Saint Therese At Oxbow Lake
SAINT THERESE AT OXBOW LAKE in BROOKLYN PARK, MN — inspection on February 26, 2026.
Found 16 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of R10's physician orders, dated 2/24/26, indicated a Foley catheter was present and the collection bag was to be kept below the level of the bladder at all times.
The order further indicated the collection bag should not rest on the floor and staff were to ensure a dignity bag was in use at all times.
Observations included the following: 2/24/26 at 11:37 a.m. - R10's catheter drainage bag was hanging from the side of the wheelchair and was not covered.
The bag contained straw-colored liquid and was visible from the hallway. 2/24/26 at 2:59 p.m. - R10's catheter drainage bag remained in the same location on the wheelchair and continued to be visible from the hallway. 2/25/26 at 9:05 a.m., 12:40 p.m., and 2:25 p.m. - R10 was observed sitting in a wheelchair with the drainage bag hanging from the side of the wheelchair without a dignity cover.
The straw color, liquid, filled bag was visible to individuals walking past the room. 2/26/26 at 8:12 a.m. - R10's catheter drainage bag continued to hang from the side of the wheelchair without a dignity cover and remained visible from the hallway.
During an interview on 2/26/26 at 9:53 a.m., nursing assistant (NA)-D confirmed the urinary catheter drainage bag was visible and stated the bag should typically be placed in a privacy or dignity cover when the resident was in areas visible to others to maintain dignity. NA-D stated R10 did not have a dignity bag available.
During an interview on 2/26/26 at 11:28 a.m., registered nurse clinical coordinator (CC)-B confirmed residents with urinary catheter drainage bags should have the bag covered or positioned in a manner that maintained the resident's dignity and prevented unnecessary exposure.
During an interview on 2/26/26 at 1:32 p.m., the director of nursing (DON) stated she expected catheter drainage bags to be covered at all times to maintain resident privacy and dignity.
The facility Promoting/Maintaining Resident Dignity policy, dated 10/22, indicated the facility would protect and promote resident rights and treat each resident with respect and dignity, as well as provide care in a manner and environment that maintained or enhanced each resident's quality of life.
The policy further indicated all staff were responsible for promoting and maintaining resident dignity and respecting resident rights.
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Saint Therese at Oxbow Lake 9751 Regent Avenue North Brooklyn Park, MN 55443
During interview on 2/26/26 at 1:32 p.m., the Director of Nursing (DON)
condition.
The DON stated attempts by the social worker to contact the resident's family or representative to schedule a care conference should be documented in the progress notes.
Review of the facility policy titled Care Planning - Resident Participation, dated 10/23, indicated the facility would discuss the plan of care with the resident and/or representative at regularly scheduled care plan conferences and allow them to review the care plan initially, at routine intervals, and after significant changes.
The policy further indicated the facility would make an effort to schedule the conference at the best time of day for the resident or resident's representative and would obtain a signature from the resident and/or resident representative following discussion or review of the care plan.
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Saint Therese at Oxbow Lake 9751 Regent Avenue North Brooklyn Park, MN 55443
minimal harm observation and interview, the facility failed to ensure the most up to date Nursing Home Resident [NAME] of Rights (RBOR) was provided to each resident residing in the facility and displayed for
residing in the facility as well as all staff and visitors.Findings include:During observation on 2/25/26 at 3:45 p.m., displayed by the memory care entrance was the RBOR, year revised 2009.During interview on 2/25/26 at 3:50 p.m. the campus executive director (E stated she was aware of the changes to the [NAME] for assisted living but was not aware of the changes made 12/22/25 to the RBOR.
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Saint Therese at Oxbow Lake 9751 Regent Avenue North Brooklyn Park, MN 55443
Survey Results.During interview on 2/25/26 at 3:51 p.m., the administrator stated a resident in a wheelchair or shorter than height at which the binder is currently stored, would not have access to the binder without assistance.
Administrator stated, It needs to come down a bit.
Review of R76's progress noted and documents in the EMR on 2/25/26, failed to indicate R76 discharged from the facility. R76's EMR also failed to indicate the medical provider and/or family were notified R76 discharged AMA.
R76's EMR failed to indicate R76 had received education and/or was not presented with AMA form for signature.
Review of notes related to medication administration indicated R76 was not administered evening medications because R76 had discharged AMA.
When interviewed on 2/25/26 at 4:32 p.m., registered nurse (RN)-C stated When a resident wanted to discharge AMA there was an AMA form that needed to be signed, the provider and family/resident representative need to be updated and this was to be documented in the residents EMR.
When interviewed on 2/26/26 at 9:42 a.m., RN-D stated when a resident discharged AMA the nurses were expected to educate the resident/family regarding inability to provide medications, the resident/family was to sign the AMA form, update that provider, director of nursing (DON) or nurse manager then document everything in the residents progress notes in the EMR.
When interviewed on 2/26/26, at 10:35 a.m. clinical coordinator (CC)-F stated when a resident discharged from the facility for any reason there should be documentation in the progress notes regarding any paperwork/information that had been discussed with the resident/family, the progress note was also expected to include the time and how the resident had discharged . CC-F reviewed R76's progress notes, CC-F stated there was no note located in the EMR regarding the discharge from the facility.
When interviewed on 2/26/26, at 1:49 p.m. DON stated when a resident discharged there should be a note located in the progress notes that the resident/family had been educated on the discharge, if the resident had discharged AMA family and/or resident needed to sign AMA paperwork which would have been scanned into resident documents in the EMR. DON stated documentation of discharge and update to provider was important to ensure resident safety, and continuity of care.
Facility Transfer and Discharge (including AMA) policy dated 3/2025, indicated resident and family/legal representative should be informed of risks involved, benefits of staying the facility and the alternatives to both.
The Physician should be notified of the intended AMA discharge.
Documentation of the notification should be entered into the nurses notes.
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Saint Therese at Oxbow Lake 9751 Regent Avenue North Brooklyn Park, MN 55443
Review of R76's electronic medical record (EMR), indicated R76 was not administered evening medications on 12/18/25, due to having discharged against medical advice (AMA).
When interviewed on 2/26/26 at 1:00 p.m., social worker (SW)-B stated Ombudsman notifications were sent for all residents who discharged or were hospitalized , SW-B further stated notification was not sent for residents that had discharged AMA.
When interviewed on 2/26/26 at 1:35 p.m., nursing home administrator stated she was informed R76 discharged AMA but was not aware Ombudsman office needed to be informed of a resident who discharged AMA.
When interviewed on 2/26/26 at 1:49 p.m., director of nursing (DON) stated the Ombudsman was to be notified of any resident that was hospitalized or discharged that included residents who had discharged AMA for resident safety.
Facility Transfer and Discharge (including AMA) policy dated 2/2025, indicated the facility would provide transfer/discharge notice to the ombudsman.
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Saint Therese at Oxbow Lake 9751 Regent Avenue North Brooklyn Park, MN 55443
Review of R19's comprehensive care plan, print date of 2/25/26, included a focus area titled Substance Use, which indicated: I have a history of substance use disorder. As evidenced by: (specify) Use of/addiction to {prescription/illegal/alcohol} drugs (specify). My drug(s) of choice is/was: ______.
The care plan failed to identify the residents' specific substance use history, triggers, risks, or individualized interventions for staff to follow.
Further review of the care plan revealed a focus area titled Trauma, which indicated: I have a history of trauma that affects me negatively. (Describe trauma): ______.
The care plan failed to describe the resident's trauma history, identify potential triggers, or include individualized trauma-informed care approaches for staff.
During interview on 2/26/26 at 12:49 p.m., registered nurse clinical coordinator (CC)-F stated care plans could be updated and revised by nursing staff, including herself, other nurses on the unit, and the social worker. CC-F stated care plans should be developed and updated when there was a change in the resident's condition and reviewed at least quarterly to ensure the information was accurate. CC-F stated the care plan was important so staff were aware of how to care for the resident and so it reflected the overall picture of the resident's care needs. CC-F confirmed the resident's care plan contained several generic areas that were not person-centered and acknowledged the care plan should have been updated.
During interview on 2/26/26 at 1:32 p.m., director of nursing (DON) acknowledged the care plan contained templated focus areas and stated the care plan should have been individualized to reflect the resident's specific needs and history.
Review of the facility policy titled Comprehensive Care Plans, dated 9/24, indicated comprehensive care plans were to be individualized and developed based on the residents' assessed needs, preferences, strengths, and goals.
The policy further indicated care plans were to include resident-specific problems, measurable goals, and individualized interventions to guide staff in providing person-centered care.
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Saint Therese at Oxbow Lake 9751 Regent Avenue North Brooklyn Park, MN 55443
each resident received the level of assistance needed to meet their needs and so there was not
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Saint Therese at Oxbow Lake 9751 Regent Avenue North Brooklyn Park, MN 55443
During interview on 2/25/26 at 1:50 p.m., NA-B stated R47 required total assistance from staff, this included shaving facial hair. NA-B was not sure the last time she assisted R47 to shave facial hair.
During interview on 2/25/26 at 3:30 p.m., NA-C stated assistance with grooming residents can happen on any shift. NA-C stated she assisted R47 with shaving, a few days ago.
During interview on 2/26/26 at 9:21 a.m., clinical coordinator (CC)-B stated she expected residents, male or female, were assisted to shave facial hair as frequently as they desired.
Assistance should be provided by facility staff unless resident or family have requested otherwise. CC-B stated R47's family has not requested to assist R47 with shaving and should not be expected to.
During interview on 2/26/26 at 10:10 a.m., director of nursing (DON) stated she expected residents were assisted with shaving daily or according to their personal preference.
This was important for each resident's happiness, self-image and dignity.
Facility policy, Activities of Daily Living (ADLs) dated January 2023, section: Policy Explanation and Compliance Guidance: number three indicated, A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming and personal oral hygiene.
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Saint Therese at Oxbow Lake 9751 Regent Avenue North Brooklyn Park, MN 55443
Review of R42's activity documentation, from 2/12/2026 through 2/25/26, revealed no documented participation in any type of activity despite the resident's identified preferences.
There was no documented evidence R42 was offered individualized or in-room activities during this period.
During interview on 2/26/26 at 9:53 a.m., nursing assistant (NA)-D stated R42 required one-to-one activities and R6, R10, and R13 typically attended activities. NA-D stated activities had not been occurring for the previous several weeks due to COVID.
During interview on 2/26/26 at 10:00 a.m., community life director (CLD)-A stated the activity department used a website to document activity participation and complete activity assessments. CLD-A stated they were new to the position. CLD-A reported the facility printed a list of residents interested in attending Mass and utilized volunteers for those services who did not document attendance. CLD-A stated if residents did not have COVID, activity staff utilized a mobile activity cart to provide one-to-one activities. CLD-A stated activity staff had not been entering participation into each resident's record, but expected activity staff should enter notes and document when activities are offered.
During interview on 2/26/26 at 10:17 a.m., activity aide (AA)-A stated activity participation was documented in Toolkit (computer software program).
Documentation included if the resident participated, declined, or received one-to-one activities, and stated all activities should be documented.
During interview on 2/26/26 at 11:28 a.m., registered nurse clinical coordinator (CC)-B stated activities were expected to continue on a smaller scale for residents who did not have COVID. CC-B stated residents who did not have an active COVID diagnosis could attend activities in the living room if they wore a mask and reported activity staff should enter each resident's room individually to check on residents and offer activities.
During interview on 2/26/26 at 1:32 p.m., director of nursing (DON) stated the Roadhouse unit had minimal activities occurring due to COVID precautions. DON expected activities were still be occurring with residents independently in their rooms.
Review of the facility policy titled Activities, dated 6/2024, indicated the facility was to provide an ongoing program of activities to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences.
Facility-sponsored group, individual, and independent activities will be designed to meet the interests of each resident, as well as support their physical, mental, and psychosocial well-being.
Activities will encourage both independence and interaction within the community.
Activities may be conducted in different ways:One-to-One programsPerson Appropriate - activities relevant to the specific needs, interests, culture, background, etc. for the resident they are developed for.Program of Activities - to include a combination of large and small groups, one-to-one, and self-directed as the resident desires to attend.
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Saint Therese at Oxbow Lake 9751 Regent Avenue North Brooklyn Park, MN 55443
During an interview on 2/26/26 at 10:48 a.m., NA-A stated residents should have foot pedals in place when staff assisted them by pushing the wheelchair.
During an interview on 2/26/2026 at 12:49 p.m., registered nurse clinical coordinator (CC)-F stated if a resident required foot pedals, it should be reflected in the care plan. CC-F further stated foot pedals were expected to be used anytime staff assisted a resident with wheelchair mobility to prevent injury.
During an interview on 2/26/2026 at 1:32 p.m., the Director of Nursing (DON) stated residents should have foot pedals in place when staff assisted them with wheelchair mobility to ensure proper positioning and prevent injury.
Review of facility policy related to wheelchair use and resident transport was requested; however, the facility did not provide the requested policy during the survey.
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Saint Therese at Oxbow Lake 9751 Regent Avenue North Brooklyn Park, MN 55443
Review of R6's comprehensive care plan printed 2/25/26, included interventions to prevent recurrence of pressure ulcers.
Interventions included: Elevate resident's heels on heel manager when in bed, initiation date of 10/10/25 Float heels on two pillows when in recliner, initiation date of 10/10/25 During observation on 2/24/26 at 11:39 a.m., R6 was reclined back in a recliner in her room with her legs elevated and eyes closed. No pillows were noted under R6's legs.
R6's heels were resting directly on the foot rest of the recliner.
During observation on 2/24/26 at 3:00 p.m., R6 was observed reclined back in her recliner with her legs elevated and eyes closed. No pillows were present under R6's legs. R6's heels were resting directly on the foot rest of the recliner.
During observation on 2/24/26 at 6:21 p.m., R6 was observed reclined back in a recliner with no pillows under her legs. R6's heels were resting directly on the foot rest of the recliner. A sign posted on the wall near the recliner instructed, Make sure resident feet are floating on 2 pillows when in recliner.
During observation on 2/25/26 at 8:35 a.m., R6 was observed reclined back in a recliner with no pillows under her legs. R6's heels were resting directly on the foot rest of the recliner while staff delivered breakfast.
During observation on 2/25/26 at 2:28 p.m., R6 was observed reclined back in her recliner with her legs extended.
One pillow was present under her legs; however, R6's heels continued to rest on the foot rest of the recliner despite the placement of the pillow.
During interview on 2/26/26 at 9:53 a.m., nursing assistant (NA)-D stated R6 previously had sores on her heels that had healed. NA-D stated when R6 was in the recliner, staff were supposed to place a pillow under her legs to prevent swelling.
During interview on 2/26/26 at 11:28 a.m., registered nurse clinical coordinator (CC)-B stated R6 previously had pressure ulcers on her heels that had since resolved.
When R6 was in the recliner, her legs were to be elevated on two pillows to ensure her heels were not resting on the foot rest. CC-B stated R6 received weekly skin checks and staff were expected to ensure the resident's heels were floating and not touching the recliner to prevent the pressure ulcers from returning.
During interview on 2/26/26 at 1:32 p.m., the director of nursing (DON) stated she expected staff to follow interventions put in place to prevent recurring pressure ulcers.
The DON stated the interventions were important because they were intended to prevent skin breakdown.
Review of the facility policy titled Pressure Injury Prevention and Management, dated 10/22, indicated the facility was committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal pressure ulcers/injuries, prevent infection, and prevent the development of additional pressure ulcers/injuries.
The policy indicated evidence-based interventions for prevention would be implemented for all residents assessed as at risk or who had a pressure injury present.
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Saint Therese at Oxbow Lake 9751 Regent Avenue North Brooklyn Park, MN 55443
During observation on 2/24/26 at 11:33 a.m., R40 propelled self, in wheelchair, from bedroom to the dining room. No attempts were made to ask R40 to ambulate to the dining room, by staff who walked past him.
During observation on 2/24/26 at 4:57 p.m., R40 propelled self, in wheelchair, from bedroom to the dining room.During observation and interview on 2/25/26 at 8:46 a.m., R40 propelled self, in wheelchair, from bedroom to the dining room. R40 stated he used to walk to meals, but is not doing it now. R40 did not know why stating, I'm able to walk but its been a while since I walked to a meal.
Staff do still offer, not like they used to. R40 stated he used ask the staff to walk with him to meals, . they always have a reason not to.
Sometimes they're too busy, or they have other residents to take care of. So I quit asking. R40 voiced a desire to walk more, I would like to walk more. So, if you talk with them and they start walking me again, I'm okay with that.During interview on 2/25/26 at 1:50 p.m., nursing assistant (NA)-B stated assisting residents to ambulate was easily done in the morning. R40 is supposed to get staff assistance to ambulate to and from meals. R40 would only do it if offered. R40 was typically offered to ambulate in the morning, If I come before he leaves his room. NA-B thought the last time R40 ambulated was sometime the week prior, but NA-B was not certain.
During interview on 2/26/26 at 8:37 a.m., registered nurse, clinical coordinator (CC)-B stated if a resident's care plan included ambulation, she expected assistance was offered. If a resident refused, she expected staff to reapproach and alert the nurse if resident continued to refuse. CC-B reviewed R40's nurse progress notes 1/28/26 through 2/25/26. CC-B was not able to locate progress notes to indicate R40 had refused ambulation assistance. CC-B was not sure if resident ambulation notes were being reviewed, CC-B did not review ambulation notes unless something occurred and was brought to her attention.
CC-B stated it was important to encourage and offer assistance to residents for ambulation to ensure they do not decline physically.During interview on 2/26/26 at 10:10 a.m., director of nursing (DON) stated residents who receive assistance with ambulation have a sneaker sticker outside their room.
DON expected, when therapy gave recommendations for an ambulation program, the resident would be assisted to ambulate according to the instructions in their care plan. If a resident refused ambulation assistance, DON expected the nurse to write a progress note, alert family and therapy of the refusal.Facility policy for ambulation was requested but was not received.
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Saint Therese at Oxbow Lake 9751 Regent Avenue North Brooklyn Park, MN 55443
Review of the facility policy titled Fall Mitigation Program, dated 1/26, indicated each resident would be assessed for fall risk and would receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls.
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Saint Therese at Oxbow Lake 9751 Regent Avenue North Brooklyn Park, MN 55443
During interview on 2/25/26 at 9:36 a.m., LPN-A stated not being aware of special instructions when administering aerosol breathing treatments (i.e. nebulizer) to a resident diagnosed with COVID.
During interview on 2/26/26 at 9:21 a.m., clinical coordinator (CC)-B stated not being the, . best person to answer . regarding infection control practices when administering an aerosol breathing treatment to a resident diagnosed with COVID. CC-B stated based on previous directions, the resident should be screened to determine if able to self administer the medication. R25 was not assessed, therefore could not self administer the nebulizer. R25 was not residing in an airborne infection isolation room (AIIR), facility did not have those type of rooms. CC-B expected the bedroom door of the COVID positive resident's room was kept closed during the nebulizer treatment. CC-B expected the nurse to also close the door after the nebulizer was finished, for at least 15 minutes.
This was important so the virus was not spread to other residents, staff and/or visitors.During interview on 2/26/26 at 10:10 a.m., director of nursing (DON) stated for residents who are COVID positive, she expected the resident's room door was closed prior to starting the nebulizer treatment and remained closed for at least 15 minutes after the nebulizer treatment was finished.
This was important because COVID is spread through the respiratory system and use of the nebulizer treatment could carry the virus to other residents and/or staff. DON stated the facility did not have rooms designated as AIIR.
Facility policy, COVID-19 Prevention, Response and Reporting dated 1/2025, failed to direct staff how to manage use of a nebulizer during administration.
The policy provided the following instructions:18.
Aerosol-generating procedures should be performed cautiously and avoided if appropriate alternatives exist.19.
Aerosol-generating procedures should take place in an airborne infection isolation room (AIIR), if possible, and the number of HCP (health care providers) present during the procedure should be limited to those essential for resident care and support.
Visitors should not be present for the procedure.
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Saint Therese at Oxbow Lake 9751 Regent Avenue North Brooklyn Park, MN 55443
immunizations was offered and/or provided the pneumococcal vaccination series as recommended by
Pneumococcal Vaccine Timing for Adults feature, dated 3/2025, identified various tables when each (or all) of the pneumococcal vaccinations should be obtained.
This identified when an adult over [AGE] years old had received no prior pneumococcal vaccine should receive PCV20 or PCV21, those who had received the complete series (i.e., PPSV23 and PCV13; see below) then the patient and provider may choose to administer Pneumococcal 20-valent Conjugate Vaccine (PCV20) for patients who had received Pneumococcal 13-valent Conjugate Vaccine (PCV13) at any age and Pneumococcal Polysaccharide Vaccine 23 (PPSV23) at or after [AGE] years old. R5's face sheet dated 2/25/26, indicated R5 was [AGE] years old.
The immunization record, undated, failed to indicate R5 had received any doses of pneumococcal vaccine. R5's electronic medical record (EMR) identified a signed consent dated 8/6/25 which indicated R5's family had consented to R5 receiving the pneumococcal vaccine, however, review of R5's EMR failed to indicate R5 was offered or received pneumococcal vaccine. R5's EMR failed to indicate their Minnesota Immunization Information Connection (MIIC) was reviewed for vaccinations R5 had received prior to admission to the facility.
When interviewed on 2/26/26 at 12:28 p.m., director of nursing (DON) stated when a resident was admitted their MIIC was reviewed for received vaccinations If there were vaccinations due, consent for the vaccination(s) was received from the resident or the resident representative after education regarding the vaccinations.
The dose(s) would be obtained from the pharmacy and administered once there were received from the pharmacy. DON reviewed R5's EMR, was unable to locate R5's MIIC report or indication that resident had received any doses of pneumococcal vaccines. DON did locate signed consent dated 8/6/25. DON stated pneumococcal vaccine was important for infection control, to help reduce the risk of associated infections.
Facility Pneumococcal Vaccine (Series) policy dated 1/2026, indicated each resident would be assessed for pneumococcal immunizations upon admission, each resident would be offered a pneumococcal immunization unless medically contraindicated or the resident had already bee immunized.
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Saint Therese at Oxbow Lake 9751 Regent Avenue North Brooklyn Park, MN 55443