Lifecare Greenbush Manor
LIFECARE GREENBUSH MANOR in GREENBUSH, MN — inspection on October 16, 2025.
Found 2 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
During an interview on 10/16/25 at 11:25 a.m., care coordinator registered nurse (RN)-B stated on 9/6/25 at approximately 3:00 p.m. NA-B made her aware of the incident with R1 during cares and NA-A, before she finished her explanation of what happened she was taken to the social service office and asked to repeat her story. It was a no brainer, needed to be reported, made her sick to her stomach and we do not talk to our residents like that here. R1 had dementia and this incident did not appear to impact her when she cleaned her bottom, did not see any irritation or emotional or physical harm.
During an interview on 10/16/25 at 9:38 a.m. DON stated she was contacted on 10/9/25 at approximately 3:44 p.m. and incident happened at 2:00 p.m. NA-A had made rude comments and inappropriately wiped R1 during cares and said ouch (assumed it was the way she wiped her). NA-A was suspended immediately pending investigation.
She had asked staff why they did not come forward sooner with concerns regarding NA-A and she was informed NA-A was intimidating and bullied them.
Verbal abuse was verified and hard to determine when she wiped was abuse, however approach was not ok. NA-A was not a person that should have been working with residents in the nursing home and was terminated.
Informal education was provided to staff immediately during stand-up and passed along from shift to shift.
Mandatory education will be completed for all staff by 10/24/25.
During an interview on 10/16/25 at 1:36 p.m., assistant administrator stated a couple of weeks prior to the 10/9/25, on 9/15/25 she was made aware of an incident involving NA-A and a resident in the dining room. NA-A served a resident chicken, NA-B asked if she usually cut up the chicken and NA-A stated she did not care, she could choke on the bone for all she cared. NA-B verbalized fearful of retaliation. NA-A was interviewed and did not deny the incident happened.
She was notified of the 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.
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.
245616 10/16/2025
Lifecare Greenbush Manor 19120 200th Street Greenbush, MN 56726
been expected to complete an assessment including skin and emotional as soon as the alleged
and completed the initial assessment (must be licensed staff) right away.
Behaviors and skin
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 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 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.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.