Below average — CMS composite of the measures below.
The next survey window likely opens around February 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 Aftenro Home during CMS and state inspections, most recent first.
Controlled Substance Emergency Kit Not Counted at Shift Change: An RN showed an emergency kit in the med room containing multiple controlled substances that was locked in a cupboard, but it was not included in the shift change narcotic count. The RN stated the kit was swapped out weekly by pharmacy and only documented if used, and the ADON confirmed it was not reconciled at each shift change despite the facility policy requiring narcotics to be securely stored, accurately documented, and reconciled.
Food storage and beverage handling were deficient when an open, undated container of heavy cream was found in the kitchen, resident food was stored with ice packs in a beverage fridge, and milk and juice were placed on trays in hot carts without ice. Milk temperatures were measured at 50.7 F, 53.6 F, and 55 F, while beverage refrigerator logs were missing multiple entries. Surveyors also found open, undated juice containers and expired chocolate milk that had not been removed.
A facility failed to designate a qualified person to direct food and nutrition services when there was no full-time RD. The DM stated she did not have a CDM, the administrator confirmed she was not enrolled in the program, and the RD stated she handled quarterly resident reviews. A policy on dietary management qualifications was requested but not provided.
Failure to provide safe therapeutic diets and allergen controls: two residents with ordered diets and food restrictions were served items they could not eat or should not have received. One resident with DM and a fish allergy reported repeated fish exposure and no alternate menu, while another resident with CHF/CKD on a 2-gram sodium diet reported receiving sausage and peppers with no offered alternative. The DON, RD, and DM stated the facility relied on spreadsheets, tray tickets, and staff judgment rather than separate therapeutic menus or a reliable allergen-identification system.
Meals and snacks were not served according to resident needs and requests, and the facility did not ensure no more than 14 hours passed between dinner and breakfast without a substantial snack. Residents, including a diabetic resident needing a bedtime snack, reported that snacks were not routinely offered, requests were delayed or unmet, and staff were seen taking resident snacks. Committee minutes and staff interviews showed ongoing concerns about limited snack options, removal of soda and other items, and a lack of consistent snack service or resident access to preferred snacks.
The facility failed to ensure proper infection prevention practices during laundry handling and meal service. Staff gave conflicting statements about whether PPE gowns were required when sorting dirty laundry, with one housekeeper saying gowns were not required and the housekeeping supervisor saying gowns were only required for biohazard-marked bags, while the DON stated gowns and gloves should always be worn. During dining services, an NA delivered meal trays to residents without offering hand cleaning wipes or other hand-cleaning opportunities and did not sanitize hands between rooms, and another NA also delivered trays without providing wipes, stating she had not seen any available.
Delayed Follow-Up to Resident Council Concerns: The facility failed to timely address repeated resident council concerns about wheelchair cleanliness, a suggestion box, and food service issues. Resident council minutes showed the same topics were discussed across multiple meetings, including dirty wheelchairs, repetitive menus, too many carbs, inadequate diabetic snacks, meal timing problems, and food not being kept warm, while residents stated the issues kept getting put off and they did not feel they were getting answers.
Care Plans Not Updated for Wounds, High-Risk Medications, and Care Conferences: The facility failed to update a resident’s care plan for pressure ulcer and skin/wound interventions, including repositioning, skin checks, and management of hearing aids and glasses that were causing ear irritation. The facility also omitted care plan considerations for high-risk meds for two residents receiving multiple psychotropic, opioid, and antianxiety medications, despite CAA findings and monitoring orders. In addition, a resident did not have a required care conference scheduled after a significant change, and the SW and DON confirmed the conference was overdue.
Incomplete Comprehensive Care Plans for Sensory Needs and Triggered Care Areas: The facility failed to fully develop and update care plans for two residents. One resident with impaired cognition, hearing aids, and corrective lenses had no care plan focus for hearing, vision, communication, or device-related skin concerns, and the DON confirmed hearing was missed. Another resident with diabetes, CKD, depression, and other diagnoses had multiple MDS-triggered care areas, including mood, psychosocial wellbeing, psychotropic use, and pressure injury risk, that were not reflected in the care plan, and the DON confirmed the content had not been updated.
Unsafe Smoking Area and Inadequate Supervision: A cognitively intact resident with heart disease, HF, anticoagulant use, hyperlipidemia, nicotine dependence, and pain diagnoses was observed smoking in a garage used as the designated smoking area. She used a rusted can inside the garage to extinguish cigarettes and discard ashes, while the area contained numerous stored items and no visible fire extinguisher or fire blanket. The resident also had access to the coded entrance and left without disposing of her cigarette butt in the outside receptacle.
Two residents had quarterly MDSs with section C, the cognitive patterns section, left unassessed. Their EMRs did not include a progress note explaining the incomplete section, and an RN confirmed the omissions during interview.
A resident with DM and intact cognition experienced significant unplanned weight loss while repeatedly reporting poor intake, disliked meals, missing snacks, incorrect food items, and dietary errors despite documented food preferences and allergies. The RD later documented a 37-lb. loss in 6 months, and facility records showed ongoing complaints about repetitive menus, lack of diabetic snacks, spoiled milk, and fish or Caesar salad being served despite the resident’s stated restrictions and preferences.
Resident rights notices were not kept current and were not being reviewed with residents during council meetings. A resident rights poster by the elevator was dated December 2015 even though the federal and state rights form had been updated, and the SW stated the admission packet still contained a December 2017 version. The resident council reported staff had not reviewed resident rights at meetings for about a year.
A facility failed to make resident trust funds readily available on evenings and weekends for most residents reviewed. Several cognitively intact residents said they had to wait for the business office to open to get money, and some did not know how to access their accounts after hours. The BOM initially said money was only available during business hours, while later identifying a cash box in the med room for after-hours access; however, nursing staff were unaware of the process and the receipt book showed no recent use.
The facility lacked a comprehensive infection prevention and control program with an annual review, affecting all 54 residents. The provided document was only a policy manual, not a full program. Interviews with the DON and ADON confirmed the absence of an annually reviewed program, highlighting the need for formal procedures to manage infection risks.
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails, potentially affecting all residents using beds. Interviews revealed that while assessments were conducted when a resident requested a side rail, there was no routine inspection program. Maintenance confirmed they did not perform regular checks, and the director of nursing acknowledged this gap. Despite a policy requiring routine checks, maintenance records were not provided, leading to the deficiency.
The facility failed to develop comprehensive care plans for two residents, leading to deficiencies in addressing their specific medical needs. One resident's care plan did not adequately address diabetic care, despite fluctuating blood sugar levels, while another resident's plan lacked details on assistance needed for ADLs. The DON confirmed the care plans were incomplete, contrary to the facility's policy for person-centered care.
A resident with severe cognitive impairment and multiple diagnoses experienced a significant weight loss of 9.4 pounds in one month, dropping from 173 to 163.6 pounds. Despite the care plan's directive to notify the RD and provider with significant weight changes, there was no follow-up nutritional assessment or intervention documented. Interviews with staff revealed a failure in communication and follow-up, as the resident's significant weight loss was not addressed with appropriate interventions or reassessment.
The facility exceeded the acceptable medication error rate with a 6.7% error rate during medication passes involving two residents. One resident with acute respiratory failure did not rinse their mouth after using a Symbicort inhaler, and another with COPD drank water instead of rinsing after using a Wixela inhaler. The TMAs involved were either inconsistent or unaware of the proper procedure.
Two residents with diabetes were not provided with their prescribed therapeutic diets, leading to inappropriate meal service. Staff were unclear about dietary codes and failed to follow meal tickets, resulting in residents receiving regular meals instead of consistent carbohydrate diets. Observations and interviews revealed a lack of understanding and communication among dietary staff regarding the dietary needs of diabetic residents.
Controlled Substance Emergency Kit Not Counted at Shift Change
Penalty
Summary
The facility failed to ensure the narcotic emergency kit was tracked to prevent potential theft and diversion of medications. During a tour of the locked medication room, an RN showed an emergency kit containing controlled substances that was locked in a cupboard with a plastic numbered lock. The RN stated the kit was swapped out weekly by pharmacy, that if it was used staff would complete a slip identifying what was used and for which resident, and that the kit was not included in the shift change narcotic count. The kit contained hydrocodone/APAP 5/325 mg, hydromorphone 2 mg, oxycodone 5 mg, tramadol 50 mg, morphine oral solution 20 mg/mL, oxycodone/APAP 5-325 mg, and lorazepam 0.5 mg. The ADON later verified that the emergency kit was not part of the controlled substance count at each shift change and stated there was potential for diversion by not accounting for the kit at each shift change. The facility policy stated narcotics would be securely stored, accurately documented, and reconciled at each shift change.
Food Storage, Dating, Temperature Control, and Expired Item Monitoring Deficiencies
Penalty
Summary
The facility failed to ensure potentially hazardous food was dated when opened and stored at safe temperatures when served to residents. During observation, an open and undated partially full container of Prairie Farms heavy cream was found in the main kitchen walk-in cooler, and the dietary manager stated milk should be dated when opened. At the second-floor beverage station, a small refrigerator and freezer contained resident food along with an ice pack in the freezer, despite a sign on the refrigerator door stating it was for labeled food only and no ice packs. Ice packs were also observed in the conference room freezer. The facility also failed to ensure resident food was properly monitored and removed when expired. Milk and juice cartons were brought to the dining area without ice and placed on trays in hot carts while plated food was being loaded for delivery to the floors. Temperatures taken from milk on a table and in hot carts were 50.7 degrees F, 53.6 degrees F, and 55 degrees F. In addition, temperature logs for beverage refrigerators on the second and third floors were missing entries for 3/7, 3/8, 3/14, and 3/15/26. Observations also found an open and undated partially full container of orange juice, one-percent chocolate milk expired on 3/15/26, and four open, undated partially full containers of juice. The dietary aid stated expired items should be removed, and the policy required food to be stored and handled according to Minnesota Food Code requirements.
Unqualified Food and Nutrition Services Leadership
Penalty
Summary
The facility failed to designate a qualified person to serve as the director of food and nutrition services in the absence of a full-time registered dietician. During interview, the dietary manager stated she did not have a certified dietary manager certificate and did not think anyone at the facility did, although the dietician was present several times a month. The administrator stated the dietary manager did not have a CDM certificate and was not yet enrolled in the program, though she had previously worked in that role at another facility, and also noted she had a food safety manager training certificate of completion dated 2/26/24. The registered dietician stated she was aware the dietary manager did not have a CDM and that she handled the quarterly resident reviews. A policy regarding dietary management qualifications was requested but not received.
Failure to Provide Safe Therapeutic Diets and Allergen Controls
Penalty
Summary
The facility failed to ensure a reliable system for identifying ingredients containing food allergens and failed to ensure residents were not served items they were allergic to. R5 had intact cognition, diabetes mellitus, unplanned weight loss, and needed set-up assistance with eating. His care plan included dietary consultation, monitoring of nutritional regimen, and later added monitoring for dysphagia and signs of malnutrition. R35 had intact cognition, hypertensive heart failure, chronic kidney disease with kidney failure, congestive heart failure, and needed set-up assistance with eating. Her provider ordered a 2-gram sodium restricted diet, and her care plan identified the need for that diet and assistance with eating. R5 stated he was allergic to fish and reported that the facility kept sending fish to him. He showed pictures of a lettuce salad with dressing and said it was Caesar salad that he could not have because of the dressing, and he reported that he had once been served tuna fish. He said he usually called the kitchen on days fish was served to ask for a burger and stated the facility did not have an alternate menu. The dietary door posted the weekly menu and noted alternative meal options were available if the kitchen was called two hours before the meal. R35 stated there were no options if she did not like the main course and said she was sensitive to salt. She reported sending back a tray of sausage and peppers because she could not eat it due to the sodium and said staff did not offer an alternative. The administrator stated the facility did not yet have an always-available menu, and the DON stated the kitchen should send the therapeutic diet and that products containing fish should not be served to a resident with a fish allergy. The DM stated the facility did not have specific menus for diabetic and low sodium diets, used a spreadsheet for substitutions, and relied on staff to check tray tickets and make decisions about allergens, while the RD stated the menus were for a general diet and that preplanning would be expected for therapeutic diets.
Meals and Snacks Not Provided in Accordance With Resident Needs
Penalty
Summary
Meals and snacks were not served in accordance with residents’ needs, preferences, and requests, and the facility did not ensure no more than 14 hours passed between dinner and breakfast without offering a substantial snack. The dining room meal service schedule listed breakfast from 7:30 a.m. to 8:15 a.m., lunch from 11:30 a.m. to 12:15 a.m., and dinner from 5 p.m. to 5:45 p.m., with residents instructed to be present during scheduled service times or a tray would be sent to their room. The administrator stated the facility was in the process of changing mealtimes so they could be within the 14 hours, indicating the current schedule did not meet that standard. Food committee and resident council minutes showed repeated resident concerns about snacks, including diabetic snacks, bedtime snacks, midnight snacks, and requests for more substantial options between dinner and breakfast. Residents reported staff were seen helping themselves to resident snacks, and concerns were raised that snack requests were not being met. Minutes also documented that the facility removed soda and unhealthy snacks, limited soda to special events or sale in the country store, and planned to provide only certain snack items such as sandwiches, fruit, vegetables, and later a list of packaged snacks at nurse stations. Residents continued to state the snack situation still needed to be remedied and that the administrator’s presence was needed at food committee meetings because nothing got done otherwise. During interviews, the dietary manager stated meals were delivered to the upper floors before dining room service began. A resident who was diabetic stated he needed a bedtime snack and there were no snacks out anymore. A TMA stated snacks were not specifically offered, but residents knew they could ask for them, and some diabetics received an extra sandwich at dinner. Another resident stated no one had ever gone around offering snacks and that even when asked, staff took a long time to check for one. The RD stated she had only recently learned of dissatisfaction with snacks and said residents needed snacks they wanted, including protein and milk for low blood sugars. A policy on timing of meals and snacks was requested but not received, and January 2026 food committee minutes were also requested but not received.
Laundry Handling and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to ensure proper measures were in place for handling resident and facility laundry. During a tour of the laundry area, dirty resident and facility laundry was observed entering through the laundry chute and being sorted by color and type. A housekeeper stated staff had been trained to wear eye protection if they had to rinse laundry, to wear gloves when sorting laundry, and to follow proper times for hand sanitizing, but said they had not been told to wear a PPE gown when sorting laundry. Another housekeeper stated they always wore gloves when sorting laundry and pointed to a single rolled-up PPE gown in a cabinet, stating they sometimes wore it for urine-soaked linen. The DON stated staff should always wear a PPE gown and gloves when sorting laundry, while the housekeeping supervisor stated gowns were required only for laundry bags marked with a biohazard sticker and were optional for general dirty laundry.
Delayed Follow-Up to Resident Council Concerns
Penalty
Summary
The facility failed to provide timely follow up to resident suggestions brought forward through resident council meetings. Resident council minutes documented repeated discussion of ongoing concerns, including wheelchair cleanliness, a suggestion box for resident feedback, and multiple food service issues such as too many carbohydrates, repetitive menus, pre-packaged foods, inadequate diabetic snacks, meal timing problems, food not being kept warm, and wrong orders. The minutes also reflected repeated follow-up items over several meetings, including wheelchair cleaning and the suggestion box, with the administrator and dietary manager noted as responsible for follow-up. During interview, the resident council stated that certain issues were brought up every month but kept getting put off, including the suggestion box, wheelchair washing, and food concerns. The council explained that the suggestion box was intended for residents who wanted to provide input but did not attend meetings, and that wheelchair washing was requested because wheelchairs appeared dirty and the facility could make a routine schedule for cleaning them. The resident council stated they did not feel they got answers and were not sure what the holdup was. A social worker stated progress had been made with the suggestion box because one had been ordered, and that maintenance and housekeeping had been working on clearing space for wheelchair washing.
Care Plans Not Updated for Wounds, High-Risk Medications, and Care Conferences
Penalty
Summary
The facility failed to revise care plans for skin and wound care interventions for a resident who was at risk for and had actual pressure ulcers. R8’s admission MDS identified impaired cognition, hypertension, hemiplegia, protein-calorie malnutrition, general weakness, reduced mobility, and dependence for all ADLs, transfers, and locomotion. A CAA worksheet identified R8 as at risk for impaired skin integrity due to urinary incontinence, impaired mobility, ambulatory dysfunction, impaired cognition, and chronic disease process, with a Braden score of 15. A later significant change MDS identified R8 as at risk for and having an actual stage three pressure ulcer. R8’s care plan, last updated on 4/3/25, included a self-care deficit focus with two staff needed for moving legs, turning, repositioning, boosting, transfers, incontinent care, and clothing adjustment, but it did not identify a frequency for incontinent care or repositioning. It also did not include routine skin monitoring by a licensed nurse, monitoring for the area under the glasses and hearing aid wires, or interventions for managing refusals of care, removing hearing aids, or removing glasses. The record also included a progress note identifying a sore on the top of R8’s ear, an order to encourage repositioning every two hours, a later order to place Band-Aids on the right ear before hearing aids, and an order to leave hearing aids out until directed by hospice RN. During observation, R8 was not wearing hearing aids and had difficulty hearing, and the spouse stated the hearing aids were likely being withheld because of a sore on the ear from the glasses and hearing aid wire rubbing. RN and DON interviews confirmed the hearing aids were not being placed because of the sore and that the issue had been missed in care planning. The facility also failed to include care plan considerations related to high-risk medications for two residents. R4’s MDS identified use of antipsychotic, antidepressant, antianxiety, and opioid medications, and the order summary included multiple psychotropic and pain medications along with monitoring orders for opioid side effects, risk for harm to self, psychotropic side effects, and oversedation. Although R4’s CAA checked psychotropic drug use as a care plan consideration, the care plan did not include any high-risk medication interventions. R12’s MDS identified use of antianxiety, antidepressant, diuretic, opioid, and anticonvulsant medications, and the order summary included monitoring for opioid side effects and psychotropic medication side effects along with several psychotropic and pain-related medications. R12’s CAA also checked psychotropic drug use as a care plan consideration, but the care plan did not include any considerations or interventions related to psychotropic, opioid, or antianxiety medications. RN-B stated the care plans were missing information on high-risk medications, and the DON stated care plans should be updated quarterly with every care conference. In addition, the facility failed to ensure a care conference was scheduled for R6 after a significant change. R6’s significant change MDS identified cognitive intactness and diagnoses including diabetes, atherosclerotic heart disease, chronic kidney disease stage 4, major depression, and hypertension. The EMR lacked evidence of a care conference in conjunction with the significant change MDS, and the most recent documented care conference was 11/26/25. The resident stated they could not recall attending or being invited to a meeting about care or the care plan. The SW stated care conferences were scheduled quarterly, for significant changes, and as needed, but R6 did not have one scheduled and was overdue. The DON stated care conferences were required with quarterly and/or significant changes, and the facility policy directed care conferences to be conducted quarterly if possible, with annual MDS assessments, within 14 days of a significant change, and within seven days of admission.
Incomplete Comprehensive Care Plans for Sensory Needs and Triggered Care Areas
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for R8’s sensory losses and devices, including the potential for skin impairment related to devices. R8’s admission MDS identified moderately impaired cognition, hearing with hearing aids, clear speech, the ability to make himself understood, and the use of corrective lenses. However, the care plan dated 4/3/25 did not contain a focus statement for communication, hearing, vision, hearing aids, or glasses. Although the care plan identified R8 as at risk for skin impairment, it did not include interventions for routine skin inspections by a licensed nurse, guidance for assisting with routine removal of devices, or direction for addressing refusal of device removal. During interview, the DON stated R8 did have hearing aids and confirmed hearing was not included in the care plan and was likely missed in the facility’s process. The facility also failed to update and incorporate significant change MDS triggered care areas into R6’s comprehensive care plan. R6’s significant change MDS identified diagnoses including diabetes, atherosclerotic heart disease, chronic kidney disease stage 4, major depression, and hypertension, and Section V indicated triggered care areas for mood state, psychosocial wellbeing, functional status, psychotropic drug use, functional abilities/self-care, nutritional status, urinary incontinence, and pressure ulcer/injury risk. At the time of facility entrance, R6’s care plan had target goal dates in May and August 2025 for all focus areas except nutrition, but it did not address pressure wound prevention, mood, psychotropic meds, or psychosocial wellbeing. The care plan also had not been updated to reflect changes in R6’s lower extremities and resulting changes in abilities. The DON stated care plans were updated as needed and at quarterly or significant change care conferences, but confirmed the content of R6’s care plan had not yet been updated.
Unsafe Smoking Area and Inadequate Supervision
Penalty
Summary
The facility failed to ensure a safe smoking area and adequate supervision for a resident who smoked. R46’s quarterly MDS identified diagnoses including heart disease, low back pain, left knee pain, heart failure, anticoagulant use, hyperlipidemia, nicotine dependence, and cognitive intactness. Her care plan stated she had chosen to smoke despite the risks to her health, that staff would educate her on smoking only in the designated area, and that a smoking assessment would be completed quarterly to include the ability to light, smoke, and discard cigarettes safely. During observation, R46 went to smoke, returned through a coded door she said she knew how to use, and later was observed smoking in the garage area designated for smoking. The smoking area in the garage contained multiple chairs, a stool with a rusted number ten can holding cigarette butts, and a lighter on the stool. R46 was observed using the can to dispose of ashes and to extinguish cigarettes, and she lit and smoked multiple cigarettes during the observation. The garage also contained numerous stored items including wheelchairs, machinery, air conditioners, boxes, furniture, carts, chairs, Christmas lights, shovels, and other items, and there was a staircase to an upper level. The administrator stated the area had become the smoking area after staff and residents used it, was unsure whether combustible items were present or whether a fire extinguisher or fire blanket was available, and later confirmed the area was too cluttered with flammable items and did not have a fire extinguisher or fire blanket. R46 left the area without placing her cigarette butt into the outside receptacle.
Incomplete MDS Cognitive Assessments
Penalty
Summary
The facility failed to ensure that all sections of the minimum data set (MDS) were completed for 2 of 4 residents reviewed for MDS accuracy. Section C of the MDS, which addresses cognitive patterns and includes staff assessment of mental status and signs and symptoms of delirium, was not assessed on the quarterly MDS for two residents. For both residents, the electronic medical record did not contain a progress note explaining why section C was incomplete. During an interview, the RN reviewed section C for both residents and confirmed that they were not assessed, stating that a note should be made in the chart when something is not assessed.
Failure to Maintain Nutritional Status Amid Significant Weight Loss
Penalty
Summary
The facility failed to ensure a resident maintained acceptable nutritional status when he experienced significant unplanned weight loss while repeatedly expressing dissatisfaction with meals, dietary restrictions, and snack availability. The resident had diabetes mellitus, intact cognition, and required set-up assistance with eating. His care plan included dietary consultation, discussion of mealtimes and dietary restrictions, offering substitutes for foods not eaten, and later monitoring for dysphagia and signs of malnutrition. The resident’s weights declined from 273 lbs. to 263 lbs., then to 246.7 lbs., 236 lbs., and later 235 lbs., with the RD documenting a 37-lb. loss or 13.5% in six months and identifying the loss as significant. The resident repeatedly reported that he was not eating because the food was terrible, that he had not had anything to eat in over a week, that he hated the food, and that he was upset about being served tuna fish despite a fish allergy and about not receiving the juice he preferred. He also stated that he was tired of the rotating menu, that the same foods were served often, that processed chicken was frequently provided, and that he was not receiving the snacks he needed as a diabetic. He described receiving incorrect or spoiled items, including milk that tasted sour, and reported that Caesar salad was served with dressing already on it despite his inability to eat it. He also stated that he had to keep frozen dinners, naan bread, condiments, and protein supplement drinks in his room because he did not want to eat the facility food. Facility records showed repeated resident complaints about food, snacks, soda access, menu repetition, and dietary accuracy. Food committee and resident council minutes documented concerns about snack availability, diabetic snacks, repetitive menus, undercooked vegetables, and discrepancies in item delivery to the floors. The resident’s dietary ticket listed multiple restrictions and preferences, including shellfish allergy, seafood allergy, no fish, and a request for hamburger instead of soup, yet the record also reflected ongoing complaints that fish and other unwanted items were still being sent. A dietary review was not found in the record for an extended period despite the resident’s ongoing weight loss and repeated dissatisfaction with intake-related issues.
Resident Rights Notice Not Kept Current
Penalty
Summary
The facility failed to ensure resident rights were current and provided to residents on admission and during their stay. The Combined Federal and State [NAME] of Rights for residents in nursing facilities or skilled nursing facilities had been updated effective 1/1/26, but during an observation on 3/18/26 a resident rights poster posted by the first floor elevator was dated December 2015. During an interview, the resident council stated staff had not reviewed resident rights at resident council meetings for about a year, although the rights were posted on the wall by the elevator. Social worker A stated new residents were given the bill of rights at admission and showed a Combined Federal and State [NAME] of Rights form dated December 2017 as the version currently in the admission packet, and also stated resident rights had not been reviewed at resident council but would be restarted as they had been in the past.
Resident Trust Funds Not Available After Hours
Penalty
Summary
The facility failed to have appropriate funds available for Medicare/Medicaid residents on the evening shift and weekends for 7 of 8 residents reviewed for personal funds, including residents who were cognitively intact. Interviews with residents showed they understood their money was held in the facility’s trust account, but several stated they would need to wait for the business office to open to access it, and some were unsure how to obtain money after hours or on weekends. One resident stated they could not get their money on the weekend because it was kept in the business office, and another stated they had no idea how to get any of the money in the account. The business office manager stated residents needed to come to the business office Monday through Friday between 8:00 a.m. and 4:30 p.m. to remove money from their personal accounts, and that after-hours requests were handled by staff leaving a note for later processing. Later, the business office manager stated there was a process for after-hours and weekend access and identified a cash box in the medication room with $80.00, but the charge nurse and other nursing staff were unaware of this process. The charge nurse found the cash box locked in the medication room and the receipt book showed the last sign-out was on 7/2/22. The social worker stated the trust account information was discussed verbally before admission, on admission, and at the first care conference, but the admission folder contained no written information about the trust account or how to access the money.
Inadequate Infection Control Program
Penalty
Summary
The facility failed to develop an infection prevention and control program with an annual review, which included written standards, policies, and procedures. These procedures should have specified when and to whom possible incidents of communicable diseases or infections should be reported, as well as when and how transmission-based precautions (TBP) and enhanced barrier precautions (EBP) should be implemented to prevent infections. Additionally, the program should have included hand hygiene procedures for staff involved in direct resident care. This deficiency had the potential to affect all 54 residents residing in the facility. During the survey, the infection control program was requested, and a document titled 'Nursing Services Policy and Procedure Manual for Long-Term Care Infection Control' dated 10/2023 was provided. However, this document was merely a policy and procedure manual, not a comprehensive infection control program. Interviews with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) confirmed that they did not have an infection control program that was reviewed annually. The DON acknowledged the absence of a formal written program for infection control and recognized the benefit of such a program in identifying necessary changes for infection prevention on a yearly basis.
Failure to Conduct Regular Bed Inspections
Penalty
Summary
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails, which could potentially affect all residents using beds. Interviews revealed that while the assistant director of nurses (ADON) involved physical therapy and conducted assessments when a resident requested a side rail, there was no clear responsibility for regular inspections. The registered nurse (RN-B) responsible for assessments followed FDA guidelines but only involved maintenance if issues were identified. Maintenance worker (MW-A) confirmed that they assembled beds and performed initial measurements but did not conduct routine inspections. The director of nursing (DON) acknowledged the absence of a routine inspection program for beds, and the administrator recognized the importance of such a system to prevent entrapment. Despite a policy in place for monitoring and evaluating side rail use, which required routine checks, maintenance records for bed inspections were not provided. This lack of a systematic approach to inspecting and maintaining beds led to the deficiency identified by the surveyors.
Deficiencies in Comprehensive Care Planning for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, leading to deficiencies in addressing their specific medical needs. For one resident, identified as R32, the care plan did not adequately address diabetic care despite the resident's diagnosis of diabetes mellitus and fluctuating blood sugar levels. The resident's care plan, last revised in September 2024, focused on nutritional issues but lacked specific interventions for managing diabetes, such as monitoring blood sugar levels and responding to high or low readings. The Director of Nursing (DON) confirmed that the care plan should have included directions for diabetes care to alert staff to the signs and symptoms of blood sugar fluctuations. Another resident, identified as R17, had a care plan that failed to specify the level of functioning, assistance needed for activities of daily living (ADLs), or the number of staff required to assist. This resident had diagnoses including hemiplegia, hemiparesis, type 2 diabetes mellitus, and congestive heart failure, which necessitated detailed care planning to address ADL deficits. The DON acknowledged that care plans are typically reviewed quarterly but was unsure how R17's care plan was incomplete. The facility's policy emphasizes the importance of comprehensive, person-centered care plans, yet these deficiencies indicate a failure to adhere to this policy, resulting in inadequate care planning for the residents involved.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to comprehensively reassess and develop interventions to address continued weight loss for a resident with severe cognitive impairment and multiple diagnoses, including dementia, chronic kidney disease, and type 2 diabetes mellitus. The resident's care plan, last revised in November, identified a potential nutritional problem with a goal of maintaining weight within 5% of 178 pounds. However, the resident experienced a significant weight loss of 9.4 pounds, or 5.4%, in one month, dropping from 173 pounds to 163.6 pounds. Despite the care plan's directive to notify the registered dietician and provider with significant weight changes, there was no follow-up nutritional assessment or intervention documented after the resident's weight loss. Interviews with facility staff, including nursing assistants and the director of nursing, revealed that while weights were recorded in the resident's chart, there was an expectation to notify the provider of significant weight changes. However, the deficiency indicates a failure in communication and follow-up, as the resident's significant weight loss was not addressed with appropriate interventions or reassessment. The director of nursing confirmed the expectation for staff to notify the provider with significant weight changes, highlighting a lapse in the facility's protocol to ensure the resident's nutritional needs were met.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 6.7 percent. This was observed during medication passes involving two residents. The first resident, with a diagnosis of acute respiratory failure with hypoxia, was observed taking two puffs of Symbicort inhaler close together without rinsing their mouth afterward, as per the provider's order. The trained medication aid (TMA) stated that the resident sometimes rinsed their mouth, indicating inconsistency in following the prescribed instructions. The second resident, diagnosed with chronic obstructive pulmonary disease (COPD), was observed taking one puff of Wixela inhaler and then drinking water instead of rinsing their mouth as required. The TMA involved was initially unaware of the need to rinse the mouth after using the inhaler, only confirming the requirement after reviewing the order. The assistant director of nursing (ADON) expressed that it was expected for TMAs to encourage residents to rinse their mouths to prevent complications. The facility's policy on inhaled medication administration was requested but not provided.
Failure to Follow Therapeutic Diets for Diabetic Residents
Penalty
Summary
The facility failed to ensure that therapeutic diets prescribed by physicians were followed for two residents, both of whom had specific dietary needs due to their medical conditions. One resident, who was cognitively intact and had diabetes mellitus, was not receiving the prescribed consistent carbohydrate diet. Despite having active orders for a specific diet and insulin regimen, the resident reported receiving meals similar to those of other residents, which did not align with her dietary needs. Observations confirmed that her meals included items not suitable for a diabetic diet, such as regular dressing and ice cream, and her meal ticket was marked with a diet code that was not understood by the staff. Another resident, also cognitively intact and with a history of diabetes and chronic kidney disease, was not receiving the consistent carbohydrate diet as ordered. This resident reported having to self-regulate her diet due to fluctuations in blood sugar levels. Observations showed that her meals included high-carbohydrate items like regular jello and juice, which were not sugar-free, contrary to her dietary requirements. The dietary staff, including dietary aides and cooks, were unclear about the dietary codes and did not consistently follow the meal tickets, leading to the residents receiving inappropriate meals. Interviews with various staff members, including dietary aides, cooks, and the registered dietician, revealed a lack of understanding and communication regarding the dietary needs of diabetic residents. The dietary manager and administrator acknowledged the expectation that therapeutic diets should be followed based on orders, but there was no consistent practice in place to ensure this. The facility's dietary management system lacked clear definitions for the diet codes used, contributing to the confusion and failure to provide appropriate meals for residents with specific dietary needs.
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Nursing homes near Duluth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Benedictine Health Center | 0.4 mi | ★★★★★ | 23 | 2 |
| Hilltop Healthcare Rehabilitation And Skilled Nurs | 1.7 mi | ★★★★★ | 17 | 0 |
| Ecumen Lakeshore | 2.4 mi | ★★★★★ | 8 | 0 |
| Bayshore Residence And Rehabilitation Center | 3.3 mi | ★★★★★ | 2 | 0 |
| Viewcrest Health Center | 3.9 mi | ★★★★★ | 0 | 0 |
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