Essentia Health Oak Crossing

In the surveyor’s words

From the most serious findings on record at Essentia Health Oak Crossing, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Nov 22, 2023

  ELOPEMENT Based on interview and document review, the facility failed to ensure supervision for 1 of 3 residents (R1) reviewed for accidents. This failure resulted in an immediate jeopardy (IJ) when R1 eloped from the facility and was not discovered missing for two hours, despite being on hourly checks. The IJ began on 11/7/23, when R1 eloped from the facility and was out of the facility for four hours and found by law enforcement approximately 2.4 miles away from the facility. The facility administrator and director of nursing (DON) were notified of the IJ at 5:30 p.m. on 11/22/23. […]

• No harm, potential for more than minimal, widespreadF812Oct 23, 2024

  Based on observation, interview and document review, the facility failed to maintain the water and ice machines in a sanitary manner to prevent potential contamination for 69 residents who currently received water and ice from the ice machines. In addition, the facility failed to maintain the coffee machine on the Meadow [NAME] unit in a sanitary manner to prevent potential contamination for the residents who currently used the coffee machine. Findings include: On 10/21/24 at 11:49 a.m., an initial tour was conducted on all units and the following concerns were identified: -The water and ice machine located outside the main dining room on the Meadow [NAME] unit was observed to have an encrusted hard white flaky substance build up under the ice and water dispenser. […]

• No harm, potential for more than minimal, patternF812Oct 28, 2021

  Based on observation, interview and document review, food was not served in a sanitary and clean manner for 23 residents who resided in the Meadow [NAME] unit, observed during dining observation. This deficient practice had the potential to affect all residents residing on the unit. Findings Include: On 10/25/21, at 5:26 p.m. dietary aide (DA)-A was in the kitchenette on the Meadow [NAME] unit. DA-A was setting up the food to be served and took temperatures of the foods on the steam tray. DA-A was noted to have no hair net on while standing over the food to be served. At 6:02 p.m. DA-A dished up the residents' food with gloves on however continued to not have a hair net on. […]

• No harm, potential for more than minimal, patternF880Oct 28, 2021

  Based on observation, interview and document review, the facility failed to ensure appropriate handwashing and personal protective equipment (PPE) protocols were observed for 2 of 2 residents (R32, R46) who required isolation precautions for Coronavirus Disease 2019 (COVID-19). This deficient practice had the potential to affect all 65 residents residing in the facility. Findings include: R32's quarterly Minimum Data Set (MDS) dated [DATE], identified R32 had slightly impaired cognition and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated R32 required extensive assistance with bed mobility, transfers, locomotion, dressing, and toileting and had limited range of motion (ROM) on one side of lower extremity. […]

• No harm, potential for more than minimal, isolatedF684Dec 3, 2025

  Based on interview and document review, the facility failed to consistently follow provider's orders for one of five residents (R1) investigated for unnecessary medication. Findings Include: R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 was cognitively intact and had diagnoses which included: heart failure, respiratory failure, anxiety and depression. R1's MDS identified R1 received diuretics (medication to help remove excess fluids). R1's care plan revised 12/3/25, identified R1 was at risk for cardiac complications related to history of respiratory failure and diagnoses of congestive heart failure (CHF), atrial fibrillation (A-Fib, irregular heart and often rapid heart rhythm) and hypertension (HTN, high blood pressure). […]