Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Aitkin Health Services during CMS and state inspections, most recent first.
Uncovered clean linen cart and incomplete WMP documentation. The facility left a clean linen cart uncovered in an alcove, with items stored on top of the folded-back cover, and an LPN/IP stated this did not meet expectations and could allow bacteria to spread. The facility also lacked a documented WMP process: the maintenance director did not know the building water flow, had no diagram, had no records of daily flushing by housekeeping, was unaware of current municipal water quality, and had limited documentation of other water management activities.
Food items were found in multiple kitchen storage areas and dining room kitchenettes without clear dates or with dates staff could not understand. An unopened vegetable base had no discernable expiration date, an open bottle of lemon juice was beyond its best use by date, frozen vegetable mix was labeled with a packing date instead of an expiration date, and several open milk containers were undated. The KM and C-A stated food and milk should be dated when opened or received, and the KM confirmed staff would not know when to discard items without clear labeling.
Incomplete Flu and Pneumococcal Vaccination Education and Documentation: The facility failed to consistently educate, offer, or administer influenza and pneumococcal vaccines for multiple residents. Records showed some residents had no flu or pneumococcal immunizations, some consent forms were unsigned or lacked evidence of education, and one resident who wanted a pneumococcal vaccine had no documentation that the vaccine was actually administered. The IP confirmed the missing education on the vaccination consent forms.
Failure to educate and offer COVID-19 vaccination to residents: A resident with dementia and two residents with intact cognition had vaccination consent forms indicating they did not want the COVID-19 vaccine, but the forms lacked evidence that the resident or resident representative was offered education about vaccination. Immunization records showed two residents had no COVID-19 vaccinations, while one resident had received a prior COVID-19 vaccine. One consent form was also unsigned by the resident.
Care plans were not revised to reflect changes in care for two residents. One resident with legal blindness and independent wheelchair use fell on an outdoor patio, but her plan did not include outside supervision. Another resident with CHF, PVD, and impaired ROM had a plan for compression stockings, but it was not updated for refusals and did not include interventions to educate or encourage footwear use; the TAR also showed inconsistent documentation of TEDs use.
A resident dependent for personal hygiene had an ADL care plan that included a Sunday bath and shaving if facial hair was present, but staff did not complete the scheduled bath and the resident was observed with food and coffee stains on her gown and visible chin hair. The resident said she had not gotten her bath as expected, and the NA and DON/RN manager acknowledged the resident should have been bathed and shaved as part of daily care.
A resident with CHF, PVD, impaired ROM, and edema had inconsistent use and documentation of compression therapy, with staff reporting frequent refusals of TEDs, tubi-grips, and ACE wraps. The resident was observed barefoot with edematous, red feet and a band-aid on the third toe of the R foot after stating she snagged it on something in her room. Staff interviews confirmed there was no incident report or treatment order for the toe injury, and the RN manager and DON described expectations for offering compression stockings, documenting refusals, and monitoring the foot.
Failure to offer annual audiology services and assist with routine hearing aid care for a resident with hearing loss. The resident had intact cognition, moderate hearing difficulty, and bilateral hearing aids, but the care plan did not address cleaning hearing aid filters and the EMR lacked documentation that audiology was offered at the care conference. Staff noted prior charging issues, partially plugged filters, and the resident was observed having difficulty hearing at conversational level despite wearing the hearing aids.
Unsafe Water Temperatures and Recliner Safety Care Plan Not Followed: The facility allowed bathroom sink water to reach scalding temperatures in an area used by a resident who was independent with hygiene and had DM, despite staff and the resident reporting the water was extremely hot. The facility also did not consistently follow a high-fall-risk resident’s care plan for a lift recliner; the chair was observed plugged in with the remote accessible while the resident was alone, even though OT and the care plan indicated it should be unplugged when staff were not present.
A resident with an indwelling Foley catheter and urinary retention had the catheter bag repeatedly observed touching the floor or placed in a chair pocket, despite the care plan directing staff to keep the bag off the floor. Staff acknowledged the bag should not contact the floor because of contamination and infection concerns, and the DON stated the drainage bag and tubing should not touch unclean surfaces.
Open enteral feeding solution and tube feeding supplies were left undated for a resident receiving G-tube bolus feedings. Staff observed an open Jevity bottle on the bedside table with rinsed, undated extension tubes and a syringe nearby, while the resident’s care plan, provider orders, and facility policy required daily dating and proper storage of the feeding container and supplies. The DON, LPN, and contracted dietician all described different handling expectations for the formula between feeds.
Oxygen tubing and humidifier maintenance was not properly documented for a resident with severe cognitive impairment and multiple cardiac and respiratory diagnoses. The resident had an order for O2 2 L PRN, but the TAR lacked instructions for cleaning, maintenance, or changing tubing across multiple months, and observation found undated tubing hanging to the floor with an undated, partially filled humidifier attached. Nursing leadership stated tubing and humidifiers were to be changed weekly and dated, and the DON and ADON expressed concern for infection risk.
A resident who was cognitively intact reported being antagonized and taunted by another resident with moderate cognitive impairment and a history of verbal outbursts. Despite reporting these concerns to the social service designee and an RN, no grievance was filed, and the resident did not receive documented follow-up or resolution, contrary to facility policy.
A resident with hemiplegia, hemiparesis, and vascular dementia, identified as high risk for falls, was repeatedly observed attempting to self-transfer and was left unsupervised for extended periods. Staff did not consistently implement or communicate fall prevention interventions, and there was confusion regarding the resident's care plan. Multiple incidents of the resident being found on the floor or attempting to crawl out of bed were documented, with inadequate assessment and supervision contributing to the deficiency.
A resident with cognitive impairment and high fall risk was left alone in her wheelchair, contrary to her care plan, resulting in a fall and head injury. The facility's communication system failed to inform agency staff of necessary interventions, contributing to the incident.
A resident with severe cognitive impairment and neurogenic bladder suffered harm due to improper catheter insertion at an LTC facility. An LPN inserted the wrong size catheter twice, causing bleeding and minimal urine output. Despite the resident's deteriorating condition, staff failed to notify a provider or document the incident properly, leading to urethral trauma, infection, and hospitalization for sepsis.
A resident with impaired cognition and an indwelling catheter experienced complications due to improper catheter insertion by facility staff. The catheter was inserted incorrectly multiple times, causing bleeding and pain, but the physician was not notified promptly. The resident was eventually sent to the hospital, where it was discovered that the catheter balloon was inflated in the urethra, leading to sepsis and acute renal failure.
A resident with severely impaired cognition and a neurogenic bladder experienced severe complications due to incorrect catheter placement, including bleeding, sepsis, and ICU admission. The facility failed to report the incident to the state agency, and staff interviews revealed the use of the wrong catheter size and delayed provider notification. No incident or vulnerable adult report was filed, contrary to facility policy.
A resident with a neurogenic bladder experienced severe complications after an LPN incorrectly inserted a catheter twice, leading to bleeding and minimal urine output. Despite these issues, the facility's management did not take immediate corrective action or notify a provider. The resident was later diagnosed with sepsis and acute renal failure. The facility failed to investigate or report the incident as required by their policy.
A resident with severe cognitive impairment and a neurogenic bladder was hospitalized for sepsis, but the facility failed to inform the resident or their representative of the bed hold policy. Staff interviews confirmed the oversight, revealing non-compliance with the facility's procedures.
A resident with dementia and hemiplegia experienced burns after staff reheated coffee in a microwave, contrary to facility protocol. Staff were inconsistently following guidelines, and the facility's policy did not explicitly prohibit microwaving beverages, leading to potential hazards for residents.
Uncovered clean linen cart and incomplete water management program
Penalty
Summary
The facility failed to ensure linens were handled properly to help prevent the spread of infection. During an observation in an alcove next to the elevator down to the conference room, a three-shelved unit storing clean linens was seen with the cover pulled up over the top of the unit and items stored on top of the folded-back cover. A sign on the cart stated, "please close the cover." On a later observation, the linen cart was again seen uncovered. During an observation and interview, the LPN who identified as the facility IP observed the uncovered linen cart and stated it did not meet his expectations and would be a risk for bacteria to get on the linens and then get spread all over. The facility policy on Linen Handling, dated 3/10/26, identified its purpose as providing guidelines for the safe handling of linen to protect residents, staff, and the environment from infection and occupational exposure, but the policy did not address clean linen handling practices. The facility also failed to maintain a water management program that identified potential areas for water-borne bacteria and maintained records of water management activities. During interview, the maintenance worker who identified as the maintenance director and responsible for the water management plan stated he did not know how the water flowed through the building and did not have a diagram. He stated that faucets and showers were flushed daily by housekeeping staff, but he did not have it documented anywhere, and he was not aware of current municipal water quality. He also noted monthly cleaning of air conditioner units but did not have further documentation of water management activities. A facility map identified the water main shut-off valve, three hot water heaters, and that the facility had no water tempering or mixing valves. The Water Management Program Legionella Prevention policy, dated 11/19/25, identified areas and conditions to be addressed in the program, including water entry points, distribution areas, heating sources, municipal water quality changes, pH balance, disinfectant levels, and stagnation points.
Food Items Found Undated or Past Use Date
Penalty
Summary
Food was not consistently dated, labeled, or discarded in accordance with facility policy and professional standards. During a kitchen tour, an unopened jar of Molly's vegetable base was found in dry storage with no discernable expiration date, and the kitchen manager stated staff were not aware the product had no expiration date and would need to date it when received so it could be discarded appropriately. In the walk-in cooler, an open bottle of lemon juice was found undated with a best use by date of 10/6/25, and the kitchen manager removed it and stated it would be discarded because it was beyond its best used by date. In freezer 2, four bags of corn and black bean fiesta mix were dated 4/15/26 with no indication of what the date represented. The kitchen manager initially stated they needed to contact the supplier for clarification, then later confirmed the date was a packing date and that the product was good for 547 days from that date, but kitchen staff would not know the expiration date unless it was labeled when received. In two dining room kitchenettes, open containers of 1% milk and chocolate milk were found undated, and another open half gallon of chocolate milk was also found undated in a separate kitchenette refrigerator. Staff stated milk should be dated when opened, and the kitchen manager stated they would be concerned not knowing how long it had been open and would discard any open, undated milk.
Incomplete Flu and Pneumococcal Vaccination Education and Documentation
Penalty
Summary
The facility failed to consistently educate, offer, or administer influenza and pneumococcal vaccinations for 4 of 5 residents reviewed. For one resident with CHF, atrial fibrillation, hypertension, and dementia, the admission record and immunization report showed no influenza or pneumococcal vaccinations, and the vaccination consent form indicated the resident had not had an influenza vaccine but wished to receive one; the form also showed no entry for whether the resident wanted a pneumococcal vaccine. The form did not contain evidence that the resident or resident representative was offered education regarding vaccinations. For another resident with intact cognition and diagnoses of hypertension, chronic pain, GERD, and hypokalemia, the immunization report showed prior influenza or pneumococcal vaccination history, but the vaccination consent form stated the resident had not had either vaccine and did not want either one; the form was not signed and did not contain evidence of education being provided. A third resident with CHF, persistent atrial fibrillation, and diabetes mellitus had prior pneumococcal vaccines documented, no influenza vaccine history, and a signed consent form stating the resident wanted a pneumococcal vaccine but did not want influenza vaccination; the form did not show education was offered. A fourth resident with lymphedema, hypothyroidism, diabetes mellitus, and CKD had prior pneumococcal vaccines documented and a signed consent form stating the resident had received education and wanted a pneumococcal vaccine, but there was no evidence the vaccine was actually given. The infection preventionist confirmed the missing education and stated the facility used the CDC PneumoRec application, but the vaccination consent forms did not show education provided.
Failure to Educate and Offer COVID-19 Vaccination
Penalty
Summary
The facility failed to ensure residents were educated about and offered the COVID-19 vaccination for 3 of 5 residents reviewed for vaccinations. R1’s quarterly MDS identified that the resident was rarely if ever understood and that a cognitive assessment was not performed. R1’s admission record listed diagnoses of CHF, atrial fibrillation, hypertension, and dementia, and the immunization report showed no COVID-19 vaccinations. An undated Vaccination Consent form stated that R1 had not had a COVID-19 vaccination and did not want one, but the form did not contain evidence that the resident or resident representative was offered education regarding vaccination. R4’s quarterly MDS identified intact cognition and diagnoses of hypertension, chronic pain, GERD, and hypokalemia, and the immunization report showed no COVID-19 vaccinations. An undated Vaccination Consent form stated that R4 had not had a COVID-19 vaccination and did not want one, but the form did not contain evidence that the resident or resident representative was offered education regarding vaccination, and the form was not signed by R4. R23’s quarterly MDS identified intact cognition and diagnoses of CHF, persistent atrial fibrillation, and diabetes mellitus. The immunization report showed a COVID-19 vaccination on 4/10/21, and a Vaccination Consent form signed by R23 stated the resident did not want to receive the COVID-19 vaccination, but the form did not contain evidence that the resident or resident representative was offered education regarding vaccination. Policies regarding vaccination were requested but not received.
Care Plans Not Updated for Changes in Resident Care
Penalty
Summary
The facility failed to review and revise care plans to reflect changes in care for 2 residents. One resident had intact cognition, legal blindness, and used a wheelchair independently, but her care plan only addressed fall risk related to vision problems and mobility assistance. After she fell from her wheelchair on the outdoor patio, the incident report identified direct supervision when she was outside for activities as an action to prevent recurrence, yet the care plan had not been updated to include supervision outside. During interview, the RN stated she had not seen the incident report and had not made changes to the care plan, and the DON stated verbal education had been provided to activity staff but the care plan still had not been updated. The second resident had intact cognition, CHF, PVD, impaired ROM in one upper extremity and both lower extremities, and needed moderate assistance with footwear. Her care plan addressed assistance with compression stockings, but it was not updated to reflect refusals to wear them. The care plan also did not include interventions to educate and encourage her to wear footwear. The provider order required TEDs or compression stockings in the morning and removal in the evening, and the TAR documented refusals on some days while also charting them as worn on other days. The resident's progress notes did not contain refusals of care.
Failure to Provide Scheduled ADL Hygiene and Shaving
Penalty
Summary
The facility failed to ensure activities of daily living (ADL) tasks were performed for a resident who was dependent on others for personal hygiene. The resident had a significant change in assessment MDS that identified intact cognition, hemiplegia and hemiparesis of the right side related to a CVA, multiple fractures of the left and right tibia and fibula, and dependence for personal hygiene. The care plan identified an ADL self-care deficit, a bath scheduled for Sunday afternoons, a preference to be shaved if facial hair was present, and the need for assistance with set-up for personal and oral hygiene. The resident's EMR showed a bed bath on 5/31/26, but during observation on 6/1/26 the resident was wearing a hospital gown with food and coffee stains on the front and had visible white chin hair about one-third of an inch long. The resident stated she had been supposed to have a bath the day before but had not gotten it and did not know why. On 6/2/26, the resident again stated she did not get her bath on Sunday and asked whether her chin hair was visible; it was observed to still be present. An NA stated she used PCC or the nursing station bath schedule to see what to do for each resident and had not gotten the resident ready that morning, so she did not notice the chin hair. The DON stated the resident should at least have been offered shaving with daily care if facial hair was visible, and the RN manager stated she would have expected the resident to still be shaved even with a bed bath.
Failure to manage edema and document a toe injury
Penalty
Summary
The facility failed to provide edema management and failed to provide root cause analysis, care, and monitoring for a skin injury for one resident with intact cognition, CHF, PVD, impaired ROM in one upper extremity and both lower extremities, and a need for moderate assistance with footwear. The resident’s care plan identified the need for assistance with TEDs or compression stockings, interventions for increased edema related to CHF, and daily skin checks, but the care plan did not include refusals of care. Provider orders included TEDs or compression stockings in the morning and removal in the evening, along with leg elevation orders and an OT order for lymphedema treatment. The resident’s treatment record showed refusals of TEDs on two days, but also documented the stockings as being worn on other days. During observations, the resident was seen with a band-aid on the third toe of the right foot, with both lower extremities and feet edematous, and was barefoot. The resident stated she snagged the toe on something in her room, possibly her wheelchair. Later observations showed the resident sitting in her wheelchair with no socks or shoes, feet flat on the floor, and both feet red and edematous; another observation showed edema shoes in use but no compression socks. Staff interviews showed inconsistent understanding and documentation of the resident’s care. A NA stated the resident could usually dress herself and could put on slipper shoes, but often refused tubi-grips. A TMA stated the resident hated compression socks, refused tubi-grips, and would pull off ACE wraps, and that refusals could be charted on the TAR. The RN manager stated she did not see an incident report or orders for treatment of the toe injury and confirmed staff should offer compression stockings and document refusals. The DON stated licensed nurses should be looking at the foot regularly depending on healing status. The facility policy required assessment of the area, removal of pressure or trauma, treatment per standing orders, notification of the provider, completion of a skin incident report, and root cause analysis for any newly opened area or redness.
Failure to Offer Audiology Services and Maintain Hearing Aids
Penalty
Summary
The facility failed to offer annual audiology services and failed to assist with routine hearing aid care for a resident with hearing impairment. The resident’s significant change in status MDS identified intact cognition and moderate difficulty hearing with hearing aids in place. The care plan identified that the resident was hard of hearing and set a goal for the hearing aids to be accessible, clean, and available for use, with interventions to assist with placing and removing the hearing aids daily, assist with charging, review hearing status quarterly, and offer audiology services annually. However, the care plan did not identify checking or cleaning hearing aid filters, and the provider orders did not include hearing aid maintenance. Record review showed the resident was seen for an initial hearing aid fitting and later had partially plugged hearing aid filters noted at follow-up. The EMR did not contain documentation of a March 2026 care conference or that audiology services were offered. During observation, the resident was wearing bilateral hearing aids but had difficulty hearing at conversational level and stated that when she first got the hearing aids she could hear everything, but now she could not hear very well. Staff interviews indicated there had been past issues with charging the hearing aids, and one RN later stated the hearing aid filters likely needed cleaning. The DON stated residents were asked at care conferences if they wanted audiology services, but the resident’s care conference was not found, the resident was not in the facility at the scheduled time, and there were no notes showing rescheduling or what happened.
Unsafe Water Temperatures and Failure to Follow Recliner Fall-Prevention Care Plan
Penalty
Summary
The facility failed to ensure safe hot water temperatures in resident bathrooms. R23, who had intact cognition, peripheral vascular disease, and diabetes mellitus, was independent with oral, personal, and toilet hygiene and used the bathroom sink. Her care plan identified that she should avoid exposure to extreme heat or cold because of diabetes. During interviews, R23 stated the bathroom sink water was scalding hot, and staff members also reported that the hot water on that side of the unit was extremely hot and could be an issue for residents who washed their own hands. On observation, the administrator measured the hot water at R23’s bathroom sink at 138.2 degrees Fahrenheit with a food thermometer and 139.4 degrees Fahrenheit with a temperature gun. The administrator stated it should be about 115 degrees Fahrenheit. The facility’s water temperature log showed temperatures in rooms 102 to 109 did not exceed 112 degrees Fahrenheit on a prior date, but the observed sink temperature was much higher than the facility’s stated range. The maintenance director stated he had used a temperature gun to check sinks in the rooms and said the gauge on the hot water tank was not working properly. The facility also failed to follow care plan interventions for fall prevention for R39. R39 was cognitively intact, had diagnoses including diabetes, lymphedema, and muscle weakness, and was assessed as high risk for falls. R39’s care plan and progress notes identified that the lift recliner should be unplugged when staff were not present, and OT confirmed this was recommended because R39 did not have the leg strength to prevent a fall if the chair moved into lift mode unexpectedly. However, multiple observations showed the recliner plugged in while R39 was seated alone, with the remote accessible and the chair functioning. Staff interviews showed inconsistent understanding of the care plan, with some staff believing the chair should be unplugged and others stating it could remain plugged in.
Foley Catheter Bag Contacted the Floor
Penalty
Summary
The facility failed to follow the care plan for a resident with an indwelling Foley catheter related to urinary retention. R39 was cognitively intact and had diagnoses including diabetes, lymphedema, muscle weakness, and urinary retention. The care plan, initiated on 5/18/26, directed staff to keep the catheter bag off the floor and included a goal that the resident would show no signs or symptoms of urinary infection. During multiple observations from 6/1/26 through 6/4/26, R39’s catheter drainage bag was repeatedly seen hanging from the side pocket of the recliner or tucked into the chair pocket with the bottom of the bag touching the floor. At one point, the bag was also observed hanging on the side of a garbage can, and later the tubing contained clear yellow urine extending up to the bottom edge of the resident’s shorts. Staff interviews confirmed the bag should not touch the floor because of contamination and infection concerns, and the DON stated the drainage bag and tubing should not contact the floor or other unclean surfaces.
Open enteral feeding solution and tube feeding supplies were left undated
Penalty
Summary
The facility failed to ensure proper storage of open enteral feeding solutions and failed to date tube feeding supplies for 1 of 2 residents reviewed for tube feeding, identified as R8. R8’s annual MDS indicated the resident was cognitively intact, and diagnoses included frontotemporal neurocognitive disorder, dysphagia, diabetes mellitus type 2, non-Alzheimer dementia, and anxiety disorder. The care plan directed bolus feeding, changing the feeding solution container and syringe every 24 hours, and following the manufacturer’s recommendations or the registered dietician’s guidance for how long formula could remain open. Provider orders also directed that the syringe and water container be changed daily before breakfast and that dietician evaluation be completed for tube feeding needs. During observations on 6/2/26 and 6/4/26, an open and undated Jevity 1.2 Calorie 1.5-liter bottle was seen on R8’s bedside table, not connected to the G-tube, with tube feeding supplies next to it, including rinsed, undated extension tubes and a rinsed, undated 60 mL syringe. LPN-A stated the Jevity, graduated cylinder, and syringe were changed daily and dated, and that a new Jevity bottle was opened each morning for gravity feeding throughout the day. The DON stated the Jevity bottle was labeled each morning when opened and that tube feeding supplies were labeled when changed. The contracted dietician stated the Jevity should be covered and refrigerated between gravity feeds and dated with the date and time opened. Facility policy required the feeding solution container to be labeled with the date, time, and nurse’s initials and the 60 mL syringe to be changed and dated daily.
Oxygen Tubing and Humidifier Not Maintained or Documented
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met for a resident with severe cognitive impairment and diagnoses including atrial fibrillation, heart failure, hypertension, pneumonia, and non-Alzheimer's dementia. The resident had a provider order for oxygen 2 liters as needed to keep oxygen saturations above 90% and for shortness of breath, but the resident's care plan did not include oxygen use. The treatment administration record reviewed on 6/2/26 included the oxygen order, but it had no instructions for cleaning, maintenance, or changing of oxygen tubing, and the TARs for 3/2026, 4/2026, and 5/2026 also lacked those instructions. During observation on 6/2/26 at 1:07 p.m., the resident's oxygen concentrator was in the room with undated oxygen tubing connected, hanging off the concentrator and cascading to the floor, and an undated, partially filled humidifier attached. Nursing staff stated the resident had used oxygen with an illness but had not needed it for several weeks, and that tubing and humidifiers were usually changed weekly and should be dated, with the nurse checking off the change on the TAR. The ADON and DON both stated oxygen tubing and humidifiers were to be changed weekly and dated, and the ADON expressed concern for potential bacteria growth if the tubing was not changed; the DON also stated there was concern for potential risk of infection.
Failure to Follow Grievance Policy After Resident Reports Peer Antagonism
Penalty
Summary
The facility failed to follow its grievance policy and procedures when a resident voiced concerns about the treatment received from another resident. One resident, who was cognitively intact and able to express his needs, reported being antagonized and taunted by another resident with moderate cognitive impairment and a history of verbal behaviors directed toward others. The concerned resident reported these issues to both the social service designee (SSD) and a registered nurse, but no grievance was filed on his behalf, and he did not receive any documented resolution or follow-up. Staff interviews confirmed that the antagonistic behavior was known among staff, with the SSD acknowledging that the resident had voiced concerns and that the issue had been discussed with the interdisciplinary team. However, the SSD did not document the conversations or initiate a grievance form, and the assistant administrator confirmed that a grievance should have been filed for any resident concern. The facility's policy required prompt investigation and written resolution of grievances, but these steps were not taken in this case.
Failure to Prevent Falls and Provide Adequate Supervision for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to adequately reduce the risk of falls and provide sufficient supervision for a resident with a high risk for falls. The resident, who had diagnoses including hemiplegia, hemiparesis, and vascular dementia, was observed multiple times attempting to self-transfer from a wheelchair to bed and to self-transfer in and out of bed without staff assistance. Staff were aware of the resident's history of falls and his tendency to attempt self-transfers, as documented in his care plan and progress notes. Despite this, the resident was left unsupervised for extended periods, and staff did not consistently implement or communicate fall prevention interventions, such as a two-hour toileting plan or prompt assistance with transfers. Observations revealed that the resident was left in common areas and in his wheelchair for long periods, during which he attempted to return to his room and self-transfer to bed. Staff interactions indicated confusion or lack of clarity regarding the resident's care plan, with some staff unsure about whether or not to assist the resident to bed and others not reporting the resident's requests for help. Documentation showed repeated incidents of the resident being found on the floor, on fall mats, or attempting to crawl out of bed, with staff sometimes attributing these events to intentional behavior rather than falls, and without clear assessment or documentation to support this distinction. Interviews with staff and the resident's family member highlighted inconsistent implementation of fall prevention strategies, such as scheduled toileting, and a lack of clear communication among staff regarding the resident's needs and care plan. The facility's policy required assessment and documentation of fall risks and interventions, but there was no evidence that all identified interventions were consistently implemented or evaluated for effectiveness. The lack of adequate supervision and failure to follow the resident's care plan contributed to ongoing risks and repeated incidents involving the resident.
Inadequate Supervision and Communication Leads to Resident Fall
Penalty
Summary
The facility failed to adequately supervise and implement fall interventions for a resident, resulting in actual harm. The resident, who had arthritis, spinal stenosis, and mild cognitive impairment, was at high risk for falls, as indicated by her care plan and fall risk assessment. Despite these documented risks, the resident was left alone in her wheelchair in her room, contrary to her care plan directives, leading to a fall that caused a laceration on her forehead requiring emergency medical attention. The communication process within the facility was inadequate, particularly in conveying critical care plan information to agency staff. The communication books, intended to update staff on resident care interventions, were not consistently signed or reviewed by staff, including agency personnel. The agency nursing assistant who left the resident alone was unaware of the care plan requirements due to a lack of access to the resident's care plan and insufficient communication from the facility. The facility's reliance on verbal communication and the communication book system was ineffective, as evidenced by the lack of signatures and updates regarding the resident's fall risk interventions. The director of nursing acknowledged that agency staff could document in electronic medical records but could not review care plans, leading to a gap in care continuity. This communication failure contributed to the resident's fall and subsequent injury.
Improper Catheter Insertion Leads to Resident Harm
Penalty
Summary
The facility failed to provide appropriate treatment and care according to professional standards for a resident who experienced multiple incorrect insertion attempts of an indwelling catheter. This resulted in significant complications, including bleeding, blood clots, pain, discomfort, low urine output, and low blood pressure, ultimately leading to a diagnosis of sepsis and admission to the Intensive Care Unit (ICU). The resident had a history of severe cognitive impairment, neurogenic bladder, and was dependent on staff for all care, which increased the complexity of their medical needs. The deficiency occurred when a Licensed Practical Nurse (LPN) inserted the wrong size catheter twice, causing bleeding and minimal urine output. Despite recognizing the error, the LPN did not notify a provider, relying instead on the Director of Nursing (DON) and floor manager's advice that some bleeding was normal for the resident. The situation was further exacerbated by the lack of documentation and failure to follow up with appropriate medical intervention, as the resident's condition deteriorated with ongoing pain and no urine output. Interviews with staff and medical professionals revealed a lack of adherence to facility policies and procedures, including the failure to notify a physician of significant changes in the resident's condition. The repeated catheter insertions and inadequate response to the resident's symptoms led to urethral trauma and infection, resulting in the resident's hospitalization. The facility's lack of documentation and failure to conduct a timely investigation into the incident further highlighted the deficiency in care provided.
Failure to Notify Physician of Catheter Complications
Penalty
Summary
The facility failed to notify a resident's physician in a timely manner following a change in the resident's condition, which led to significant complications. The resident, who had severely impaired cognition and was dependent on staff for care, experienced issues with an indwelling catheter. The catheter was improperly inserted multiple times, resulting in bleeding, blood clots, pain, discomfort, low urine output, and low blood pressure. Despite these symptoms, the facility staff did not promptly inform the resident's physician, leading to the resident being sent to the emergency room and subsequently developing sepsis. The resident's care plan indicated a risk for bleeding due to anticoagulant use and a risk for urinary tract infection due to the indwelling catheter. The plan directed staff to monitor for changes and contact the provider as needed. However, the staff failed to follow these directives. The licensed practical nurse (LPN) inserted the wrong size catheter twice, causing bleeding, and did not notify the physician. The director of nursing (DON) and floor manager were informed but did not take appropriate action, believing the bleeding was normal for the resident. The situation escalated when the resident continued to experience pain and no urine output. Despite multiple communications with the DON, the registered nurse (RN) on duty did not contact the physician until the resident's condition worsened significantly. The resident was eventually sent to the hospital, where it was discovered that the catheter balloon was inflated in the urethra, causing a false tract and significant bleeding. The delay in notifying the physician and the repeated improper catheter insertions contributed to the resident's development of sepsis and acute renal failure.
Failure to Report Catheter Misplacement and Resulting Complications
Penalty
Summary
The facility failed to report a significant incident involving a resident whose indwelling catheter was incorrectly placed three times, leading to severe complications. The resident, who had severely impaired cognition and a neurogenic bladder, experienced bleeding, blood clots, pain, discomfort, low urine output, and eventually sepsis. The incorrect catheter placement resulted in the resident being sent to the emergency room and admitted to the ICU. The hospital admission notes indicated that the catheter balloon was inflated in the urethra instead of the bladder, causing acute renal failure, septic shock, and anemia due to acute blood loss. Interviews with facility staff revealed that the wrong catheter size was used, and there was a delay in notifying a provider about the resident's condition. The floor manager LPN and RN acknowledged that the bleeding was not typical and that a vulnerable adult report should have been filed. However, no facility incident report or vulnerable adult report was submitted. The director of nursing confirmed that the facility's policy was not followed regarding reporting the incident, and an incident report should have been filed under medication error. The facility's maltreatment reporting guidelines require immediate reporting of any alleged maltreatment involving neglect to the appropriate authorities.
Failure to Investigate and Address Catheterization Error
Penalty
Summary
The facility failed to thoroughly investigate and address the neglect of care for a resident who experienced significant complications following the incorrect insertion of an indwelling catheter. The resident, who had severely impaired cognition and a neurogenic bladder, was dependent on staff for all care. During a catheter change, a Licensed Practical Nurse (LPN) inserted a catheter of the wrong size twice, resulting in bleeding and minimal urine output. Despite these issues, the LPN was advised by the floor manager and Director of Nursing (DON) that the bleeding was normal, and no immediate corrective action was taken. The resident's condition worsened, leading to an emergency room visit where it was discovered that the catheter balloon was inflated in the urethra, causing significant bleeding and no urine output. The resident was diagnosed with a urinary tract infection, sepsis, acute renal failure, and anemia due to acute blood loss. Interviews with medical staff revealed that the incorrect catheterization increased the risk of urethral damage and infection, and the lack of urine output should have prompted immediate medical intervention. The facility's Director of Nursing admitted that no incident report was filed, and no investigation was initiated until the surveyor's arrival. The facility's policy required immediate investigation and reporting of such incidents, but this was not followed. The lack of documentation and failure to notify a provider about the incorrect catheter size and bleeding were significant oversights, contributing to the resident's severe health decline.
Failure to Inform Resident of Bed Hold Policy During Hospitalization
Penalty
Summary
The facility failed to inform a resident or their representative of the bed hold policy during a hospitalization event. The resident, who had severely impaired cognition, a neurogenic bladder, and was dependent on staff for all care, was transferred to the hospital due to low urine output and was later diagnosed with sepsis. Despite the resident's hospitalization, there was no documentation indicating that the resident or their family/legal representative was informed about the facility's bed hold policy. Interviews with facility staff, including a floor manager RN and a social service designee, confirmed that the bed hold policy was not communicated to the resident or their representative. The facility's policy requires that residents or their representatives be given the option to hold their bed during hospitalizations or therapeutic leaves, but this was not adhered to in this case. The social service designee admitted to never having issued a bed hold before, indicating a lack of compliance with the facility's established procedures.
Failure to Prevent Burns from Hot Beverages
Penalty
Summary
The facility failed to prevent future burns from hot beverages for a resident who spilled his coffee after staff reheated it in the microwave. The resident, who had dementia and hemiplegia, experienced redness on his thigh and hand following the incident. The facility's report indicated that staff had been educated on not using microwaves to heat beverages and were instructed to provide fresh cups of coffee instead. However, observations and interviews revealed that staff were not consistently following this protocol, and the facility's policy did not explicitly prohibit the use of microwaves for heating beverages. A nursing assistant admitted to microwaving the resident's coffee at the family's request, unaware that the mug was not microwave-safe. Dietary staff also reported using microwaves to reheat beverages without checking temperatures afterward. The Director of Nursing confirmed that the facility's policy lacked clear instructions against using microwaves for heating beverages. The policy focused on serving temperatures and safe handling but did not address the risks associated with microwaving beverages, leading to inconsistent practices among staff and potential hazards for residents.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 11 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Aitkin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aicota Health Care Center | 0.9 mi | ★★★★★ | 11 | 0 |
| Heartwood | 11.3 mi | ★★★★★ | 0 | 0 |
| Good Samaritan Society - Bethany | 26.8 mi | ★★★★★ | 4 | 0 |
| Good Samaritan Society - Woodland | 27.5 mi | ★★★★★ | 1 | 0 |
| Cura Of Onamia | 31.7 mi | ★★★★★ | 6 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 August 2026) and official state health department websites.