Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Oak Hills Living Center during CMS and state inspections, most recent first.
A resident who was dependent on staff for ADLs did not receive routine personal hygiene, including shaving and nail care, as directed by the care plan and task list. The resident had moderate cognitive impairment, hemiplegia after CVA, and a spinal fracture history, and was observed with visible facial hair and overgrown fingernails. Staff acknowledged the shaving and nail care had not been completed as expected.
A resident with CHF, respiratory failure, HTN, obesity, and moderate cognitive impairment did not receive ordered TG shapes to both lower extremities. Staff observed the resident without the compression in place, and the resident did not recall ever wearing it. An NA said the order was not on the task list, an LPN said the order did not forward for completion, and the RN case manager confirmed the task had been removed from PCC and not restored.
A resident with multiple health conditions, including an amputation and peripheral vascular disease, required supervision and use of a gait belt and walker for ambulation. During an incident, a nursing assistant did not hold the gait belt while assisting the resident, contrary to the care plan and facility policy. The resident let go of the walker and fell, sustaining a femur fracture that required surgery.
The facility failed to comprehensively assess falls and implement effective interventions for two residents, leading to repeated falls and a hip fracture for one resident. Despite being at high risk for falls, the care plans were not adequately revised, and interventions were insufficient to prevent incidents.
The facility failed to develop and implement an individualized toileting care plan for a resident with moderate cognitive impairment and a history of urinary incontinence. Despite identifying the resident's usual elimination times and conditions impacting urinary status, the care plan did not include specific toileting schedules. The resident experienced multiple falls related to self-transferring to the toilet, and staff were unaware of any specific toileting times for the resident.
The facility failed to implement an individualized toileting program and did not consistently follow catheterization orders for a resident with urinary retention, leading to inadequate care and increased risk of UTIs. Staff were unaware of specific toileting times, and there was inconsistent documentation of urinary output and catheterization procedures.
Failure to Provide Routine Personal Hygiene
Penalty
Summary
The facility failed to ensure routine personal hygiene was provided for a resident who was dependent on staff for ADLs, including shaving and nail care. The resident’s MDS identified moderate cognitive impairment and need for substantial to maximal assistance with personal hygiene, and the care plan and task list directed staff to provide hygiene assistance, including daily shaving and nail care. The resident also had diagnoses including a wedge compression fracture of T11-T12 and hemiplegia following a cerebral infarction affecting the right dominant side. Documentation showed missed care: the resident task look-back indicated nail care was not completed on 3/25/26 and 4/1/26, and shaving was not completed on 3/26/26, 3/28/26, and 3/29/26. During observation, the resident had facial hair along the jaw line, lower cheeks, and upper lip, and stated she did not want the facial hair and wanted it shaved. The resident also showed fingernails that had grown over the fingertips and were curving downward, and stated she wanted them trimmed. Staff later acknowledged the resident should have been shaved that morning and that nail care was typically done weekly with showers.
Failure to Follow Ordered Leg Compression
Penalty
Summary
The facility failed to follow a provider order for TG shapes to both lower extremities for a resident with chronic congestive heart failure, chronic respiratory failure, hypertension, obesity, moderate cognitive impairment, and use of oxygen and a wheelchair. The physician’s order dated 6/25/25 directed TG shapes to bilateral lower extremities on in the morning and off at bedtime, but during observation the resident was seated with exposed legs, had indentations from socks, and was not wearing TG shapes. The resident stated she did not recall ever wearing leg compression and did not know her doctor had ordered it. During subsequent interviews, the resident again had no TG shapes on her lower legs and stated she used to wrap her legs herself but could not remember having anything on her legs for compression while at the facility. A nursing assistant stated she was not aware of the order and had never applied TG shapes for the resident, and verified the task was not on the task list. An LPN stated the order had no directions indicated and therefore did not forward for completion, and the RN case manager confirmed the order should have been on the NA task list but had been removed by a consultant on 2/10/26 and not restored. The DON stated the consultant had removed the order from tasks while cleaning up PCC and forgot to put it back, and that provider orders should be followed for all residents.
Failure to Hold Gait Belt During Ambulation Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when staff failed to implement a known safety intervention for a resident with multiple medical conditions, including type 2 diabetes, peripheral vascular disease, and an amputation. The resident required supervision and the use of a gait belt, walker, and one-person assistance for ambulation, as documented in the care plan. During an incident, a nursing assistant ambulated the resident using a gait belt and walker, with a wheelchair positioned behind, but did not hold onto the gait belt as required. The resident let go of the walker to scratch her nose and subsequently fell, resulting in a displaced fracture of the left proximal femur/hip that required surgical intervention. Interviews and documentation revealed that the nursing assistant was unaware that the gait belt should be held during ambulation, rather than simply placed on the resident. The physical therapist confirmed that staff are expected to hold the gait belt at all times when assisting residents who require help walking. The care plan and facility policy specified that staff must maintain an upward grasp on the gait belt throughout ambulation. The failure to follow these established procedures directly led to the resident's fall and injury.
Failure to Prevent Falls and Implement Effective Interventions
Penalty
Summary
The facility failed to comprehensively assess each fall and identify causal factors to determine the reasons for falls, and failed to comprehensively evaluate and implement fall interventions for two residents. One resident, identified as R1, experienced multiple falls due to self-transferring to the bathroom without assistance, despite being at high risk for falls. The facility did not revise R1's care plan with effective interventions after each fall, leading to R1 sustaining a right hip fracture from the ninth fall, which resulted in hospitalization and surgical repair. The facility's inaction in addressing R1's fall risk and self-transferring behavior contributed to the severity of the incident. R1 had a history of neuropathy, vascular dementia, urinary retention, weakness, unsteadiness on feet, and muscle wasting. Despite being identified as a high fall risk, R1's care plan did not adequately address his toileting routine or provide effective interventions to prevent falls. R1 experienced multiple falls, often related to self-transferring to the bathroom, and the facility's interventions, such as using a bed alarm and educating R1 to use the call light, were insufficient. The facility did not conduct a comprehensive assessment or revise the care plan with new interventions after each fall, leading to repeated incidents. Another resident, identified as R3, also experienced multiple falls from a recliner chair. R3 had severe cognitive impairment, required extensive staff assistance, and was at high risk for falls. Despite this, the facility did not develop or implement new fall interventions after each incident. R3's care plan included interventions such as using a floor mat and keeping the bed in the lowest position, but these measures were not sufficient to prevent falls. The facility's failure to conduct a comprehensive analysis and implement effective interventions contributed to the recurrence of falls for R3.
Removal Plan
- Reviewed falls policy and implemented a new process for data collection/analysis.
- R1 was provided with 1:1 supervision.
- Completed comprehensive fall analysis/assessments, reviewed/revised/implemented R1's care plan with appropriate interventions.
- Identified like residents who were high risk for falls with falls. Completed a comprehensive analysis and reviewed/revised care plans for appropriate interventions.
- All staff were provided education with competency testing on fall program policy and following care plans as it pertained to their scope of practice.
Failure to Implement Individualized Toileting Care Plan
Penalty
Summary
The facility failed to develop and implement an individualized toileting care plan for a resident (R1) based on a comprehensive assessment. R1 had moderate cognitive impairment and required supervision and assistance for various activities, including toileting. Despite having a history of urinary incontinence and urinary tract infections, and being frequently incontinent, the facility did not create a specific toileting plan for R1. The bladder evaluations conducted on two separate dates identified R1's usual elimination times and conditions impacting urinary status, but these were not incorporated into the care plan. The care plan only included general interventions without specific toileting schedules, and the evaluation for a bladder program potential was left blank in both assessments. R1 experienced nine falls between January and March, with seven falls related to self-transferring to the toilet, all occurring after 8:00 p.m. on the evening and overnight shifts. Interviews with nursing assistants and the RN revealed that staff were aware of R1's tendency to self-transfer for toileting but were unaware of any specific toileting times for R1. The Director of Nursing stated that it was the expectation for all residents to be screened for toileting by the therapy department, but this was not reflected in R1's care plan. The facility did not provide a policy regarding the development and implementation of individualized toileting plans.
Failure to Implement Individualized Toileting Program and Follow Catheterization Orders
Penalty
Summary
The facility failed to implement an individualized toileting program based on the comprehensive assessment and did not consistently follow intermittent catheterization physician orders for a resident with urinary retention. The resident had a history of urinary incontinence and urinary tract infections (UTIs) and required assistance with toileting and catheterization. Despite these needs, the resident's care plan did not include an individualized toileting schedule, and there was inconsistent documentation of urinary output prior to catheterization. Additionally, the resident was not consistently catheterized according to physician orders, and there was no evidence that the family member assisting with catheterization had been properly educated on the procedure. Observations and interviews revealed that the resident often experienced discomfort and burning sensations related to the catheter, and staff did not consistently monitor or document the resident's urinary output. The resident's treatment administration record (TAR) indicated multiple instances where catheterization was not performed or was refused without further assessment or intervention. Furthermore, the resident's care plan was not updated to reflect the individualized toileting schedule, and staff were unaware of any specific toileting times for the resident. The facility's policy for urinary catheter care was not followed, as staff did not consistently assess and document the ongoing need for the catheter or observe for complications. The resident's care plan was updated after a hospitalization, but the facility failed to provide a policy for straight catheterization. Interviews with staff indicated a lack of awareness and training regarding the resident's toileting and catheterization needs, leading to inadequate care and increased risk of UTIs for the resident.
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Illustrative
What surveyors actually found near you
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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 New Ulm
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Divine Providence Community Home | 12.3 mi | ★★★★★ | 11 | 0 |
| Sleepy Eye Rehabilitati Center | 12.4 mi | ★★★★★ | 8 | 0 |
| Living Meadows At Luther - Madelia | 18.9 mi | ★★★★★ | 3 | 0 |
| Bayside Manor Llc | 21.1 mi | ★★★★★ | 13 | 1 |
| Gil-mor Manor | 22.8 mi | ★★★★★ | 3 | 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.