Minnewaska Community Health Services
Minnewaska Community Health Services in STARBUCK, MN — inspection on November 24, 2025.
Found 1 citation. 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 observation on 11/10/25 at 12:45 p.m., director of nursing (DON) walked in hallway near dining room and was heard telling a nursing assistant to remember purple stars means gowns.
Then at 1:02 p.m.
DON applied a purple star to R5's nameplate near R5's door, then moved the dresser with PPE from the end of the hall and placed it next to R5's door.
During interview on 11/10/25 at 1:12 p.m., DON verified R5 had wounds and was on EBP. DON stated her expectation was gowns and gloves be worn during personal cares and wound cares for R5. DON indicated the facility used purple stars to notify staff residents were on EBP. DON confirmed R5 did not have a purple star up until she applied one that afternoon, and she had put purple stars up and PPE outside other residents' rooms that day who were also on EBP. DON further stated her expectation was that staff complete hand hygiene after remove gloves, prior to applying new gloves to prevent spread of infection.
The facility policy titled Enhanced Barrier Precautions, undated, identified EBP was for the prevention of transmission of multidrug resistant organisms.
The facility would have the discretion on how to communicate to staff which residents required the use of EBP, as long as staff were aware of which residents required the use of EBP prior to providing high-contact care activities.
Gowns and gloves would be available immediately near or outside a resident's room and to ensure alcohol-based hand rub was in every resident room, ideally both inside and outside of the room.
Position a trash can inside resident's room and near the exit for discarding PPE after removal.
The facility policy titled Hand Hygiene Policy, undated, identified all staff would perform proper hand hygiene to prevent spread of infection to other personnel, residents, and visitors.
The policy identified if task required gloves, to perform hand hygiene prior to donning gloves, and immediately after removing gloves.
The facility policy titled Clean Dressing Change, undated, identified facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination.
Instructions included to wash hands and put on gloves.
After removing the soiled dressing, remove gloves, wash hands and put on clean gloves.
Clean wound, measure wound, remove gloves, then wash hands and put on new gloves.
Apply ointments or creams, and secure dressing, mark and initial, then dispose of gloves, and wash hands.
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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.