identified R16 was independent with personal hygiene,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure 1 of 5 resident (R51, R56) was offered or received pneumococcal vaccinations in accordance with the Center for Disease Control (CDC) recommendations reviewed for immunizations. Findings include: Review of the current CDC recommendations dated 3/15/2023, revealed older adults who received Pneumococcal conjugate vaccine (PCV13) at any age and Pneumococcal polysaccharide vaccine (PPSV23) before age [AGE] years, the CDC recommended they receive one dose of PCV20 or PPSV23. Review of R51's facesheet identified R51, age [AGE] was admitted to the facility on [DATE]. Review of R51's Minnesota Immunization Information Connection (MIIC) undated, identified R51 had received the PPSV23 on 10/24/2006. R51's medical record lacked documentation R51 had been offered or received the PCV20 vaccine or another dose of the PPSV23. Review of R56's facesheet identified R56, age [AGE] was admitted to the facility on [DATE]. Review of R56's MIIC undated, identified…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.