Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at First Care Living Center during CMS and state inspections, most recent first.
A resident grievance about another resident entering a room and going through belongings was not investigated, documented, or tracked to resolution. The resident was cognitively intact and dependent in most care areas, while the other resident had severe cognitive impairment with dementia and psychotic disorder. The resident reported the issue to staff, but the grievance was not recorded in the facility’s grievance log, and the SWD and DON acknowledged the lack of documentation for the informal grievance.
Failure to assess and evaluate wandering behaviors in a resident with dementia, hallucinations, and psychotic disorder. The resident was documented and observed entering other residents’ rooms, rummaging through belongings, and accusing another resident of stealing her dentures. Staff said they mainly used redirection and close observation, but there was no care plan or regular documentation addressing the wandering behavior, and the DON stated the behavior should have been assessed and included in the care plan.
The facility failed to assess pneumococcal immunization status, provide education, and document discussion and offering of pneumococcal vaccination for two residents. One resident had diabetes and HTN, and another had CAD, HF, and thyroid disease; both had prior pneumococcal vaccines documented, but their EHRs lacked evidence that they or their representatives received education or that the vaccine was offered per CDC guidance. Staff and the DON stated immunizations were reviewed on admission, but the records did not show the required documentation.
COVID-19 vaccination status was not assessed, discussed, offered, or documented for two residents reviewed for immunizations. One resident with diabetes and HTN had a last documented COVID-19 vaccine in 2021, but the record lacked evidence of admission assessment, CDC-based discussion, or an offer of the recommended vaccine. Another resident with CAD, HF, and thyroid disease also had no documentation of vaccination assessment, education, offer, or declination. Staff and the DON stated immunizations were expected to be reviewed and documented at admission.
A resident with severe cognitive impairment and total dependence for mobility continued to have a restorative ambulation program listed in their care plan, despite documentation and staff interviews confirming the resident had not walked or received ambulation services for nearly a year. The care plan was not updated to reflect the resident's current non-ambulatory status, contrary to facility policy requiring review after changes in condition.
A resident lost the ability to perform ADLs without a documented medical reason, as the facility did not ensure that declines in functional abilities were clinically unavoidable.
A resident with multiple sclerosis and impaired mobility did not consistently receive range of motion (ROM) exercises as ordered by therapy and outlined in the care plan. Documentation showed that ROM was offered less frequently than required, and staff interviews confirmed inconsistent documentation of refusals and missed opportunities to provide exercises. The resident also reported infrequent offers of exercise and lack of follow-up when initially refusing.
A resident with cognitive impairment and an indwelling catheter received PRN furosemide on three occasions when the required 3-pound weight gain parameter was not met, due to nursing staff not verifying the physician-ordered criteria before administration. The MAR and weight records showed discrepancies, and the nurse did not clarify the order or ensure proper documentation, resulting in medication being given in error.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
A resident with a stage 3 pressure ulcer on the right heel did not receive routine wound monitoring and documentation as required. The facility's designated wound nurse left, leading to inconsistent documentation practices. The resident's care plan required weekly wound measurements, but none were recorded from mid-April to early June. A dressing change revealed purulent drainage and an additional reddened area. Staff interviews highlighted the lack of consistent documentation and access to necessary forms, impacting wound care tracking.
The facility failed to perform proper hand hygiene for two residents during ADLs, as staff did not wash hands after removing soiled gloves. Additionally, the facility did not implement Enhanced Barrier Precautions for a resident with a stage 3 pressure ulcer, as required by CDC guidelines. The facility's policies on hand hygiene and EBP were not followed, leading to potential infection risks.
A deficiency was identified involving the improper use of a full-body mechanical lift during resident transfers, leading to a fall and head injury for a resident with chronic pain, depression, obesity, and long-term anticoagulant use. The care plan required a nurse's presence during transfers by two nursing assistants. Issues included inappropriate sling size, incorrect strap securing, and failure to follow manufacturer guidelines. Staff interviews revealed challenges with lift leg extension, sling adjustments, and battery power management, contributing to the incident.
Failure to Document and Track a Resident Grievance About Room Entry and Belongings
Penalty
Summary
The facility failed to investigate, document, and track resolution of a resident grievance involving another resident entering the room and going through belongings. R22 was cognitively intact, required set up and clean up assistance with eating and oral hygiene, and was dependent on staff in all other care areas; diagnoses included hemiplegia and hemiparesis. R8 had severe cognitive impairment and diagnoses that included dementia, depression, and psychotic disorder. R22’s nursing progress note documented that he wanted to speak to someone in charge about R8 digging in his drawers, but his care plan did not identify a wish to prevent other residents from entering his room uninvited, and the medical record contained no further documentation about his concerns. A review of the facility’s formal and informal grievances from 8/1/25 through 5/26/26 did not identify R22’s grievance, including any investigation or action taken by the facility. During interview, R22 stated R8 came into his room and accused him of stealing her things, especially her dentures, and that he turned on his call light but staff arrived after R8 had left. R22 said he had told staff he did not like R8 coming into his room and was told to turn on his call light if she did. The SWD stated there was no documentation because R22 had not wanted to file a formal grievance and his daughter understood the situation, but also acknowledged that R22 had a right to privacy and that the informal grievance should have been documented. The DON stated staff were expected to follow the grievance process for both formal and informal grievances so all grievances could be tracked and resolution determined.
Failure to Assess and Care Plan Wandering Behaviors in a Resident With Dementia
Penalty
Summary
The facility failed to assess and evaluate wandering behaviors for a resident with dementia and other psychiatric diagnoses, including entering other residents’ rooms and going through personal belongings. The resident’s significant change MDS identified severe cognitive impairment and worsening behaviors, and the behavioral symptoms CAA identified worsening behaviors with hallucinations, isolation, pain, anxiety, hollering out, and disruptive sounds; however, it did not comprehensively assess wandering or include a plan to minimize it. The resident was documented as wandering into three other residents’ rooms and being caught digging in drawers, and later was observed wandering down a hallway and entering another resident’s room. One cognitively intact resident reported that the resident repeatedly entered his room, accused him of stealing her belongings and dentures, rummaged through his closet, and became upset when told to leave. Staff interviews confirmed the resident wandered into other residents’ rooms, often after meals and possibly more frequently in the evening or night, but staff described the response as redirection and close observation. Multiple staff members stated there was no care plan or regular documentation addressing the wandering behavior, and the DON stated the resident’s wandering should have been assessed and the care plan updated to identify the behavior and interventions.
Failure to document pneumococcal vaccine assessment, education, and offering
Penalty
Summary
The facility failed to assess pneumococcal immunization status, provide education, and document discussion and offering of pneumococcal vaccination in accordance with current CDC recommendations for 2 residents reviewed for immunizations. One resident was cognitively intact, able to make needs known, and had diagnoses including diabetes and hypertension. Her preventive health record showed she received Prevnar13, but the electronic health record did not include evidence that she or her representative received education regarding a pneumococcal vaccine booster, and there was no indication that the vaccine was offered in conjunction with the provider. A second resident had diagnoses including coronary heart disease, heart failure, and thyroid disease. The immunization record showed prior receipt of PCV13 and PPSV23, but the electronic health record again lacked evidence that the resident or representative received education regarding pneumococcal vaccine booster and there was no indication the vaccine was offered per CDC guidance with the provider. Staff stated immunizations were offered on admission and seasonally, and the DON stated she expected immunizations to be discussed with the resident and/or representative upon admission and per CDC guidance, with documentation in the medical record; however, she was uncertain what process the IP used to determine when a resident was due for pneumococcal vaccine and noted there were no notes documenting discussion or offering for the resident.
COVID-19 Vaccination Status Not Assessed or Documented for Two Residents
Penalty
Summary
The facility failed to assess COVID-19 vaccination status and ensure current CDC-recommended COVID-19 vaccination was offered and documented for 2 of 5 residents reviewed for immunizations, including R20 and R27. R20 was admitted with diagnoses of diabetes and hypertension, was cognitively intact, and able to make her needs known. Her record showed the last documented COVID-19 vaccination was given on 11/23/21, but there was no evidence that her vaccination status was assessed on admission, that current CDC recommendations were discussed, or that she was offered the recommended COVID-19 vaccination after admission. R27 was admitted to the facility and had diagnoses of coronary heart disease, heart failure, and thyroid disease. Her medical record also lacked evidence that staff assessed her COVID-19 vaccination status upon admission, provided education regarding current CDC recommendations, offered vaccination, or obtained a documented declination. The infection preventionist stated immunizations were offered upon admission and seasonally, and the DON stated she expected immunizations to be discussed with the resident and/or resident representative upon admission and per CDC guidance, with documentation in the medical record. The facility's standard work process stated staff reviewed vaccination history at admission, assessed whether vaccinations including COVID-19 were needed, discussed the most current VIS, and documented administration or declination.
Failure to Update Care Plan After Resident Loss of Ambulation
Penalty
Summary
The facility failed to revise the care plan for a resident who was no longer ambulatory, resulting in the continued inclusion of a restorative nursing ambulation program in the care plan. The resident had severe cognitive impairment and was dependent on staff for transfers and bed mobility, with documentation from both medical and behavioral health professionals indicating that the resident had not been able to walk for an extended period. Despite this, the care plan continued to list ambulation with restorative aides as an intervention, and staff interviews confirmed that the resident had not ambulated for nearly a year. Multiple staff members, including trained medication assistants, restorative aides, registered nurses, and the DON, acknowledged that the resident was not receiving ambulation services and had not walked for a significant amount of time. The facility's policy required care plans to be reviewed and updated quarterly or with any change in resident condition, but this was not done in response to the resident's decline in mobility. The deficiency was identified through interviews and document review, which showed a lack of timely care plan revision to reflect the resident's current status.
Failure to Prevent Unnecessary Loss of ADL Abilities
Penalty
Summary
Residents experienced a loss in their ability to perform activities of daily living (ADLs) without a documented medical reason. The facility failed to ensure that residents maintained their ADL abilities unless a decline was clinically unavoidable due to a medical condition. This deficiency was identified through observations and record reviews that did not show appropriate justification for the decline in residents' functional abilities.
Failure to Provide and Document Restorative ROM Services as Care Planned
Penalty
Summary
The facility failed to provide range of motion (ROM) exercises as care planned for a resident with multiple sclerosis and impaired mobility. According to therapy recommendations and the resident's care plan, the resident was to receive ROM exercises to both upper and lower extremities three times per week. However, documentation showed that the exercises were only offered one to two times per week, and in some weeks, not at all. The resident's care plan and therapy screening indicated the importance of these exercises to maintain mobility, but the facility's records did not reflect consistent implementation of the program. Interviews with staff revealed that the trained medication aide responsible for restorative nursing did not consistently document refusals or unavailability, and the registered nurse coordinating the program confirmed that exercises should be offered three times weekly with proper documentation of refusals. The resident reported that staff rarely offered the exercises and did not attempt to return at a later time if she initially refused. Additionally, the facility was unable to provide a policy for restorative nursing when requested.
Failure to Administer PRN Medication According to Physician Parameters
Penalty
Summary
The facility failed to provide medications as ordered for a resident with moderate cognitive impairment and an indwelling catheter. The resident had physician orders for furosemide (Lasix) 40 mg to be administered only if there was a 3-pound weight gain overnight, with daily weights to be obtained each morning. Review of the Medication Administration Record (MAR) and corresponding weights revealed that furosemide was administered on three occasions when the resident did not meet the required 3-pound weight gain parameter. Specifically, on two dates, the weight gain was less than 3 pounds, and on another date, the previous day's weight was not recorded, making it impossible to determine if the parameter was met. Nursing staff did not verify that the resident met the ordered parameters before administering the PRN furosemide, as required by facility policy. The nurse responsible for the errors did not clarify the order prior to administration and failed to ensure accurate documentation of weights and medication administration. The facility's consultant pharmacist confirmed that the resident received furosemide in error on three occasions, although it was not considered clinically significant in this case. The facility policy directed that nurses must compare the medication and dosage schedule with the MAR and verify that all physician parameters for administration are met prior to giving the medication.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive infection prevention and control program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure in Routine Wound Monitoring and Documentation
Penalty
Summary
The facility failed to perform routine monitoring of a wound to promote healing for a resident with a stage 3 pressure ulcer on the right heel. The resident, who was cognitively intact and had Type 2 diabetes, was identified as having impaired skin integrity related to incontinence and was at risk for skin breakdown. The care plan required weekly wound measurements and documentation, but the Wound Management Detail Report showed no measurements from mid-April to early June. The resident's wound was debrided in April, but subsequent documentation was inconsistent, and a dressing change revealed purulent drainage and an additional reddened area. Interviews with staff revealed that the facility's designated wound nurse left in mid-April, leading to inconsistent documentation practices. The LPN stated that wound documentation was entered on bath days, but not all staff documented in the same place. The RN confirmed the lack of measurements after mid-April and emphasized the importance of wound monitoring for healing and infection prevention. The DON acknowledged the inconsistency in documentation due to the lack of access to the wound form by LPNs, which resulted in incomplete documentation of required information such as measurements and wound descriptions. A wound care policy was requested but not provided.
Inadequate Hand Hygiene and EBP Implementation
Penalty
Summary
The facility failed to perform proper hand hygiene for two residents during activities of daily living (ADLs). One resident with severe cognitive impairment was assisted by two nursing assistants who did not perform hand hygiene after removing soiled gloves and before applying clean ones. They continued to assist the resident with dressing and oral care without washing their hands, despite acknowledging the importance of hand hygiene. Another resident with mild cognitive impairment was assisted by a nursing assistant who also failed to perform hand hygiene after removing soiled gloves and before handling items that would go into the resident's mouth. Additionally, the facility did not implement Enhanced Barrier Precautions (EBP) for a resident with a stage 3 pressure ulcer. The care plan and physician orders did not include EBP, and there was no signage or personal protective equipment available for the resident. A licensed practical nurse performed a dressing change without wearing the appropriate PPE, under the assumption that EBP was not necessary because the wound was not infected. The director of nursing acknowledged the need for EBP for residents with draining wounds but admitted that the facility had not interpreted the guidance correctly. The facility's policies on hand hygiene and EBP were not followed, leading to potential risks of infection transmission. The hand hygiene policy required staff to wash hands before and after resident contact and after removing gloves, which was not adhered to in the observed cases. The EBP policy, aligned with CDC guidelines, required the use of gowns and gloves for residents with wounds, which was not implemented for the resident with a pressure ulcer.
Mechanical Lift Transfer Safety Deficiency
Penalty
Summary
The deficiency identified in the report pertains to a nursing home's failure to ensure safe transfers using a mechanical lift, resulting in an immediate jeopardy situation for one of the residents (R1). The incident occurred when R1 fell during a transfer in a full-body mechanical lift that tipped over, causing him to hit his head on the floor. It was noted that the facility did not confirm if the staff were correctly using the lift per manufacturer recommendations during the incident, and subsequent observations revealed that manufacturer guidelines for safe use were not consistently followed. R1, the resident involved in the incident, had a documented medical history that included chronic pain, depression, obesity, and long-term use of anticoagulants. His care plan specified the use of a full-body mechanical lift for transfers, with a requirement for a nurse to be present in the room during transfers involving two nursing assistants. The report highlighted instances where the sling size used for R1 was not appropriate based on his weight gain, and where staff did not follow manufacturer recommendations for securing the straps of the sling during transfers, leading to safety concerns and the eventual fall. Interviews with staff members and R1 himself provided insights into the events leading up to the deficiency, including issues with extending the lift's legs under the bed, challenges with sling adjustments, and concerns about the battery power of the lift. The report also referenced the manufacturer's safety guidelines for the mechanical lift, emphasizing the importance of proper positioning, sling attachment, and battery maintenance to ensure safe transfers. The deficiency was further compounded by staff actions such as not addressing low battery warnings and inadequate verification of strap security, ultimately resulting in the immediate jeopardy situation for R1.
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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 Fosston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mcintosh Senior Living | 8.2 mi | ★★★★★ | 6 | 0 |
| Cornerstone Nsg & Rehab Center | 16.5 mi | ★★★★★ | 1 | 0 |
| Mahnomen Health Center | 21.1 mi | ★★★★★ | 11 | 0 |
| Fair Meadow Nursing Home | 25.2 mi | ★★★★★ | 12 | 0 |
| Jourdain Perpich Ext Care Fac | 39.1 mi | ★★★★★ | 9 | 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.