Fair Oaks Lodge: Staffing and Infection Failures - MN
That detail emerged during a February 2025 complaint inspection at the 201 Shady Lane Drive facility. The resident, identified in inspection records only as R41, was supposed to be monitored at all times because of several previous falls. The family member told inspectors they had come in on a few occasions over the past couple of months and had to personally assist R41 in the bathroom. The family member said they believed R41 was going to have another fall because the unit was understaffed.
Nobody disputed the staffing was short. A nursing assistant identified as NA-E told inspectors there were times when the memory care unit operated with one nursing assistant and one nurse after a second aide had been pulled to cover another floor. There were times, NA-E said, when the entire facility had only three nursing assistants on at once. Call lights weren't getting answered in time. Residents weren't being walked. Exercises weren't being done. "Nursing staff had to ask for help but it usually did not change anything," NA-E told inspectors.
A second nursing assistant, NA-I, said the weekends were the worst. NA-I described being the only aide on the floor responsible for all the residents, with others pulled away whenever a different unit ran short. The activity director acknowledged activities were not getting done consistently on the memory care unit and said the facility was working on hiring more staff.
The director of nursing confirmed the practice of floating staff from scheduled areas to wherever the need was greatest, which left the areas they came from short. The director said the expectation going forward would be to keep schedules complete and mandate staff to stay until coverage arrived, rather than simply working short.
The staffing findings were not the only problem inspectors documented.
During morning care on February 12, a nursing assistant identified as NA-F spent roughly 30 minutes caring for a resident called R3, a cognitively intact woman with heart failure, peripheral vascular disease, and a lower extremity amputation who was entirely dependent on staff for bathing, dressing, and toileting. NA-F never changed her gloves. She applied lotion to R3's foot and leg, then applied lotion to R3's hands without changing gloves or sanitizing. She then washed R3's perineal area and, with the same gloves and the same washcloth, wiped R3's buttocks and wiped ointment from an incision scar site. She used her walkie-talkie to call for help while wearing those same gloves.
When asked about it afterward, NA-F said it was a habit to leave gloves on throughout resident cares. She also told inspectors she had never received training on washing from clean areas to dirty ones. "Not sanitizing hands or changing gloves when needed could be a problem," she said, "because the gloves and hands could be considered soiled."
The director of nursing, in a follow-up interview, said the expectation was that staff wash their hands before and after glove use and change gloves after moving from dirty tasks. She said residents should always be washed clean to dirty, using different gloves and washcloths.
On February 10, inspectors watched two nursing assistants, NA-A and NA-B, use a mechanical lift to transfer a resident identified as R20 from a wheelchair to a recliner. R20 touched the lift during the transfer. Without sanitizing the lift or their hands, the aides then wheeled it directly into R31's room, where both of R31's arms came into contact with the same unsanitized equipment. From there, NA-A headed toward a third resident's room with the lift. When asked about it minutes later, both aides confirmed they had not sanitized their hands or the lift and said they should have.
That same afternoon, dietary aides were observed delivering beverages on the memory care unit by carrying glasses and a coffee cup gripped at the top rim with their bare hands. Both aides confirmed what inspectors had seen, and both said the practice could spread bacteria and cause illness. Their manager confirmed the expectation was to hold glasses at the base and cups by the handle, not to touch rims.
A resident identified as R25, who had an open pressure ulcer on her right heel, was placed on enhanced barrier precautions, an infection control measure requiring staff to wear gowns and gloves during hands-on care. When inspectors arrived on the afternoon of February 10, there was no protective equipment outside R25's room and no sign on the door indicating she was on the precautions. The director of nursing said she had been unaware of the gap until inspectors raised it that evening. By 7 p.m. the same day, a bin of protective equipment and a sign had appeared outside R25's door.
The family member of R41 told inspectors what they feared most: that with the unit running as short as it was, another fall was coming.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Fair Oaks Lodge from 2025-02-12 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: July 6, 2026 · Our methodology
Fair Oaks Lodge in WADENA, MN was cited for violations during a health inspection on February 12, 2025.
That detail emerged during a February 2025 complaint inspection at the 201 Shady Lane Drive facility.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.