Glenoaks Senior Living Campus

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

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

noticed a change with NA-P's behavior with residents.During an interview on 9/11/25 at 3:32 p.m., assistant director of nursing (ADON)-A described NA-P demure as lacking a bed side manner but was meeting the needs of the residents appropriately. Further stated NA-P had not had any rough cares. When the NA-P's written warning was brought up ADON-A would not count rushed and harsh as rough cares.During an

interview on 9/12/25 at 7:40 a.m., DON stated she had gone over the grievance form with NA-P on 9/5/25, and asked NA-P slowed down and encouraged NA-P to treat residents as individuals and had individual care needs and to provide quality care to all residents.Review of NA-P employee files included:-a coaching/teachable moment dated 7/18/25, for her tone of voice and disrespectful and condescending to coworkers.- a written warning dated 8/1/25, NA-P being harsh and rushed, staff have complained about tone and verbiage coming from NA-P that was demeaning and lacked appropriate bedside manner.- a grievance 9/5/25, DON wrote for Resident R1, where Resident R1 identified NA-P by name and reported NA-P was too fast

during cares and that it was possible would not like NA-P to assist with cares if possible. Review of facility policy Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy dated 7/8/24 indicated the following: -Personal degradation of a dependent adult, means a will act or statement by a caretaker intended to shame, degrade, humiliate, or otherwise harm the personal dignity of a dependent adult, or where the caretaker knew or reasonably should have known the act or statement would cause shame, degradation, humiliation, or harm to the personal dignity of a reasonable person.-Mental abuse is

the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. Mental abuse includes agitating

a resident to solicit a response, derogatory statement directed to the resident.

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

09/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Glenoaks Senior Living Campus

100 Glen Oaks Drive New London, MN 56273

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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and document review the facility failed to report an allegation of abuse timely to the State Agency for 1 of 1 resident (Resident R1) who reported staff to resident physical abuse. Findings include:A facility five-day investigation submitted by the administrator to the State Agency on9/3/25 indicated on 8/28/25, Resident R1 had clinic appointment and had become upset with the physician. The report included a statement Resident R1 made to

the physician then we should talk about Glen Oaks and the staff that is beating me up. In review of facility reported incidents to the State Agency there was no indication Resident R1's allegations of abuse were reported to

the State Agency. Resident R1's significant Minimum Data Set (MDS) dated [DATE REDACTED], indicated Resident R1 did not have cognitive impairment. Resident R1 had verbal behaviors and rejection of cares.During an interview on 9/11/25, at 10:17 a.m., Administrator confirmed she submitted the five-day report to the State Agency that included the allegation of abuse Resident R1 had made. On 8/28/25, she was told by the facility scheduler (SCH)-A who heard Resident R1 make the allegation to the physician during her appointment on 8/28/25. The Administrator indicated when

she had talked with Resident R1 she was not able to provide specific details of the incident including who the staff member involved and was not willing to further discuss the incident and therefor did not consider the incident reportable.During an interview on 9/12/25 at 7:40 a.m., director of nursing (DON) stated was made aware of incident on 9/5/25 when Resident R1 made a grievance towards NA-P. DON filled out the grievance form and talked with NA-P. DON did not make a report to the SA, regarding the allegation of rough cares as she did not consider rough cares as a reportable event. Review of facility policy Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy dated 7/8/24 indicated the following:Reporting:-All allegation of resident abuse, neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation of property should be reported immediately to the administrator.-All allegations of resident abuse shall be reported to the appropriate state entity not later than two hours after

the allegation is made.

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

09/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Glenoaks Senior Living Campus

100 Glen Oaks Drive New London, MN 56273

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 - Some

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

immediately.The administrator will complete documentation of allegation of resident abuse and collect any supporting documents relative to the alleged incident.-Review documentation in resident record.-Assess

the resident for injury if the allegation involves physical or sexual abuse.-provide proper notification of primary care provider, responsible party, etc.-attempt to obtain witness statements (oral and/or written) form all known witnesses.-If there is physical evidence that can be preserved, attempt to do so, maintain in a safe location to minimize risk of evidence being tampered with.Upon receiving a report of an allegation of resident abuse, neglect, exploitation or mistreatment, the facility shall immediately implement measures to prevent further potential abuse of residents from occurring while the facility investigation is in process. If this allegation of abuse is by an employee, this will be accomplished by separating the employee accused of abuse from all residents through the following process or a combination of the following, if practicable:1) suspending the employee; 2) segregating the employee by moving the employee to an area of the facility where there will be no contact with any residents of the facility.

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

09/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Glenoaks Senior Living Campus

100 Glen Oaks Drive New London, MN 56273

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 0689 Level of Harm - Actual harm

to prevent rolling issues.Occupant Restraints:-the occupant must be secured in the wheelchair in case of an accident. A seat belt will prevent the occupant from being ejected from the chair, protecting them from additional injury.

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

09/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Glenoaks Senior Living Campus

100 Glen Oaks Drive New London, MN 56273

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 0730

Observe each nurse aide's job performance and give regular training.

Level of Harm - Minimal harm or potential for actual harm

Based on interview and record review the facility failed to ensure performance evaluations for 4 of 4 nursing assistants (NA-P, NA-D, NA-S, and NA-L) were provided within the past 12 months.Findings include:Review of nursing assistant (NA)-P employee record identified a hire date of 10/25/23 and did not include a performance evaluation since NA-P's hire date. During interview on 9/12/25, nursing assistant (NA)-P could not remember receiving a performance evaluation since she was hired. Review of (NA)-D's employee

record identified a hire date of 11/10/22 and included a performance evaluation dated 3/13/23; there were no subsequent performance evaluations included in her record.Review of NA-S employee record identified

a hire date of 4/15/22 and included a performance review dated 3/13/23; there were no subsequent performance evaluations included her the record. During interview on 9/12/25 at 8:27 a.m., NA-S could not remember receiving a performance evaluation since 2023. Review of NA-L's employee file identified a hire date of 2/18/20, a performance evaluation for 2022 was found but no other performance evaluation were located in her file.During an interview on 9/12/25 at 7:40 a.m., director of nursing (DON) indicated she had not done any performance evaluations for nursing assistants in her three years as DON at the facility.During

an interview on 9/12/25 at 12:30 p.m., Administrator indicated there was no policy for annual evaluations of nursing assistants but was an expectation they were completed.

Residents Affected - Some

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

Event ID:

Facility ID:

If continuation sheet