Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Oaklawn Care & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with type 2 DM on hypoglycemic meds and a continuous glucose monitor did not have a comprehensive, individualized diabetic management care plan. The care plan lacked a specific DM focus, target BG ranges, use of the CGM, interventions for high/low BG, monitoring and reporting parameters, and individualized interventions related to hypoglycemic medications or signs/symptoms of hypo-/hyperglycemia. Review of BG records showed multiple low BG readings with no documented assessment for hypoglycemia, no timely rechecks, and no documented interventions to raise BG. An LPN and the DON acknowledged that diabetic management should be included in the care plan and that staff were expected to follow protocols, but this was not reflected in the resident’s written care plan or documentation.
Two residents with bowel and bladder incontinence, including one with an indwelling Foley catheter and history of UTIs, did not receive peri care in accordance with EBP, glove use, and hand hygiene requirements. Staff were observed providing incontinence and catheter-area care without washing hands between glove changes, wiping stool around the vaginal and catheter areas in improper directions, handling clean supplies and room items with contaminated gloves, and entering an EBP room without gown and gloves. Nursing leadership reported they did not conduct audits or supervision of peri care practices to reduce UTI risk, despite facility policies requiring front-to-back wiping, proper glove changes, hand hygiene, and EBP use for residents with medical devices.
Staff failed to follow professional standards for eye drop administration by not pulling down the lower eyelid to create a pocket, instead placing drops at the inner corner of the eye for three residents with significant medical conditions. Care plans did not address eye care needs or resident preferences, and staff were either unaware of or did not adhere to facility policy, as confirmed by interviews and observations.
A resident dependent on staff for personal hygiene and grooming was observed with visible chin hairs over two days and reported wanting assistance with shaving, but staff did not provide this care during morning grooming. Nursing staff interviews revealed a lack of awareness and follow-through regarding the resident's grooming needs, despite facility expectations for regular shaving and resident preference.
Two residents with a history of smoking were observed using the designated smoking area and properly disposing of cigarettes, but a large accumulation of cigarette butts was found scattered around the area. Staff interviews revealed that no one was assigned to monitor or clean the smoking area, and the administrator was unaware of the issue, despite facility policy requiring staff enforcement and oversight.
The facility did not ensure that the culinary services director was a certified dietary manager or enrolled in the required course while overseeing nutrition and food services in the absence of a full-time RD. The CSD had been in the position for two years without the necessary certification, and the part-time RD provided limited on-site support, potentially affecting all residents receiving meals.
Surveyors identified that food items in two resident-designated refrigerator/freezers were not consistently labeled, dated, or properly stored, with some perishable items kept beyond recommended timeframes and no clear staff responsibility for monitoring. Additionally, a cook was observed handling resident meals without a beard cover, contrary to facility policy requiring beard restraints for food handlers.
Staff failed to properly don and doff PPE when caring for a resident on transmission-based precautions for Covid-19. Multiple staff members entered the resident's room without required eye protection and removed all PPE, including the N95 mask, before exiting the room, contrary to CDC guidelines. Staff interviews revealed a lack of awareness of the correct doffing procedure, and required PPE was not always available on the PPE cart.
A resident with a history of heart failure, muscle weakness, and prior pneumonia was not offered or administered the PCV20 vaccine as recommended by CDC guidelines. Review of the medical record showed no documentation of the vaccine being offered or refused, despite facility policy requiring all residents to be offered pneumococcal vaccination.
Failure to Develop Comprehensive Diabetic Management Care Plan and Monitor Hypoglycemia
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, individualized care plan for diabetic management for one resident with type 2 diabetes and hyperglycemia. The resident’s face sheet and MDS identified a diagnosis of type 2 diabetes, use of hypoglycemic medications, and a therapeutic diet, and the MAR showed an order for a continuous glucose monitoring system (FreeStyle Libre 2) to be applied every 14 days. Although the resident’s diabetes diagnosis was referenced as a related factor in other care plan problem areas (falls, vulnerable adult, nutrition, skin integrity), there was no dedicated diabetic care plan focus. Specifically, the care plan did not identify target blood glucose ranges, use of the continuous glucose monitor, interventions for high or low blood glucose levels, or monitoring and reporting parameters for abnormal readings. It also lacked individualized interventions related to the resident’s hypoglycemic medications and did not address monitoring for signs and symptoms of hyperglycemia or hypoglycemia. Review of blood glucose records, progress notes, and the MAR for a nearly two‑month period showed multiple low blood glucose readings without documented assessment for signs or symptoms of hypoglycemia, without timely rechecks, and without documented interventions to raise blood sugar. Examples included readings of 53 mg/dL, 68 mg/dL, 70 mg/dL, and 59 mg/dL with delays of several hours before rechecks and no documentation of treatment. In interviews, the LPN care coordinator described expected blood glucose ranges, the function of the continuous glucose monitor, and the expectation that staff would check blood glucose more frequently when low and follow protocol, including rechecking within 30–60 minutes after interventions and notifying the provider if levels did not improve. However, the LPN confirmed that the resident’s care plan did not contain specific diabetic management guidance for staff. The DON stated that care plans are updated with significant changes and reviewed quarterly and that care plans should include diabetic management, but the facility’s care planning policy requiring interventions to be derived from a comprehensive assessment and used for daily care was not followed for this resident’s diabetic care.
Failure to Implement Proper Peri Care and EBP to Prevent UTIs
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper peri care techniques, including use of Enhanced Barrier Precautions (EBP), appropriate glove changes, and hand hygiene, to prevent or mitigate the risk of urinary tract infections for two residents. One resident had diagnoses of cystitis without hematuria, neuromuscular dysfunction of the bladder, a personal history of UTIs, diabetes, and an indwelling Foley catheter, and was care planned for EBP and frequent perineal care with monitoring for UTI signs and symptoms. Nursing orders directed staff to follow EBP during catheter maintenance and to keep the perineal area clean and dry, while the resident’s assistant care sheet identified contact precautions for diarrhea and an indwelling Foley catheter. Despite these orders and care plans, staff did not consistently follow required infection prevention practices during high-contact peri care. During observations, a nursing assistant in training provided peri care to the catheterized resident after an episode of loose stool while wearing a gown but failed to perform hand hygiene between glove changes. The assistant removed soiled items, handled trash, and manipulated items in the room with contaminated gloves before sanitizing hands only after leaving the immediate care area. Later, another nursing assistant entered the same resident’s room without donning EBP despite signage on the door, did not wash hands before putting on gloves, and did not wear a gown. This assistant removed a soiled brief with dark brown liquid stool pooled over the resident’s vaginal area and into abdominal folds, allowed stool to contact her gloved hand, then touched the resident’s thigh leaving visible stool without changing gloves. She rolled the resident over soiled pads, wiped stool around the vaginal folds and catheter area without changing gloves or performing hand hygiene, wiped the catheter toward the vaginal area, and continued wiping stool toward the vaginal area. She then applied powder under the abdominal fold, handled room items, call lights, cupboards, garbage, and dirty linens while still wearing the same contaminated gloves, and exited the room without appropriate glove changes or hand hygiene. For the same catheterized resident, a registered nurse entered the room on observation without donning gown and gloves despite the EBP sign on the door. The RN used a stethoscope to assess bowel sounds and applied and reapplied a blood pressure cuff on both arms without wearing EBP. In a separate case, another resident with hemiplegia and documented bowel and bladder incontinence, care planned for peri care with staff assistance, received peri care from a nursing assistant who wiped stool from the resident’s bottom and removed a soiled brief, then obtained a clean brief from a drawer without removing gloves or performing hand hygiene. The assistant touched the resident’s shirt with dirty gloves, applied Tena cream, and wiped the inner thighs and vaginal area in multiple directions, then placed a new brief. After removing gloves, the assistant did not perform hand hygiene before handling clean shirts in the closet, dressing the resident, and transferring the resident to a wheelchair, only sanitizing hands when leaving the room. Interviews with an RN, an LPN care coordinator, and the DON/IP revealed that audits or supervision of nursing assistants’ peri care practices to reduce UTI risk were not being conducted, and the DON/IP stated she had not identified UTI trends and did not obtain UA/UC reports from hospitals, despite facility policies outlining catheter care steps, front-to-back wiping, glove changes, hand hygiene, and use of EBP for residents with medical devices.
Failure to Follow Professional Standards in Eye Drop Administration
Penalty
Summary
The facility failed to ensure that professional standards of practice were followed during the administration of eye drops for three residents observed during medication administration. Staff, including a registered nurse and a trained medication aide, were observed administering eye drops by placing the tip of the bottle at the inner corner of the eye without pulling down the lower eyelid to create a pocket, as required by professional standards and the facility's own policy. In one instance, a drop was observed to run down a resident's face, indicating improper technique. Both the RN and TMA later confirmed that the correct method involves pulling down the lower eyelid, but admitted they did not do so during administration. The residents involved had significant medical histories, including progressive neurological conditions, hemiplegia or hemiparesis, multiple sclerosis, and glaucoma. Care plans for these residents did not address specific care needs related to their eyes or document any refusals or preferences regarding eye drop administration, despite staff and the DON being aware of at least one resident's reported discomfort with having her face touched. Interviews with staff and the DON confirmed that the expected procedure was not followed and that care plans were incomplete regarding these issues. Facility policy on eye drop administration clearly states that staff should gently pull down the lower eyelid to form a pouch and instill the prescribed number of drops into the pouch near the outer corner of the eye. Staff were either unaware of this policy or did not follow it during observed administrations. The DON confirmed that proper technique is covered during staff orientation and that care plans should reflect any resident-specific refusals or needs, which was not the case for the residents observed.
Failure to Provide Shaving Assistance for Dependent Resident
Penalty
Summary
A resident with diagnoses including muscle weakness, pain, high blood pressure, and heart failure was dependent on staff for assistance with personal hygiene and grooming, as documented in the care plan and Minimum Data Set (MDS) assessment. The resident was observed on two consecutive days to have visible chin hairs up to 1/2 inch long and expressed dissatisfaction with the presence of chin hairs, stating a desire for staff assistance with shaving. Despite having a razor available and being assisted with other aspects of morning grooming, staff did not offer or provide shaving during these times. Interviews with nursing staff revealed a lack of awareness and follow-through regarding the resident's need and preference for shaving. One nursing assistant stated she was unaware of the need and did not offer shaving during morning care, while a registered nurse and the director of nursing both indicated that residents should be shaved at least weekly or as requested, especially if visible chin hair was present. The facility's policy on shaving and grooming was requested but not provided.
Failure to Maintain Safe and Supervised Smoking Area
Penalty
Summary
The facility failed to ensure the designated smoking area was free from accident hazards and adequately supervised to prevent accidents for two residents with a history of smoking. Both residents, one with diagnoses including spina bifida and nicotine dependence and another with diabetes and malnutrition, were observed smoking independently in the designated area and properly disposing of their cigarettes in the provided container. However, approximately 100 cigarette butts were found scattered in the grass, under trees, and on the patio surrounding the smoking area, indicating improper disposal of smoking materials over time. Interviews revealed that neither resident currently using the area was responsible for the scattered cigarette butts, with one resident attributing the mess to a former resident who had been discharged months prior. Staff interviews confirmed that no one had been assigned to monitor or clean the smoking area, and the administrator was unaware of the accumulation of cigarette butts. The facility's policy required staff to enforce proper disposal of smoking materials and monitor compliance, but this was not being done, resulting in a failure to maintain a safe environment in the designated smoking area.
Unqualified Culinary Services Director Overseeing Nutrition Services
Penalty
Summary
The facility failed to ensure that, in the absence of a full-time registered dietician (RD), the culinary services director (CSD) was certified to oversee nutrition and food services. The CSD had been in the role for two years but was not a certified dietary manager (CDM) and had not completed the required course, only enrolling in it after the survey began. The part-time RD worked only one or two days a week and communicated with the CSD remotely, acknowledging that the CSD was inexperienced with resident clinical issues such as monitoring weights. The facility's job description for the CSD required graduation from or current enrollment in an approved culinary services course, which was not met at the time of the survey. This deficiency had the potential to affect all 45 residents receiving meals from the kitchen.
Improper Food Storage and Staff Hygiene Lapses Identified
Penalty
Summary
The facility failed to properly monitor and manage two resident-designated refrigerator/freezers used for storing food brought in from outside. During observations, multiple food items were found in both the North and South wing refrigerators and freezers that were either not labeled, not dated, or improperly stored, such as uncovered containers, items with no resident name or date, and perishable foods kept beyond the indicated time frame. The facility had posted signs with clear instructions for labeling and dating, but these were not consistently followed. Additionally, there was no assigned staff responsible for monitoring these refrigerators, and the responsibility was described as shared among all staff, resulting in lapses in compliance with storage protocols. Furthermore, a culinary services cook was observed transporting resident meals without a beard cover, despite having a full beard. Both the cook and the culinary services director were unaware of the requirement for beard restraints, and the facility's policy on employee hygiene and sanitary practices did specify the use of hair nets or beard restraints to prevent hair from contacting food, equipment, or utensils. The facility's policy on food brought in from outside did not address food stored for individual residents in common area refrigerators, contributing to the lack of oversight.
Failure to Ensure Proper PPE Use and Doffing for Resident on Covid-19 Precautions
Penalty
Summary
The facility failed to ensure that staff properly donned and doffed personal protective equipment (PPE) when caring for a resident who was under transmission-based precautions due to a positive Covid-19 diagnosis. Observations revealed that a nursing assistant entered the resident's room without wearing required eye protection, and there was no eye protection available on the PPE cart outside the room. Additionally, the nursing assistant removed all PPE, including the N95 mask, before exiting the room, contrary to CDC guidelines which require the respirator to be removed after leaving the room. Other staff, including an LPN and another nursing assistant, were also observed doffing all PPE, including the N95 mask, inside the resident's room and stated they were unaware of the correct procedure. Interviews with staff indicated a lack of awareness or recall regarding the proper sequence for doffing PPE, specifically the requirement to remove the N95 mask after exiting the room. The nurse manager acknowledged that the doffing instructions were posted but noted the print was small and staff might not notice them. The director of nursing and a regional nurse consultant confirmed that staff had been trained on donning and doffing procedures but expected adherence to proper protocols. The facility's policy, consistent with CDC guidelines, was available but not effectively implemented by staff during the observed incidents.
Failure to Offer or Document Pneumococcal Vaccination
Penalty
Summary
The facility failed to ensure that the pneumococcal (PCV20) vaccine was offered or administered to a resident as recommended by CDC guidelines. Review of the resident's records, including the facesheet, admission MDS, physician's orders, and care plan, showed no documentation that the PCV20 vaccine was offered or refused. The resident had a history of heart failure, muscle weakness, fatigue, obesity, and a past history of pneumonia, and required assistance with self-care due to weakness and visual impairment. During interview, the DON confirmed that the vaccine should have been offered to all residents and was unable to explain why this was missed for this resident. The facility's policy, updated in February 2024, states that all residents should be offered pneumococcal vaccines in accordance with CDC recommendations.
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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 Mankato
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Laurels Peak Care & Rehabilitation Center | 1.6 mi | ★★★★★ | 19 | 0 |
| Pathstone Living | 2.1 mi | ★★★★★ | 25 | 0 |
| Hillcrest Care & Rehabilitation Center | 3 mi | ★★★★★ | 5 | 0 |
| Benedictine Living Community Of St. Peter | 13.1 mi | ★★★★★ | 8 | 0 |
| Whispering Creek | 14.1 mi | ★★★★★ | 5 | 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.