Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Essentia Health Oak Crossing during CMS and state inspections, most recent first.
Failure to Complete Ordered Daily Weights: A resident with CHF, A-fib, HTN, and respiratory failure had a provider order for daily weights, but the weights were missed on multiple days and were documented as inaccurate, unavailable, not obtained, unable to obtain, or refused. The resident stated she had not refused the weights, while staff and the NP said the weights were important for monitoring fluid status and dosing heart medications and diuretics. The record lacked documentation of education about missed weights or notification to the NP when the ordered weights were not completed.
The facility failed to maintain water, ice, and coffee machines in a sanitary manner, leading to potential contamination for 69 residents. Surveyors observed lime scale build-up on machines across multiple units, confirmed by dietary staff. The facility's cleaning schedules did not include de-scaling these machines, and the facility lacked manufacturer's manuals for them.
The facility failed to ensure accurate reflection of advanced directives in the medical records of three residents, leading to potential discrepancies in emergency situations. One resident's records showed conflicting DNR and Full Code statuses, another had inconsistent POLST and EMR information, and a third resident's wishes for CPR were not accurately documented. Staff interviews revealed reliance on various sources for code status, risking incorrect actions during emergencies.
A resident with a stage three pressure ulcer on the left heel did not receive appropriate pressure-relieving interventions as outlined in their care plan. Despite being at risk for pressure ulcers, the resident was often observed with feet flat on the floor, contrary to instructions to offload the heel. The facility continued using Mepilex dressing due to cost issues with iodosorb, and there was a lack of communication and follow-up with podiatry. Nursing staff failed to update the care plan and implement necessary interventions, and the facility did not provide a pressure ulcer management policy.
Two residents in the facility experienced multiple falls due to inadequate identification of root causes and failure to implement effective interventions. One resident, with a history of falls and cognitive impairment, had several falls resulting in injuries, yet the care plan was not consistently updated with new interventions. Another resident, also with a history of falls and on hospice care, continued to fall despite existing interventions. Staff interviews revealed inconsistencies in documenting and implementing fall prevention strategies, highlighting a failure in the facility's fall prevention policy.
Failure to Complete Ordered Daily Weights
Penalty
Summary
The facility failed to consistently follow a provider order for daily weights for a resident with cognitive intactness and diagnoses including heart failure, respiratory failure, anxiety, depression, CHF, A-fib, and HTN. The resident’s care plan identified the resident as at risk for cardiac complications and noted that the resident sometimes refused weights, monitoring for signs and symptoms, and vital signs as ordered. A physician order dated 11/28/25 included daily weights for heart failure starting 11/10/25. Review of the medication administration record showed that the resident’s weights were not obtained on multiple days between 11/10/25 and 12/3/25, including entries documented as inaccurate weight, resident unavailable, staff unable to attain, not obtained, unable to obtain, and refused. The record showed the weights were not obtained 16 of 21 days during one period and 2 of 3 days during a later period. The resident’s medical record did not include further documentation about the missed weights, education to the resident about risks versus benefits, or notification to the NP about the missed weights. During interviews, the resident stated she was fine with daily weights and had not refused them. Nursing staff stated the weights were important because of the resident’s heart conditions and fluid status, and that the provider should be notified if weights were not completed daily. The NP stated she ordered daily weights because of heart failure and expected the facility to contact her if weights were not being completed and why, noting that daily weights were important for dosing heart medications and diuretics. The facility policy also stated the RN was responsible for communicating the plan of care and changes to the care team, and the notification-of-change policy required education about treatment, risks and benefits, communication of resident preferences to the provider, and implementation of provider orders.
Sanitation Deficiency in Water, Ice, and Coffee Machines
Penalty
Summary
The facility failed to maintain the water and ice machines, as well as a coffee machine, in a sanitary manner, leading to potential contamination for 69 residents who received water and ice from these machines. During an initial tour, surveyors observed an encrusted hard white flaky substance, identified as lime scale, on the ice and water dispensers, grates, and trays of machines located on the Meadow [NAME], Harbor Springs, and Cedar Ridge units. Additionally, the coffee machine on the Meadow [NAME] unit had a similar build-up on the center nozzle, and the sink in the same area was covered with the substance. Interviews with the dietary supervisor and manager confirmed the presence of lime scale build-up and revealed that the facility's cleaning schedules did not include de-scaling these machines. The dietary supervisor acknowledged the issue had persisted for some time, and the dietary manager was unaware of the lime scale on the coffee machine. The facility's policy on cleaning and sanitation, dated 7/22, required equipment used in food preparation, storage, and service to be cleaned and sanitized to prevent disease transmission, but the facility lacked manufacturer's manuals for the machines involved.
Inconsistent Advanced Directives in Resident Records
Penalty
Summary
The facility failed to ensure that advanced directives for emergency care and treatment were accurately reflected in the medical records of three residents, leading to potential discrepancies in emergency situations. Resident R10's records showed conflicting information regarding their code status, with the electronic medical record (EMR) indicating a 'Do Not Resuscitate' (DNR) status, while the physician order report and a scanned POLST indicated 'Full Code' and 'Attempt Resuscitation/CPR', respectively. This inconsistency could result in actions contrary to the resident's wishes during an emergency. Similarly, Resident R60's records contained conflicting information. The EMR and physician order report indicated 'Full Code', while a scanned POLST showed 'Do Not Attempt Resuscitation/DNR'. Another POLST in the paper chart indicated 'Attempt Resuscitation/CPR'. These discrepancies could lead to confusion and incorrect implementation of the resident's wishes in an emergency. Resident R68's records also showed inconsistencies, with the EMR indicating a DNR status, while the physician order report showed 'Full Code'. The resident expressed a desire for CPR, but the records did not accurately reflect this. Interviews with staff revealed that their usual practice involved checking various sources for code status, which could lead to errors if the information was not consistent across all records. The Director of Nursing confirmed these findings and acknowledged the potential for incorrect actions based on the discrepancies in the records.
Failure to Implement Pressure Ulcer Interventions
Penalty
Summary
The facility failed to appropriately implement pressure-relieving interventions for a resident with a stage three pressure ulcer on the left heel. The resident, who had moderate cognitive impairment and several medical conditions including dementia and chronic kidney disease, was identified as being at risk for pressure ulcers. Despite having a care plan that directed staff to free float the resident's heels in bed and recliner and encourage the use of a post-op shoe, these interventions were not consistently followed. Observations revealed that the resident was often found sitting in a recliner with feet flat on the floor, contrary to the care plan's instructions. The resident's pressure ulcer history showed a progression from a suspected deep tissue injury to an unstageable pressure ulcer, and eventually to a stage three ulcer. Despite orders from podiatry to offload the left heel and use specific dressings, the facility continued to use Mepilex border dressing due to cost issues with obtaining iodosorb. Observations and interviews indicated that nursing staff did not consistently offload the resident's heel, and there was a lack of communication and follow-up with podiatry appointments. Interviews with nursing staff and the director of nursing confirmed the expectation that changes in the resident's condition should be communicated to the primary doctor and podiatrist. However, there was a failure to update the care plan and implement necessary interventions to promote healing and prevent further deterioration of the pressure ulcer. The facility did not provide a policy for pressure ulcer management when requested, indicating a possible gap in procedural adherence.
Failure to Implement Effective Fall Prevention Strategies
Penalty
Summary
The facility failed to identify the root cause of falls and implement appropriate interventions for two residents who experienced multiple falls. One resident, identified as R29, had a history of falls and was at risk due to impaired mobility, cognition, and incontinence. Despite having a care plan that included interventions such as two-hour toileting and alarms, the resident experienced several falls, some resulting in injuries like a hip and wrist fracture. The incident reports and progress notes revealed that the facility did not consistently update the care plan with new interventions after each fall, and there was a lack of documentation regarding the timing of toileting, which was a critical component of the resident's care plan. Another resident, identified as R127, also experienced multiple falls within a short period. This resident had a history of falls, dementia, and was on hospice care. The care plan included interventions like hourly rounding and alarms, but the resident continued to fall, including incidents where the resident was found on the floor in various locations. The facility's documentation lacked comprehensive assessments and adjustments to the fall prevention interventions after each fall. The interdisciplinary team reviewed the falls but concluded that the interventions were effective, despite the resident continuing to fall. Interviews with staff revealed inconsistencies in the implementation and documentation of fall prevention strategies. Nursing assistants and nurses were aware of the residents' fall risks and interventions but did not always document refusals of care or update care plans with new interventions. The facility's policy on fall prevention and follow-up was not effectively implemented, as evidenced by the repeated falls and lack of new interventions to address the root causes of the falls.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Detroit Lakes
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Emmanuel Nursing Home | 0.6 mi | ★★★★★ | 9 | 1 |
| Frazee Care Center | 8.9 mi | ★★★★★ | 6 | 0 |
| Sunnyside Care Center | 10.8 mi | ★★★★★ | 3 | 0 |
| Perham Living | 19.4 mi | ★★★★★ | 7 | 0 |
| Pelican Valley Health Center | 20.1 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.