Lifecare Greenbush Manor: Verbal Abuse of Dementia Resident - MN
That remark, made in the dining room at Lifecare Greenbush Manor on or around September 15, 2025, was reported to the assistant administrator. The nursing assistant was interviewed. She did not deny saying it. Then, for the next three and a half weeks, she kept working.
The resident in the dining room was not the only one.
On September 6, a nursing assistant identified in inspection records as NA-B made the care coordinator aware of something that had happened during personal care involving a resident with dementia, referred to in the report as R1, and the nursing assistant identified as NA-A. Before NA-B could finish describing what she had witnessed, she was taken to the social services office and asked to repeat the story from the beginning.
What NA-B described was this: NA-A had made rude comments to R1 and had wiped her in a way that caused R1 to say ouch during the care. Inspectors noted the assumption was that the way NA-A wiped her caused the pain.
R1 had dementia. She spoke few words. Some days she randomly sang. The care coordinator, a registered nurse, told inspectors on October 16 that when she assessed R1 after the incident, she did not see irritation or emotional or physical harm, and that the incident did not appear to impact R1 visibly. She also said it was a no-brainer that it needed to be reported, that it made her sick to her stomach, and that this was not how staff spoke to residents at this facility.
But the September 6 incident was not reported to the director of nursing until October 9, more than a month later.
When the director of nursing asked staff why they had not come forward sooner with concerns about NA-A, she got a consistent answer: NA-A was intimidating. She bullied them. They were afraid of what she might do if they said something.
NA-B told the assistant administrator the same thing when describing the dining room incident. She was fearful of retaliation.
NA-A, for her part, had her own account of what was happening. She told inspectors she had been pulled into the director of nursing's office two to three weeks before October 9 and informed she had been reported for saying something inappropriate in the dining room. Her version of events was that none of the staff liked her, that she was being targeted, that the accusations were false, and that she was the victim of retaliation. She said she received a call on October 10 asking her to come in, that she was unable to, that she was interviewed by phone, and that later that same day she was called back and terminated. Her last shift had been October 9.
The director of nursing told inspectors she was contacted on October 9 at approximately 3:44 p.m. about what had happened during R1's care that afternoon around 2:00 p.m. NA-A had already left the building for the day. She was not allowed to return.
The director described the verbal abuse as verified. The wiping, she said, was harder to categorize as abuse, but the approach was not acceptable. Her conclusion was direct: NA-A was not a person who should have been working with residents in a nursing home.
NA-A was terminated on October 10.
The gap between September 6 and October 9 is the part of this story that the inspection report does not fully resolve. A nursing assistant witnessed something troubling enough to report on September 6. A care coordinator found it serious enough that she had the witness taken immediately to the social services office to repeat it. And yet the director of nursing did not learn about the September 6 incident until the day of a second, separate incident more than a month later.
The inspection report does not explain who received NA-B's account on September 6, what was done with it, or why it did not travel up the chain of command. It records only that the director of nursing asked staff why they hadn't come forward sooner, and that the answer she received was fear.
The assistant administrator confirmed that the dining room incident on September 15 was known to management before the October 9 incident involving R1. NA-A had been interviewed about the chicken remark and had not denied making it. She was not terminated after that. She continued working through the end of her shift on October 9.
After October 9, the facility moved quickly. NA-A was suspended immediately pending investigation, then terminated the following day. Informal education was provided to staff during morning stand-up meetings and passed from shift to shift. Mandatory education for all staff was scheduled to be completed by October 24.
The care coordinator's description of assessing R1 after the September 6 incident, finding no visible injury or distress, was the facility's primary accounting of R1's condition. The inspection report does not indicate R1 was re-evaluated after the October 9 incident or that any formal assessment of emotional harm was conducted at that time.
R1 had dementia. She spoke few words. She sometimes sang. Whether she understood what was said to her during her care, or felt the manner in which it was done, is not something the inspection report addresses, and may not be something anyone at the facility could answer with certainty.
The facility's own abuse policy, dated February 19, 2025, defined verbal abuse as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of age, ability to comprehend, or disability. The policy was explicit that a resident's ability to understand what was said to them did not determine whether verbal abuse had occurred.
NA-A knew that policy existed. She had worked in the building under it.
The coworkers who witnessed what she said and did, and who stayed quiet for weeks because they were afraid of her, knew it too.
The state survey was completed October 16, 2025. The deficiency was cited at a level of minimal harm or potential for actual harm, affecting few residents. The investigation that produced that finding was a complaint inspection, meaning someone had contacted regulators before inspectors arrived.
The report does not say who made that call.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lifecare Greenbush Manor from 2025-10-16 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 8, 2026 · Our methodology
LIFECARE GREENBUSH MANOR in GREENBUSH, MN was cited for abuse-related violations during a health inspection on October 16, 2025.
That remark, made in the dining room at Lifecare Greenbush Manor on or around September 15, 2025, was reported to the assistant administrator.
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.