Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mahnomen Health Center during CMS and state inspections, most recent first.
Failure to Submit PBJ Staffing Data: The facility failed to accurately submit PBJ staffing data to CMS based on payroll and other verifiable and auditable data. CMS identified the quarter as triggered for failure to submit data. The CFO stated the staff member with access to the PBJ submission program left the facility, no one else had access, and the Q4 data had not been submitted before the submission window passed.
The facility failed to ensure the QAA committee had required members present and that attendance was documented at quarterly meetings. Several QAPI minutes did not identify attendees, and the medical director was not identified as attending multiple meetings. The infection prevention information presented to the committee was also incomplete, with UTIs, pneumonias, wounds, and other infections lacking full documentation of cultures, symptoms, medications, and trend analysis. The DON/IP stated the facility was still trying to figure out what was needed for QAPI infection control information, and the medical director could not recall the last meeting he attended.
Failure to Track, Trend, and Analyze Infections: The DON, who also served as the IP, stated the facility did not have a system to track resident symptoms or infections and relied on chart review and staff communication instead. QAPI minutes showed multiple UTIs, pneumonias, wounds, and other infections, but the records lacked key details such as signs and symptoms, testing, organism, precautions, and resolution status, and did not include analysis of potential infections or trends. The DON later reviewed each case individually and stated many UTIs did not meet Loeb's criteria, while also noting a bathtub drainage issue had been discussed as a possible source without bacterial testing or organism pattern analysis.
Failure to monitor antibiotic use and follow the antibiotic stewardship program. Two residents were treated for UTI despite UA results showing no predominant organism and no culture confirmation. One resident had confusion, weakness, and an ER transfer before receiving IV Rocephin and later TMP-SMX; another had urinary frequency and was ordered Macrobid. The DON stated there was no tracking system to quickly identify symptoms or infections, and the medical director was uncertain how antibiotic use was tracked.
The facility failed to ensure the DON serving as the IP had completed specialized infection prevention training and certification, and could not provide documentation of an approved infection prevention course or the IP job description. The facility also failed to implement an infection surveillance plan and a comprehensive antibiotic stewardship program, including monitoring antibiotic use for two residents prescribed antibiotics.
MDS Medication Coding Errors: The facility failed to code medications correctly on the MDS for two residents. One resident’s MAR showed a diuretic and an antianxiety medication, and another resident’s MAR showed an antiplatelet medication, but those medication classes were not entered on the MDS. RN-A stated the medications were missed when the MDS was completed, and the DON said each portion of the MDS was expected to be completed correctly because it can affect care plans, payment, and quality measures.
A resident with a high fall risk and functional impairments frequently self-transferred to the bathroom without using the call light, relying on a chair alarm that alerted staff too late. The care plan lacked adequate interventions for frequent toileting and increased supervision, despite the resident's use of diuretics and history of falls. Staff interviews revealed the ineffectiveness of the alarm system and the need for updated care plans and frequent checks.
Failure to Submit PBJ Staffing Data
Penalty
Summary
The facility failed to accurately submit PBJ staffing data to CMS based on payroll and other verifiable and auditable data. The facility’s PBJ submission for the quarter ending 12/31/25 was identified by CMS as triggered for failure to submit data for that quarter. During interview, the CFO stated that the staff member who had access to the PBJ submission program and submitted the data in 2025 no longer worked at the facility in 2026, and no one else in the facility had access to the program. The CFO stated the staff member had not submitted the Q4 2025 data before leaving, and by the time the facility realized the data had not been submitted, the submission window had passed.
QAA Committee Attendance and Infection Surveillance Documentation Deficiencies
Penalty
Summary
The facility failed to ensure the Quality Assessment and Assurance (QAA) committee had the required members present and that attendance was documented at quarterly meetings. Review of QAPI meeting minutes showed that several meetings failed to identify who attended, including the June 2025, September/October 2025, and November/December 2025 meetings. In the July/August 2025 and January 2026 meetings, the medical director was not identified as attending, and in the February 2026 meeting the medical director was again not identified as attending. The facility’s QAPI policy dated 1/22/26 identified that the QAPI committee was to be attended by the medical director. The infection prevention information presented to the QAA committee was incomplete and did not provide a comprehensive review of infection surveillance or antibiotic use. The June 2025 minutes noted one resident with a UTI treated for five days without the medication name or urine culture analysis, and another resident started on an antibiotic for possible aspiration without the medication name or symptoms documented. Other meeting minutes listed UTIs, pneumonias, wounds, and other infections, but several entries lacked organism identification, treatment details, symptom documentation, or analysis of culture results. January 2026 minutes referenced a COVID outbreak and stated to see outbreak information, but the minutes still lacked a comprehensive review of surveillance trends and analysis. During interview, the DON, who was also the facility IP, stated the QAPI meeting was held at least quarterly and was supposed to include the DON/IP, administrator, medical director, and care coordinators, with other department heads also attending. The DON stated attendance was taken and entered into the minutes, but also said the medical director would attend if able and would have to review the minutes to see when he last attended. The DON further stated the facility was still trying to figure out what was needed with QAPI regarding infection control information and follow-up needed for areas of concern. The medical director stated he attended QAPI meetings sometimes but could not clearly recall the last time he had attended, although he reviewed the meeting minutes.
Failure to Track, Trend, and Analyze Infections
Penalty
Summary
The facility failed to establish and implement an infection prevention and control program with an outcome surveillance process to track, trend, and analyze resident actual and potential infections. The last three months of infection control tracking, trending, and analysis were requested but not provided. The DON, who also served as the infection preventionist, stated she did not have a system to track resident symptoms or infections and instead reviewed medical records and communicated with nursing staff to identify possible illnesses or infections. She later stated she had not been formally tracking infections, although she referenced interdisciplinary notes and QAPI minutes as the basis for what had been done regarding infections. Review of the QAPI minutes from the prior standard survey showed infection entries that lacked comprehensive data collection, including resident name, whether the infection was facility acquired, location, signs and symptoms, testing, results, organism, precautions, and resolution status. The minutes primarily listed infections that required antibiotics and did not include potential infections or analysis for trends. During interview, the DON had to look up each resident and identify signs, symptoms, and progression because the infections had not been tracked, trended, or analyzed. She also described clusters of UTIs in which the facility noted a bathtub drainage issue, but the drain was only cleaned and staff were educated; the drain was not tested for bacteria and microorganisms were not investigated for patterns. The DON stated many of the UTIs did not meet Loeb's criteria and acknowledged she had not documented other possible reasons for the continued UTIs or analyzed microorganisms for patterns.
Failure to Monitor Antibiotic Use and Follow Stewardship Program
Penalty
Summary
The facility failed to implement its comprehensive antibiotic stewardship program and failed to maintain a facility-wide system to monitor antibiotic use for two residents who were prescribed antibiotics. For one resident, progress notes documented confusion and weakness, followed by transfer to the ER and return to the facility with a diagnosis of UTI and new orders for outpatient IV Rocephin. The resident’s UA showed no predominant organism and no further identification or susceptibility testing was done, yet the facility continued treatment for UTI and later discontinued IV antibiotics and started sulfamethoxazole-trimethoprim. For the second resident, progress notes documented frequent requests to use the bathroom, a UA was sent, and the UA again showed no predominant organism with no culture completed, yet Macrobid was ordered for UTI and a 72-hour antibiotic time-out documented continued treatment through the end date. The DON, who also served as the infection preventionist, stated she did not have a tracking system to quickly identify resident symptoms or infections and reviewed the residents’ medical records. She also stated that, for the most part, providers over prescribed antibiotics and many residents had not met Loeb’s criteria for UTI. The medical director stated he was uncertain how the facility tracked antibiotic use and noted that mid-level practitioners often prescribed 3-day antibiotics while physicians usually prescribed 5-day antibiotics. The facility’s Antibiotic Stewardship Program stated it was intended to promote appropriate antibiotic use and included assessment using Loeb criteria and a 72-hour antibiotic time-out.
Unqualified IP and Failed Infection Surveillance and Antibiotic Stewardship
Penalty
Summary
The facility failed to designate a qualified infection preventionist responsible for the infection prevention and control program because the DON, who also served as the facility IP, had completed online infection control courses but had not taken the certification test and could not provide documentation or a certificate of completion of an approved infection prevention course. During interview, the DON stated she had worked as the IP nurse for two years. A copy of the facility’s Infection Preventionist job description was requested but not received. The report also states the facility failed to establish and implement a surveillance plan to track, trend, and analyze resident actual and potential infections, and failed to implement a comprehensive antibiotic stewardship program and a facility-wide system to monitor antibiotic use for two residents who were prescribed antibiotics.
MDS Medication Coding Errors
Penalty
Summary
The facility failed to ensure medications were coded correctly on the Minimum Data Set (MDS) for 2 of 5 residents reviewed for unnecessary medications. The MDS 3.0 RAI Manual dated 10/25 directs facilities to document how many days the resident received specific medication classes, including antipsychotic, antianxiety, antidepressant, hypnotic, anticoagulant, antibiotic, diuretic, opioid, antiplatelet, hypoglycemic, and none of the above. For one resident, the February 2026 MAR showed Aldactone, a diuretic, 25 mg every morning for CHF and Buspirone, an antianxiety medication, 7.5 mg twice a day for anxiety, while the annual MDS identified diagnoses of CHF, high blood pressure, and anxiety and also indicated the resident was taking an antipsychotic, antidepressant, and hypoglycemic medication. The MDS did not identify that the resident received a diuretic or an antianxiety medication during the observation period. For the second resident, the February 2026 MAR showed Plavix, an antiplatelet medication, 75 mg once daily for heart attack, while the admission MDS identified a diagnosis of left hip fracture and indicated the resident was taking antipsychotic, antianxiety, antidepressant, and opioid medications. The MDS did not identify that the resident received an antiplatelet medication during the observation period. RN-A stated the medications were missed and did not get entered into the MDS, and the DON stated it was the expectation that each portion of the MDS be completed correctly because it can affect care plans, payment, and quality measures.
Failure to Implement Effective Fall Prevention Strategies
Penalty
Summary
The facility failed to develop and implement effective interventions to reduce fall risks for a resident identified as a high fall risk. The resident, who had intact cognition but was socially isolated, had functional impairments and required assistance with various activities of daily living. Despite being identified as a fall risk with a history of falls, the resident's care plan lacked adequate interventions related to frequent toileting and increased supervision, even though the resident was on a diuretic, which commonly causes frequent urination. The resident's care plan and ADL worksheet were not updated to reflect the current level of care and assistance required. The resident frequently self-transferred to the bathroom without using the call light, relying instead on a chair alarm that only alerted staff after the resident had already stood up. Interviews with staff revealed that the resident often reached the bathroom before staff could respond to the alarm, indicating that the alarm system was ineffective in preventing falls. Staff were aware of the resident's impulsive behavior and shortness of breath during ambulation, yet the care plan did not include a toileting schedule or frequent checks to mitigate these risks. The facility's policies on bed and chair alarms and care planning were not adequately followed, as the resident's care plan was not updated in a timely manner to reflect changes in the resident's condition. The director of nursing acknowledged the resident's high fall risk and impulsive behavior but confirmed that the care plan lacked necessary interventions such as frequent checks and a toileting schedule. The failure to update the care plan and implement effective fall prevention strategies contributed to the resident's continued risk of falls.
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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 Mahnomen
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fair Meadow Nursing Home | 20.7 mi | ★★★★★ | 12 | 0 |
| Viking Manor Nursing Home | 20.7 mi | ★★★★★ | 0 | 0 |
| First Care Living Center | 21.1 mi | ★★★★★ | 10 | 0 |
| Mcintosh Senior Living | 23.2 mi | ★★★★★ | 6 | 0 |
| Benedictine Care Community | 26.1 mi | ★★★★★ | 31 | 1 |
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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.