Emmanuel Nursing Home
EMMANUEL NURSING HOME in DETROIT LAKES, MN — inspection on February 11, 2026.
Found 4 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 R30's electronic health record (EHR) lacked a self-administration of medication (SAM) assessment. R30's Order Summary Report signed 1/9/26, directed staff to administer DuoNeb 0.5-2.5 (3) mg /3ml inhalation solution Ipratropium-Albuterol) 3ml Further, it directed staff to administer Bu inhalation suspension via nebulizer four times daily for shortness of breath . R30's Order Summary Report lacked an order to self-administer medication.
During a continuous observation on 2/10/26 at 12:15 p.m., R30 was lying in bed with a nebulizer mask on her face and steam coming out of the mask with no staff present. At 12:17 p.m., trained medication aide (TMA)-A entered R30's room turned the nebulizer machine off ,removed the nebulizer mask from R30's face, placed the nebulizer mask on a bedside table and left the room.
During an interview on 2/10/26 at 12:22 p.m., TMA-A verified she had placed the nebulizer mask on R30, turned on the machine and left the room. TMA-A stated she administered the nebulizer because she turned the machine on and placed the mask on R30's face.
TMA-A stated she was unsure if a SAM assessment had been completed for R30. TMA-A stated she was unsure what a [NAME] was and what the process was for a resident that did not have an order to self-administer medications.
During an interview on 2/10/26 at 12:45 p.m., registered nurse (RN)-A confirmed there was not a [NAME] completed for R30. RN-A stated her expectation was nursing staff would have stayed in the room with R30 while she received the nebulizer treatments to ensure R30 received the nebulizer treatments appropriately.
During an interview on 2/10/26 at 3:10 p.m., director of nursing (DON) verified R30 was not safe to self-administer medications. DON stated if a resident had not been assessed to safely self-administer medication or have a physician order to self-administer medications staff were expected to remain with the resident the entire nebulizer treatment. A facility policy titled Self-Administration of Medications revised 2021, identified the interdiciplinary team (IDT) would assess residents cognitive and physical abilities to determine is self-administering medications is safe for the resident.
Identified if it were deemed to be safe and appropriate for a resident to self-administer medications it would be documented in the resident's clinical record.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
245489 02/11/2026
Emmanuel Nursing Home 1415 Madison Avenue Detroit Lakes, MN 56501
were used for comfort. DON indicated the turn aid pillows could be considered a restraint if a resident
method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body.
The definition of restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it, given that resident's physical condition (i.e., side rails are put back down, rather than climbed over), and this restricts his/her typical ability to change position or place, that device is considered a restraint.
Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted, including: using bedrails to keep a resident from voluntarily getting out of bed as opposed to enhancing mobility while in bed; tucking sheets so tightly that a bed-bound resident cannot move; placing a resident in a chair that prevents the resident from rising; and placing a resident who uses a wheelchair so close to the wall that the wall prevents the resident from rising.
Restraints maybe only be sued if/when the resident has a specific medical symptom that cannot be addressed by another less restrictive intervention and a restraint is required to treat the medial symptom; protect the resident safety; and help the resident attain the highest level of his/her physical or psychological well-being.
Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints.
The assessment shall be used to determine possible underlying causes of the problematic medical symptoms and to determine if there are less restrictive interventions, programs, devices, referrals, etc.) that may improve the symptoms.
245489 02/11/2026
Emmanuel Nursing Home 1415 Madison Avenue Detroit Lakes, MN 56501
document refusal.
Policy titled Shaving the resident, revised 2/18, identified if the resident refused
living, supporting revised on 3/18, revealed residents who are unable to carry out activities of daily
personal and oral hygiene.
Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care). If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problems and not just assume the resident is refusing or declining care.
Approaching the resident in a different way or at a different time, or having another staff member speak with the resident may be appropriate.
245489 02/11/2026
Emmanuel Nursing Home 1415 Madison Avenue Detroit Lakes, MN 56501
staff to wear gowns when a resident was on EBP to help prevent the spread of infection.
(EBPs) are utilized to prevent the spread of multidrug-resistant organisms (MDROs) to residents.
resident care activities when contact precautions do not otherwise apply.
Gloves and gowns are applied prior to performing the high-contact resident care activities.
Examples of high-contact resident care activities requiring the use of a gown and gloves for EBPs include device care of use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.), and wound care.