Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 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 Saint Therese At Oxbow Lake during CMS and state inspections, most recent first.
A facility failed to ensure a resident's resuscitation wishes, as indicated on a signed POLST, were accurately reflected in the EMR. The resident's POLST indicated a wish for CPR, but a verbal order in the physician's orders indicated a DNR/DNI status, leading to confusion and inconsistency. Staff interviews revealed a lack of clarity and consistency in verifying and documenting the resident's wishes, and there was no documentation of discussions or updates regarding changes in resuscitation wishes.
The facility failed to cool meat properly, maintain cleanliness of the ice and water machine, and ensure the dish machine reached proper temperatures. A turkey was improperly cooled, risking bacterial growth. The ice machine had mineral buildup, and the dish machine did not reach correct temperatures, with staff not following infection control techniques.
A resident with multiple diagnoses, including diabetes and arthritis, was found with medications at their bedside without a completed self-administration assessment. The facility failed to document consistent medication usage and lacked a physician's order for one of the medications. Nursing staff were unaware of the medications at the bedside, and the assessment was only initiated after the observation.
The facility failed to follow proper infection control protocols for a resident with C. diff, as staff did not consistently adhere to contact precautions and hand hygiene requirements. Additionally, improper glove use and hand hygiene were observed during personal care for another resident. The facility's infection control policies were outdated, and staff interviews revealed a lack of adherence to expected protocols, posing potential risks of infection spread.
The facility failed to ensure that three residents were offered and/or provided updated pneumococcal vaccinations and one resident was not offered an influenza vaccine, as per CDC recommendations. The medical records lacked documentation of consent, declination, and shared clinical decision-making for additional vaccinations. The infection preventionist confirmed the use of CDC guidelines but could not locate necessary documentation. The facility's policy required offering vaccines and documenting education, but these were not followed, leading to the noted deficiencies.
A resident recovering from joint replacement surgery was unable to reach their call light, which had fallen to the floor, leading to a delay in receiving assistance for knee pain. Staff interviews revealed that the call light was not secured as required by facility policy, and the oversight was acknowledged by the nursing staff.
A resident with a known cinnamon allergy was served food containing cinnamon on multiple occasions, including a snickerdoodle cookie and cinnamon raisin bread. The facility's meal ticket system failed to prevent the selection of allergenic foods, and there was no policy in place regarding food allergies. The resident experienced tongue swelling after consuming the cookie, and staff were unaware of the allergy when preparing and serving meals.
The facility failed to develop person-centered baseline care plans and implement individualized fall interventions for three residents admitted with fall risks. The care plans lacked specific interventions for cognitive impairments, cardiovascular diagnoses, and other medical conditions, leading to falls shortly after admission.
The facility failed to assess fall risk and implement individualized interventions for three residents, leading to multiple falls. One resident with a femur fracture and history of falls was not properly assessed, resulting in a fall shortly after admission. Another resident with a traumatic brain injury fell twice due to inadequate supervision and assistance. A third resident with a urinary tract infection and fall history fell after attempting to self-transfer, lacking necessary adaptive devices and supervision.
Failure to Accurately Reflect Resuscitation Wishes in EMR
Penalty
Summary
The facility failed to ensure that a resident's resuscitation wishes, as indicated on a signed POLST, were accurately reflected throughout the electronic medical record (EMR). This deficiency was identified during a review of the records for a resident who had passed away in the facility. The resident's POLST, signed and dated, indicated a wish for attempted resuscitation/CPR if found with no pulse and/or active breaths. However, a verbal order in the resident's physician's orders indicated a DNR/DNI status, which conflicted with the POLST. Interviews with staff revealed that there was confusion and inconsistency in the documentation of the resident's resuscitation wishes. The report highlights that the facility did not have or follow policies and procedures for implementing advance directives. Staff interviews revealed that there was a lack of clarity and consistency in verifying and documenting the resident's resuscitation wishes. The clinical coordinator and other staff members were unable to provide a clear reason for the discrepancy between the POLST and the EMR. Additionally, there was no documentation of any discussions or updates regarding changes in the resident's resuscitation wishes, and the facility failed to involve the provider to resolve the discrepancies. The deficiency was further compounded by the lack of a clear process for updating and verifying POLST forms and advance directives. Interviews with various staff members, including the interim DON, revealed that there were discrepancies between residents' code status in the EMR and their POLSTs. The facility's failure to ensure accurate and consistent documentation of resuscitation wishes had the potential to affect all residents in the facility, as it indicated a systemic issue with the management of advance directives and POLST forms.
Deficiencies in Food Safety and Equipment Maintenance
Penalty
Summary
The facility failed to properly cool meat, specifically a whole turkey, in the main kitchen refrigerator, which was observed uncovered and undated. The turkey was intended for a turkey salad to be served three days later. The dietary director acknowledged that the turkey should have been broken apart and cooled to the proper temperature within the specified timeframe to prevent bacterial growth. The turkey was found to be at 46 degrees Fahrenheit, which was outside the safe cooling parameters, and the dietary director confirmed it should be discarded to avoid exposing residents with weakened immune systems to bacteria. Additionally, the facility did not maintain cleanliness in the second-floor kitchen's ice and water dispensing machine, which had visible mineral buildup and brownish particles. The dietary aide used this machine to dispense ice for residents, and the dietary director confirmed that the machine should be cleaned daily and maintenance should be notified of any buildup. The maintenance director was aware of ongoing issues with the machine but had not received recent specific concerns. The facility's policy required regular cleaning of the machine to prevent contamination. The dishwashing process in the first-floor kitchen was also deficient, with the dish machine not reaching the proper rinse temperatures and staff not following appropriate infection control techniques. The dish machine's temperature sensor showed incorrect readings, and an error code was displayed, indicating a need for maintenance. Staff were observed using the same gloves for handling both dirty and clean dishes, and dishes were not dried properly before being stacked. The dietary director and maintenance director confirmed these issues, and the facility's policy required proper hand hygiene and equipment handling to prevent contamination.
Failure to Complete Self-Administration Assessment for Resident
Penalty
Summary
The facility failed to ensure a self-administration of medications assessment was completed for a resident, identified as R9, who was observed with medications at their bedside. R9 was cognitively intact and had multiple diagnoses, including palliative care, depression, hypertension, renal disease, lymphedema, diabetes mellitus with diabetic neuropathy, arthritis, and osteoarthritis. Despite R9's cognitive status, the facility did not complete a self-administration assessment to determine if R9 could safely self-administer medications. R9's care plan also lacked direction related to medication self-administration. R9 was observed with Tums and Aspercreme at their bedside, and R9 reported using Tums for chest pain, which was effective. However, the facility's records did not indicate consistent documentation of Tums usage, and there was no physician's order for Aspercreme. Interviews with nursing staff revealed a lack of awareness and verification of medications at R9's bedside, and the self-administration assessment was only initiated after the observation. The facility's policy required a completed assessment and provider's orders for residents to self-administer medications, which was not adhered to in this case.
Infection Control Deficiencies in Hand Hygiene and Contact Precautions
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols, specifically in managing contact precautions and hand hygiene for a resident diagnosed with Clostridium difficile (C. diff). The resident, who had severely impaired cognition and was on vancomycin treatment for C. diff, was observed in a room with signage indicating the need for contact and enteric precautions. However, staff did not consistently follow these precautions. A nursing assistant was seen exiting the resident's room without wearing a gown and using alcohol-based hand sanitizer (ABHS) instead of washing hands with soap and water, which is required for C. diff precautions. The assistant admitted to not understanding the difference between handwashing and using ABHS for this resident, despite training on transmission-based precautions. Another incident involved improper hand hygiene and glove use during personal care for a different resident. Two nursing assistants were observed assisting the resident with morning care without changing gloves between tasks or performing hand hygiene. One assistant used the same gloves to handle soiled linens, apply a clean brief, and perform other tasks, while the other assistant entered the room with gloves used in another resident's room and did not perform hand hygiene before assisting with perineal care. Both assistants acknowledged their failure to follow proper protocols, citing being in a hurry as a reason for the oversight. The facility's infection preventionist confirmed that several infection control policies were outdated and had not been reviewed annually as required. The interim director of nursing and other staff interviews highlighted expectations for proper hand hygiene and glove use, which were not met in these instances. The facility's policies clearly stated the need for handwashing with soap and water for residents with C. diff and emphasized that glove use does not replace hand hygiene, yet these protocols were not consistently followed, leading to potential risks of infection spread.
Failure to Ensure Updated Vaccinations for Residents
Penalty
Summary
The facility failed to ensure that three residents were offered and/or provided updated vaccinations for pneumococcal disease in accordance with CDC recommendations. Resident 9, who had chronic kidney disease and end-stage kidney disease, had previously received a PCV-13 vaccine but lacked documentation of consent or declination for further doses. The medical record did not include a discussion of shared clinical decision-making regarding additional pneumococcal vaccines. Similarly, Resident 20, with heart disease, alcohol abuse, and obstructive sleep apnea, had received prior pneumococcal vaccinations but lacked documentation of consent or declination for additional doses. The medical record also lacked a discussion of shared clinical decision-making for further vaccinations. Resident 30, who had diabetes, heart disease, and a history of breast cancer, declined the influenza vaccine for the current season and had previously received a pneumonia vaccine, but the record did not specify when or which vaccine was administered. The medical record lacked documentation of re-attempts at vaccination consent or declination for the current influenza season and did not include a discussion of shared clinical decision-making regarding pneumonia vaccinations. The facility's infection preventionist confirmed the use of the CDC's PneumoRecs VaxAdvisor to review eligibility for pneumococcal vaccinations but was unable to locate documentation of declinations or shared clinical decision-making for the residents involved. The interim director of nursing stated that the infection preventionist was responsible for overseeing immunizations, but any staff member could relay a resident's vaccination wishes. The facility's policy required offering influenza vaccines annually between October 1 and March 31 and pneumococcal vaccines upon admission, unless contraindicated or received elsewhere. The policy also directed staff to provide education on the benefits and potential side effects of immunizations and document the education and whether the resident received the immunizations. However, the facility failed to adhere to these policies, resulting in the deficiencies noted.
Resident's Call Light Inaccessibility
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is a deficiency in accommodating the needs and preferences of residents. The incident involved a resident who had been admitted following joint replacement surgery and had a history of falls. The resident required extensive assistance for daily activities and was at risk of falling. During an observation, the resident was found reaching for a call light that had fallen to the floor, making it inaccessible. The resident reported calling out for help for half an hour due to knee pain, but staff had not responded. Interviews with staff revealed that the call light was not within reach because it had fallen off the bed, and staff had not checked on the resident adequately. The registered nurse and nursing assistants involved acknowledged the oversight, with one nurse stating that the call light was a critical safety line for residents. The interim director of nursing confirmed that call lights were expected to be within reach and secured to prevent such incidents. The facility's policy required staff to ensure call lights were accessible, but this was not adhered to in this case.
Failure to Prevent Serving Allergenic Food to Resident
Penalty
Summary
The facility failed to ensure that a resident with a known allergy to cinnamon was not served food containing the allergen. The resident, who had undergone hip and knee replacement, was documented to have a cinnamon allergy in her care plan. Despite this, she was served a snickerdoodle cookie containing cinnamon and a breakfast meal with cinnamon raisin bread. The resident reported experiencing tongue swelling after consuming the cookie, which she was unaware contained cinnamon until she took a bite. The breakfast meal was served without a meal ticket, and the toast was prepared by a dietary aide and finished by a nursing assistant, who was unaware of the resident's allergy. The facility's culinary director acknowledged that the meal ticket system, which was supposed to prevent residents from selecting allergenic foods, failed to catch the cinnamon raisin bread selection. Additionally, the facility lacked a policy regarding food allergies, and the resident's allergy was not communicated upon admission but was noted during her initial care conference. The director of nursing and a nurse practitioner expressed concern over the resident being served allergenic food, highlighting the potential for a serious allergic reaction.
Failure to Implement Individualized Fall Interventions for Residents
Penalty
Summary
The facility failed to develop a person-centered baseline care plan upon admission and did not assess, revise, or implement new fall interventions for three residents who were admitted with fall risks and sustained falls after admission. The report highlights deficiencies in the initial 48-hour baseline care plans for these residents, which lacked individualized interventions based on their specific needs and conditions. The care plans did not adequately address the residents' cognitive impairments, cardiovascular diagnoses, pain conditions, and other relevant medical issues. One resident, admitted with a left femur fracture and a history of falls, was found on the floor shortly after admission. The initial care plan did not specify the required assistance for toileting and transfers, nor did it address the resident's cognitive impairments and other medical conditions. Despite being identified as a fall risk, the care plan lacked individualized interventions to mitigate this risk, leading to a fall shortly after admission. Another resident, admitted with multiple fractures and a traumatic brain injury, also experienced falls after admission. The care plan did not address the resident's incontinence or specify the required assistance for activities of daily living. The resident's cognitive impairments and pain management needs were not adequately addressed, and the care plan lacked specific fall prevention interventions. Similarly, the third resident, admitted with a urinary tract infection and a history of falls, had a care plan that did not address the use of a suprapubic catheter or the resident's cognitive impairments. The lack of individualized fall prevention strategies contributed to a fall after admission.
Failure to Implement Individualized Fall Interventions
Penalty
Summary
The facility failed to comprehensively assess fall risk and implement individualized fall interventions for three residents, leading to multiple falls. Resident 1, admitted with a left femur fracture and a history of falls, was identified as a high fall risk. Despite this, the facility did not complete a fall risk assessment upon admission, and the baseline care plan lacked individualized interventions. Resident 1 fell shortly after admission, and the care plan was not updated with new interventions to prevent further falls. Resident 2, admitted with a left femur neck fracture and a traumatic brain injury, was also identified as a fall risk. The facility did not complete a fall risk assessment upon admission, and the baseline care plan lacked individualized interventions. Resident 2 fell twice after admission, and the care plan was not updated with new interventions to prevent further falls. The facility failed to provide adequate supervision and assistance, leading to Resident 2 attempting self-transfers and falling. Resident 3, admitted with a urinary tract infection and a history of falls, was identified as a fall risk. The facility did not complete a fall risk assessment upon admission, and the baseline care plan lacked individualized interventions. Resident 3 fell after attempting to self-transfer, and the care plan was not updated with new interventions to prevent further falls. The facility failed to provide necessary adaptive devices and supervision, contributing to Resident 3's fall.
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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 Brooklyn Park
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Maranatha Care Center | 2.1 mi | — | 3 | 0 |
| The Villas At Osseo Llc | 2.4 mi | — | 2 | 0 |
| Park River Healthcare And Rehabilitation Center Ll | 3.5 mi | — | 22 | 2 |
| Woodlake Healthcare And Rehabilitation Center | 4.2 mi | — | 10 | 0 |
| The Estates At Fridley Llc | 4.4 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.