Average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Aitkin Health Services during CMS and state inspections, most recent first.
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.
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.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near 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 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.