Lifecare Greenbush Manor

F 0600 Level of Harm - Minimal harm or potential for actual harm

for the vulnerable adult is of utmost priority. Examine, assess and interview the resident immediately upon knowledge to determine any injury. Verbal abuse was defined 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.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/16/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Lifecare Greenbush Manor

19120 200th Street Greenbush, MN 56726

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

to bring that to our attention and report it. The nurse would observe the skin when they assist with a transfer and pass medications. She was not asked to add behavior charting to Resident R1's medical record. RN-B stated there was behavior charting, check off list under tasks for the NA's and would be expected to complete it daily every shift. RN-B verified there was not consistent documentation under the behaviors task list by the NAs. During an interview on 10/16/25 at 1:36 p.m., assistant administrator stated she was notified of the Resident R1's incident that occurred on 10/9/25 at 3:44 p.m., NA-A had left for the day, was not allowed to work again, and terminated on 10/10/25. The staff nurse would have been expected to complete an assessment including skin and emotional as soon as the alleged perpetrator was removed and document. Important to assess immediately to collect a baseline identify injuries and extent of them. The care coordinator in this case should have collected the data and completed the initial assessment (must be licensed staff) right away. Behaviors and skin assessments should have been completed and monitored daily every shift for at least the first three days to identify a baseline, worsening condition and physical or emotional changes had occurred. If no changes were identified such as behaviors of abuse and/or skin the order would have been discontinued or extended. She entered Resident R1's orders for nursing to monitor skin and behaviors and had not realized for some reason it did not go onto the TAR. Those assessments were not completed. She would have expected the care coordinator nurse to monitor and review the notes over the weekend and should have been caught at that time. NAs were expected to document under tasks every shift Resident R1's behaviors and if none were identified a check mark should have been place in the last column none observed. The five-day facility investigation report did not identify as initial assessment was completed after the incident and should have to identify the severity of the abuse. Facility policy [NAME] Adult-Resident Abuse, Neglect, Mistreatment and Misappropriation of Property dated 2/19/25, identified each resident will be free from abuse, neglect, mistreatment, and misappropriation of property. Abuse can include but is not limited to physical harm, pain, mental anguish, verbal abuse (derogatory terms), sexual abuse, or involuntary seclusion from any source. All residents will be protected from abuse, neglect, and harm while they reside at the facility. No abuse or harm of any type will be tolerated, and residents and staff will be monitored for protection. In the event of suspected maltreatment, the needs of the resident will be immediately (upon knowledge) assessed, and the safety of the resident will be ensured. The resident will be assessed for physical appearance, skin injuries, trauma, or changed in resident affect, mood, and behavior. The investigation will consist of at least the following: a root cause analysis of all circumstances surrounding the incident. Ensuring safety and well-being for the vulnerable adult is of utmost priority. Examine, assess and

interview the resident immediately upon knowledge to determine any injury. Verbal abuse was defined 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.

Event ID:

Facility ID:

If continuation sheet