Below average — CMS composite of the measures below.
The next survey window likely opens around December 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 Aicota Health Care Center during CMS and state inspections, most recent first.
Unsafe milk temperatures and missing hair restraints were observed during meal service. Milk and half and half were left on a serving table without ice and were measured above safe temperatures, while a cook worked without a hair net and a culinary supervisor with a full beard worked without a beard net. Staff used the milk to prepare beverages for residents before it was found to be too warm.
The facility inaccurately submitted PBJ staffing data to CMS, showing no RN hours and no 24-hour licensed nursing coverage on multiple days even though payroll documentation showed an RN and licensed nursing coverage were present. The DON stated the facility had difficulty accessing the program, submitted a file that was formatted incorrectly, and missed the deadline because of the Eastern time zone.
The facility failed to ensure agency nursing staff received proper orientation, training, and supervision. Surveyors found multiple agency orientation forms incomplete, altered, or missing required signatures, and five agency staff had no orientation paperwork available. Agency staff reported they were given assignments without orientation, and some said they were told to sign or back date forms. The SC, RN, and DON gave inconsistent accounts of who was responsible for orientation, and no agency orientation policy was provided.
Failure to honor a resident’s meal preferences: A cognitively intact resident with multiple chronic conditions was served lunch without being asked what she wanted or offered an alternative, and she stated she received food she did not like. Records reviewed showed likes and dislikes were not documented on the care plan, Kardex, meal ticket, or kitchen meal distribution report, and staff confirmed the menu was posted outside the dining room while residents were expected to tell nursing staff their choices.
A resident with ESRD, kidney transplant rejection, and respiratory failure had a care plan focused on dialysis-related complications, but it did not include post-dialysis assessment instructions or documentation needs. The EMR also lacked documentation of the resident’s return from dialysis and post-treatment assessment, despite orders for AV fistula checks every shift and daily dialysis treatments. An RN manager confirmed the care plan did not include post-dialysis assessments.
Failure to Follow Bowel Protocol: A resident with dementia, constipation, and bowel/bladder incontinence did not have the ordered bowel protocol followed when no BM was documented for several days. The bowel report and charting showed no BM documentation, no bowel-related progress notes, and PRN bowel meds were not given until after staff interviews, despite the resident’s standing bowel orders and the facility’s PM-shift bowel report process.
A resident who was cognitively intact and frequently incontinent of bladder was not toileted timely and was observed wet while waiting for help. Her care plan and Kardex identified her as needing a 2-person assist with Hoyer lift transfers for toileting, but she reported staff often did not offer toileting every few hours and that call lights could take up to 30 minutes to be answered. Staff described staffing and timeliness issues, and the DON stated wet residents should receive toileting assistance in about 10 minutes.
A resident with ESRD and dependence on renal dialysis returned from offsite dialysis without documented post-dialysis vital signs, assessment, or fistula status in the EMR. The resident said the facility did nothing after dialysis, while staff described using a communication binder with the dialysis center and checking vitals and the fistula, and the DON stated those findings should have been charted. RN-A also noted the care plan did not include post-dialysis assessments.
Daily nurse staffing information was posted in a format that was not clear to residents and visitors. The posting listed RN, NAR, LPN, and NAIT staffing, but the shift times and totals were mixed together for the 24-hour period rather than shown by shift. A visitor and resident said they could not understand the abbreviations or tell how many staff were working each shift, and the DON stated the posting had all required elements.
The facility did not submit staffing data for two quarters to CMS as required. The DON was unaware of the failure until an internal audit revealed that an incorrect data file had been used for submission.
The facility failed to provide a surety bond to protect resident trust funds, affecting all 26 residents with trust accounts. Key staff responsible for managing the trust fund were either unaware of the bond or unsure of its details. A surety bond was eventually provided, but there was no evidence of a bond effective before the current one. The facility's policy did not address surety bonds.
The facility failed to ensure accurate MDS assessments for 35 residents, with incorrect documentation of restraint use despite being a restraint-free facility. Additionally, several residents' assessments lacked required BIMS scores, indicating incomplete cognitive evaluations.
The facility failed to conduct required in-person regulatory visits, opting for telehealth instead, affecting 33 residents with various medical conditions. This practice began in August 2024 with the Twin Cities Physician Group, despite a CMS memo prohibiting telehealth for such visits. The facility's policy did not address the federal requirement for in-person visits.
A facility failed to ensure non-pharmacological interventions were attempted before administering psychotropic medications to a resident with multiple diagnoses, including anxiety and hallucinations. The resident's care plan lacked evidence of such interventions, and staff interviews revealed inconsistent documentation and attempts of non-pharmacological measures. The Director of Nursing confirmed the absence of documentation, despite facility policy requiring these interventions before PRN psychotropic medication administration.
The facility failed to ensure PRN psychotropic medication orders were time-limited to 14 days for two residents. One resident, who was cognitively intact, had no documented review of their PRN Ativan order for several months, while another resident with severe cognitive impairment had a PRN lorazepam order with no end date. The facility's policy required a 14-day review, but this was not adhered to, as confirmed by the DON.
Unsafe Milk Temperatures and Missing Hair Restraints During Food Service
Penalty
Summary
The facility failed to ensure milk products were served at safe temperatures for consumption. During observation in the dining room, a partially full gallon of milk and a quart of half and half were left on a serving table without ice while residents were still eating. A dietary aide later checked the milk at 42 degrees F and the half and half at 64 degrees F. The dietary aide stated the milk and creamer should be at 41 degrees F or lower and that the normal practice would be to place them back in the refrigerator between uses. The facility also failed to ensure staff preparing food had proper hair restraints in place. During the breakfast and lunch observations, a cook was working behind the steam table without a hair net, and a culinary supervisor with a full beard of about one inch in length was dishing up plates without a beard net. Milk remained on the serving table during the lunch meal, and staff used the milk to prepare chocolate milk and serve residents. The culinary supervisor later checked the milk temperature at 55 degrees F and stated it was too warm and should be thrown out. The report identified residents with diagnoses including lung cancer, chronic kidney disease, atrial fibrillation, vascular dementia, hypertension, diabetes, COPD, anemia, Alzheimer's disease, and rheumatoid arthritis among those potentially affected.
Inaccurate PBJ Staffing Data Submission
Penalty
Summary
The facility failed to accurately submit PBJ staffing data to CMS based on payroll and other verifiable and auditable data. For the period reviewed, the PBJ data submitted to CMS identified multiple days with no RN hours and multiple days without licensed nursing coverage 24 hours a day, even though the facility was able to provide payroll documentation showing that an RN was present on those days and that licensed nursing coverage was available around the clock on those days. During an interview, the DON stated the facility was not able to get into the program at first, then received a username, but when the file was submitted it was formatted incorrectly. The DON stated they worked on trying to submit the data up until the deadline but missed it because of the time difference, as the program was based in the Eastern time zone.
Incomplete Agency Staff Orientation and Documentation
Penalty
Summary
The facility failed to ensure agency nursing staff received appropriate orientation, training, and supervision. Surveyors reviewed agency orientation paperwork and found multiple forms incomplete, altered, or lacking required documentation. Several staff records had blank sections, crossed-out dates, missing initials, or no completed-by information, and none of the orientation paperwork contained the orientation leader’s signature. Five agency staff hired between October and December 2025 had no orientation paperwork available at all. The facility’s scheduling coordinator stated she was responsible for agency orientation, that agency staff working off shift or weekends might only have a note left for someone to sign the paperwork, and that agency staff were expected to be competent and ready to start work. During interviews, agency staff reported they did not receive orientation or training when they started at the facility. One staff member stated they were just given an assignment and told to go, and another stated agency staff were being told to sign and back date orientation sheets or have their contracts cancelled. Another staff member stated they were made to sign orientation papers with a fake date, and others confirmed their paperwork had not been filled out, only signed. The RN stated agency staff had no official orientation role and were expected to come prepared to care for residents. The DON stated agency staff were expected to complete the paperwork, identified possible orientation leaders as a nursing assistant, a nurse, or the scheduling coordinator, and verified she was ultimately responsible for agency staff orientation. A policy on agency staff orientation was requested but not provided.
Failure to Honor Resident Meal Preferences
Penalty
Summary
The facility failed to facilitate resident preferences for meals for 1 of 1 resident reviewed for choices, R27. R27’s annual MDS identified diagnoses including atrial fibrillation, heart failure, gastroesophageal disease, depression, and COPD, and also identified her as cognitively intact and able to understand and be understood. Her care plan identified nutrition as a concern and directed staff to provide her ordered diet, note dislikes, encourage food choices at all meals, and provide snacks and supplements, but the care plan provided did not identify likes or dislikes. Documentation reviewed showed R27’s nursing assistant Kardex listed her as independent for eating but did not include likes or dislikes. Her meal ticket identified a regular texture and regular house diet, and the dislikes section was blank. The kitchen’s meal distribution report also listed R27’s regular diet and regular texture, but the dislikes section was left blank. The posted menu outside the dining room listed lunch and dinner items, but no alternatives were listed on the menu observed. During observation, staff brought R27 her lunch tray, and R27 stated she received brussel sprouts and did not like them. She also stated she did not have an opportunity to order her lunch and was not told what was for lunch or offered an alternative. Staff interviews indicated the menu was posted outside the dining room, residents needed to tell nursing staff their preferences, and the kitchen relied on nursing staff to communicate dislikes and alternatives. Multiple staff members verified R27’s dislikes were not documented and that she had not been asked about her lunch choice before the tray was delivered.
Care Plan Missing Post-Dialysis Assessment Instructions
Penalty
Summary
The facility failed to develop a person-centered care plan that included necessary post-treatment assessments and documentation needs for 1 of 2 residents reviewed for care planning. The resident had intact cognition and diagnoses of acute and chronic respiratory failure with hypoxia, kidney transplant rejection, end-stage renal disease, and dependence on renal dialysis. The care plan identified a focus on high risk of complications related to ongoing dialysis treatments, but it did not include instructions to assess the resident after dialysis for overall condition and status, vital signs, presence of thrill or bruit in the fistula, or the status of fistula dressings. Provider orders directed staff to check the AV fistula every shift and every day, and to provide dialysis on Mondays, Wednesdays, and Fridays with the resident ready at 7 a.m.; there was also an order for weight to be taken on bath day. The electronic medical record lacked documentation of the resident's return from dialysis and assessment after dialysis treatments. During interview, the nurse manager stated the care plan should have included post-dialysis assessments because they could help with early intervention for potential blood pressure issues, and confirmed the current care plan did not include this.
Failure to Follow Bowel Protocol
Penalty
Summary
The facility failed to follow the bowel protocol for a resident with severely impaired cognition, Alzheimer’s dementia, anxiety disorder, major depressive disorder, uterovaginal prolapse, and constipation. The resident’s MDS identified moderate assistance needs for bed mobility, transfers, and toilet hygiene, and also noted occasional bowel and bladder incontinence and participation in a toileting program. The care plan identified the resident as incontinent of bowel and bladder and needing one-person assistance to the toilet and incontinent care as needed, but it did not address constipation. The resident’s provider orders included a bowel movement protocol with prune juice, Senna, milk of magnesia, Dulcolax suppository, Fleet enema, and MiraLAX. The bowel report showed no documented bowel movement from 1/4 through 1/7/26, and progress notes for those dates did not include bowel documentation. The MAR did not show a PRN bowel medication given until after staff interviews, when Senna was administered on 1/7/26 and recorded as ineffective, followed by milk of magnesia on 1/8/26 and recorded as effective. Staff interviews indicated the PM shift was responsible for running the bowel report and giving PRN medication, and the DON stated alerts would appear if a resident had not had a bowel movement in more than 48 or 72 hours and that an assessment would be expected after several days without one.
Delayed Toileting Assistance and Incontinence Care
Penalty
Summary
The facility failed to ensure timely toileting for a resident who was cognitively intact, understood and could be understood, and who was identified on the MDS as frequently incontinent of bladder, occasionally incontinent of bowel, and dependent on staff for toileting hygiene. The resident’s care plan and nursing assistant Kardex identified her as continent with episodes of incontinence and requiring a two-person assist for toilet use, including Hoyer lift and medium sling transfers. During observation and interview, the resident stated she was wet, had told a male staff member who said he would get help, and reported that she often sat wet several times a day. She also stated staff did not come in every few hours to offer toileting and that her call light could take up to 30 minutes to be answered. The resident’s call light was observed on during the interview, and a male staff member later answered it, after which the resident again stated she was wet and still waiting for help. Two unidentified female staff then assisted her to the commode, and one staff member remarked it was often difficult to find two female staff for toileting assistance. Additional observations showed the resident being returned from activities and left waiting while staff said they would be right back, and later being gotten up late in the morning, which she said was later than her preferred time of 10:00 a.m. to 10:30 a.m. During interviews, staff stated they cared for about 27 residents with a partner or alone and were not always able to complete tasks timely, including toileting and getting residents up. The DON stated a resident identified as wet should receive toileting assistance in about 10 minutes and identified the concerns as dignity and skin breakdown and irritation.
Failure to Document Post-Dialysis Assessment and Fistula Monitoring
Penalty
Summary
The facility failed to provide safe, appropriate dialysis care for a resident who required ongoing renal dialysis. The resident had intact cognition and diagnoses including acute and chronic respiratory failure with hypoxia, kidney transplant rejection, end-stage renal disease, and dependence on renal dialysis. The care plan identified a high risk for complications related to ongoing dialysis and included interventions such as checking bruit and thrill every shift, avoiding lotion on the dialysis site, coordinating with the dialysis center, and using a dialysis binder for communication. Provider orders also required AV fistula checks every shift and dialysis on Mondays, Wednesdays, and Fridays, with the resident ready at 7 a.m. For dialysis treatment dates reviewed, the resident's EMR did not identify vital sign values, a progress note, or an assessment for the resident's return from dialysis. During interview, the resident stated the facility did not do anything after dialysis and described returning with the fistula bandaged by the dialysis center. Staff interviews indicated they used a communication book with the dialysis center, took pre-dialysis weight and vitals, and checked the fistula for a thrill, but the DON stated that vitals and site checks were done on return and should have been charted. The DON also stated the risks after dialysis could include bleeding or blood pressure issues, and RN-A stated the care plan should have included post-dialysis assessments, which it did not.
Daily Nurse Staffing Posting Was Not Clear
Penalty
Summary
The facility failed to ensure that the daily nurse staffing information was posted in a format that was clear to residents and visitors. On 1/8/26, surveyors reviewed the Daily Staffing Posting, which listed the date, facility name, census, and shift categories for RN, NAR, LPN, and NAIT, but the shift times and staffing totals were presented in a way that mixed multiple shifts together and totaled staff for the 24-hour period rather than by shift. During an interview, a visitor and resident reviewed the posting and stated they did not understand the abbreviations NAR or NAIT and could not tell how many or what staff were working on each shift without doing additional calculations. On 1/9/26, the DON stated the posting had all required elements, and a staffing policy was requested but not provided.
Failure to Timely Submit Staffing Data to CMS
Penalty
Summary
The facility failed to timely submit staffing data for two of the four quarters reviewed to the Centers for Medicare and Medicaid Services (CMS) as required. Specifically, for fiscal year 2024, quarters 1 and 2, no staffing data was submitted. During an interview, the Director of Nursing (DON) stated that it was their responsibility to send staffing data to CMS and was unaware of the submission failure until an internal audit revealed the issue. The DON identified that an incorrect data file had been used for the submission of staffing data.
Failure to Provide Surety Bond for Resident Trust Funds
Penalty
Summary
The facility failed to consistently provide a surety bond to protect the account balance of the resident trust fund, affecting all 26 residents with trust accounts. During interviews, the revenue cycle manager and business office manager, who were responsible for managing the resident trust fund account, were either unaware of the surety bond or unsure of its details. A surety bond from Merchants Bonding Company, effective from 1/1/25 to 1/1/26, was eventually provided, but there was no evidence of a surety bond effective prior to 1/1/25. The facility's policy on trust funds, dated 5/10/24, did not address the requirement for surety bonds.
Inaccurate MDS Assessments and Missing BIMS Scores
Penalty
Summary
The facility failed to ensure the accuracy and comprehensiveness of the Minimum Data Set (MDS) assessments for 35 out of 54 residents. Specifically, the MDS assessments for multiple residents inaccurately indicated the use of restraints in Section P, despite the facility's policy of being restraint-free. The Director of Nursing confirmed that no residents were using restraints, indicating a discrepancy between the facility's practices and the documented assessments. Additionally, the MDS assessments for several residents lacked the Brief Interview for Mental Status (BIMS) scores in Section C, which is required to assess cognition. The absence of BIMS scores was noted in the assessments of multiple residents, suggesting a failure to complete the cognitive section of the MDS assessments as required. The MDS coordinator was unavailable for an interview to provide further clarification on these discrepancies.
Failure to Conduct In-Person Regulatory Visits
Penalty
Summary
The facility failed to ensure that required face-to-face regulatory visits between residents and their doctors occurred, as mandated by federal regulations. Instead, the facility conducted these visits via telehealth for 33 out of 54 residents reviewed for compliance. This practice began in August 2024 when the facility switched to the Twin Cities Physician Group, which primarily used telehealth for regulatory visits. The facility's policy on telehealth, dated May 1, 2020, did not address the federal requirement for in-person visits. The deficiency affected residents with various medical conditions, including cognitive impairments, coronary artery disease, heart failure, atrial fibrillation, hypertension, dementia, and other serious health issues. These residents received telehealth visits on multiple occasions, with some having significant changes in their MDS assessments. The facility's director of nursing and the Twin Cities Physician Group's vice president of operations confirmed the use of telehealth for these visits, believing them to be compliant with federal regulations. However, a CMS memo issued on April 7, 2022, clearly stated that long-term care regulatory visits could no longer be conducted via telehealth as of 30 days from the memo's issuance. Despite this, the facility continued to use telehealth for regulatory visits, leading to the deficiency. The medical director explained that a registered nurse was sent to the facility to operate telehealth equipment and perform necessary assessments, but this did not meet the requirement for in-person visits.
Failure to Attempt Non-Pharmacological Interventions Before Psychotropic Medication Administration
Penalty
Summary
The facility failed to ensure that non-pharmacological interventions were attempted prior to administering psychotropic medications to a resident, identified as R252, who was reviewed for psychotropic medication use. R252's admission Minimum Data Set (MDS) did not include a cognitive assessment, and the resident had active diagnoses including cerebrovascular accident, hemiplegia, anxiety, hallucinations, attention deficit disorder, and depression. The care plan for R252 included the use of anti-anxiety and sedative/hypnotic medications, but it lacked evidence of non-pharmacological interventions being attempted before administering as-needed psychotropic medications. The facility's Medication Administration Record indicated that R252 received multiple doses of psychotropic medications such as Haldol, lorazepam, and clonazepam between January 2 and January 17, 2025. However, there was no documentation to support that staff attempted non-pharmacological interventions before administering these medications. Interviews with nursing staff revealed that while they assessed residents before giving medications, there was no specific place to document non-pharmacological interventions, and such interventions were not consistently attempted or recorded. The Director of Nursing (DON) confirmed that there was no documentation of non-pharmacological interventions being attempted prior to administering psychotropic medications to R252. The facility's policy on psychotropic medications required non-pharmacological interventions to be attempted before administering PRN psychotropic medications, but this was not adhered to in practice. The deficiency was identified through observation, interviews, and document review, highlighting a failure to comply with the facility's policy and regulatory requirements.
Failure to Review PRN Psychotropic Medications Every 14 Days
Penalty
Summary
The facility failed to ensure that PRN psychotropic medication orders were time-limited to 14 days for two residents. For one resident, identified as R29, the facility did not document a review of the PRN Ativan order between August 16, 2024, and November 15, 2024, nor was there a documented rationale for extending the order beyond 14 days. The resident, who was cognitively intact, had diagnoses including major depression and anxiety disorder. The hospice agency's order dated November 15, 2024, indicated a review in 60 days, but the facility's documentation lacked evidence of compliance with the 14-day review requirement. Another resident, identified as R42, had a PRN order for lorazepam with no end date, and the facility did not provide evidence of a 14-day review for continuation. This resident had severe cognitive impairment and multiple diagnoses, including PTSD, bipolar disorder, and dementia. The facility's policy required PRN psychotropic medications to be ordered for two weeks and re-evaluated if an extension was needed, but the facility did not adhere to this policy. The Director of Nursing confirmed the lack of evidence for the required reviews during interviews.
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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 Aitkin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aitkin Health Services | 0.9 mi | ★★★★★ | 0 | 0 |
| Heartwood | 10.6 mi | ★★★★★ | 0 | 0 |
| Good Samaritan Society - Bethany | 26.4 mi | ★★★★★ | 4 | 0 |
| Good Samaritan Society - Woodland | 27 mi | ★★★★★ | 1 | 0 |
| Cura Of Onamia | 32.2 mi | ★★★★★ | 6 | 0 |
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