Glenoaks Senior Living: Wheelchair Lift Safety Failures - MN
That was what MM-A told inspectors at Glenoaks Senior Living Campus on September 12, 2025. A resident had fallen while on the lift mounted to one of the facility's passenger vans. After the incident, MM-A said he looked the lift over and couldn't find anything wrong with it. But there was no written record that the inspection had ever happened. No documentation. Nothing in any file.
He also didn't have the owner's manual when he did it. He had found it online.
The manufacturer's manual for the Century 2 wheelchair lift is specific about what operators are supposed to know before touching the controls. It requires that attendants read the manual and all safety precautions before operating the lift. It specifies that a wheelchair passenger must be positioned fully inside the yellow boundary markings, that the wheelchair brakes must be locked, that the inner roll stop and outer barrier must both be in the upright position with the outer barrier latches fully engaged. It warns that accidental activation of the control switches can cause unintended operation. It states, plainly, that failure to follow the safety precautions may result in serious bodily injury.
The manual is supposed to be kept in a storage pouch mounted directly on the lift. It was not there.
The fall was classified as causing actual harm to the resident.
What inspectors found next made the post-incident response look almost orderly by comparison.
Glenoaks uses a Drivers Skills Validation checklist to certify that employees are qualified to operate the facility's vehicles, including the vans equipped with wheelchair lifts. The checklist instructs evaluators to mark each item with a check if the driver performs it satisfactorily, mark it with an X if further training is needed, and leave items blank only if they were not evaluated at all.
MM-A had signed SCH-A's checklist on July 2, 2025, certifying her as a qualified driver. There were no check marks on it. No X marks either. Every item that should have reflected an evaluation was blank, which by the checklist's own instructions meant none of it had been evaluated. MM-A certified her as qualified anyway.
His own checklist told the same story. The previous administrator had signed MM-A's Drivers Skills Validation form on February 8, 2025, the same day she signed him off as a qualified driver. That checklist was also blank. No checks. No X marks. No evidence that a single skill had been observed or tested.
When inspectors interviewed MM-A, he said he hadn't read the directions on how to fill out the form. He just remembered signing SCH-A's sheet and marking her as qualified.
The facility's own Fleet Safety policy, updated in May 2025, four months before the inspection, required that employees be trained on how to use the lift, how it operates, and how to position a wheelchair on the platform before loading. It required that occupants be secured with a seat belt to prevent ejection from the chair in the event of an accident.
The policy existed. The checklists designed to confirm the training had happened were signed and filed. They were just empty.
A resident was on that lift when something went wrong. Whether the outer barrier was up, whether the brakes were locked, whether the attendant knew what the yellow boundary lines meant — none of that is in the record, because the training that was supposed to establish any of it was never documented as having occurred. The post-incident inspection that might have identified a mechanical cause was never documented either.
What the files at Glenoaks show is a system of paperwork that looked like oversight and wasn't. Checklists signed to say a thing had been evaluated when nothing had been evaluated. An inspection conducted with a manual pulled from the internet, leaving no trace it happened. A resident who fell, and a facility whose records, if you read them without looking closely, might suggest everything was in order.
Everything was not in order.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Glenoaks Senior Living Campus from 2025-09-12 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 20, 2026 · Our methodology
GLENOAKS SENIOR LIVING CAMPUS in NEW LONDON, MN was cited for violations during a health inspection on September 12, 2025.
That was what MM-A told inspectors at Glenoaks Senior Living Campus on September 12, 2025.
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.