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Mahnomen Health Center

414 West Jefferson Avenue, Mahnomen, MN 56557 · Government - City/county · 32 certified beds · (218) 935-2511 Medicare & Medicaid certified

Call the home — (218) 935-2511 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Mar 2024$12,534 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Mar 2024
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (15) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $12,534 in federal fines (most recent 2024-02-06)
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection rating is low (2/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 4 of 5

Worth a closer look. This home's staffing and quality-measure ratings run 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
40520 County Highway 34 · (218) 983-4300 · Call to confirm hours
Pharmacy
211 S Main St · (218) 935-2525 · Call to confirm hours
Grocery
115 W Monroe Ave · (218) 935-2538 · Call to confirm hours
Park
Place of worship
120 W Jefferson Ave · (218) 935-2503

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 4 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 1 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating1★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased29.3%18.2%15.4%worse
Long-stay residents who lose too much weight5.4%4.1%5.4%typical
Long-stay residents with a catheter left in their bladder0.0%1.9%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection1.9%2.6%2.0%typical
Long-stay residents with depressive symptoms0.0%4.1%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury2.8%4.0%3.3%better
Long-stay residents whose ability to walk worsened20.1%20.5%16.1%worse
Long-stay residents on antianxiety or hypnotic medication21.3%12.5%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%96.1%95.3%typical
Long-stay residents with pressure ulcers0.0%5.2%4.7%check this — see note marked star below the table
Long-stay residents with worsening bladder/bowel control32.7%24.5%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table15.4%17.1%17.1%typical
Short-stay residents who newly got an antipsychotic medication4.3%1.9%1.4%worse

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

0.09U.S. median 0.31
Therapy hours / resident / day
0.05hours / resident / day
Physical therapy
0.04hours / resident / day
Occupational therapy
<0.01hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.09 therapist hours per resident per day in 2026Q1 — more than 5% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 0% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFsnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.80
RN hours/ resident / day
0.55
LPN hours/ resident / day
2.89
Aide hours/ resident / day
4.24
Total nurse hours/ resident / day
0.43
RN hoursweekends
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 32 beds and averages 28.5 residents a day — about 89% occupied, or roughly 4 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.24 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.80 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.89 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.83 hrs/resident/day on weekends vs 4.41 on weekdays — 13% thinner on weekends. RN hours go from 0.95 to 0.43 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

6
deficiencies at the latest standard inspection (2026-03-11)
3
at the previous standard inspection (2025-06-04)

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

15 citations, most serious first. The 10 most serious are shown; the remaining 5 are one tap away and print in full.

  • Potential for harm · F2026-03-11 · tag F0851 — widespread
    Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and document review, the facility failed to accurately submit the payroll-based journal system (PBJ) staffing data to Centers for Medicare and Medicaid Services (CMS). This had the potential to affect all 31 residents residing in the facility.Findings include:The facilities PBJ data submitted to CMS for 10/1/25, through 12/31/25 (Q4 25), identified the facility was triggered for failure to submit data for the quarter.On 3/10/26 at 10:40 a.m., the chief financial officer (CFO) stated the staff member that submitted the PBJ data in 2025 no longer worked for the facility as of 2026. The staff member had access to the PBJ submission program, however there wasn't anyone else in the facility with access and the staff member had not submitted Q4 2025 data prior to leaving their position. The CFO stated by the time they realized the data hadn't been submitted, the timeframe had passed, and they were unable to submit. The CFO stated they have a plan to move forward to ensure the data will be submitted in a timely manner.A policy regarding submitting data to the Centers for…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2026-03-11 · tag F0868 — widespread
    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and document review the facility failed to ensure the Quality Assessment and Assurance (QAA) committee failed to ensure the medical director was present quarterly and attendance of key members was documented. In addition, the facility infection preventionist (IP) failed to provide comprehensive infection control and antibiotic infomration as required for proper QAA analysis. These findings had potential to affect all 29 residents residing within the facility. Findings include:The Quality Assurance and Performance Improvement (QAPI) meeting minutes from the last standard survey dated 6/4/25 were reviewed and identified the following:June 2025 meeting minutes failed to identify who attended the meeting. The director of nursing (DON), medical director or their designee, and at least three other staff members are required, one of which must be either the administrator, owner, board member or other individual in a leadership role along with the infection preventionist (IP)July/August 2025 meeting identified the following were in attendance: DON who is also the IP, the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2026-03-11 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and document review the facility failed to establish and implement an outcome surveillance program to track, trend and analyze resident actual and potential infections. This had the potential to affect all 29 residents that resided in the facility. Findings include:The last three months of infection control tracking, trending and analysis were requested and not received. On 3/9/26 at 5:11 p.m., the director of nursing (DON), who also worked as the infection preventionist, stated she did not have a system to track resident symptoms or infections. She stated she reviewed the resident's medical records and communicated with the nursing staff to help identify symptoms of illnesses or infections.On 3/10/26 at 8:20 a.m., the DON stated although she had not been formally tracking infections, she did have interdisciplinary (IDT) notes and Quality Assessment and Performance Improvement (QAPI) minutes to show what she had been doing regarding infections.The QAPI meeting minutes from the last standard survey dated 6/4/25 were reviewed and identified the following:June 2025,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2026-03-11 · tag F0881 — failed to use antibiotics responsibly — widespread
    Implement a program that monitors antibiotic use.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and document review, the facility failed to implement their comprehensive antibiotic stewardship program to help reduce unnecessary antibiotic use and infections; and implement a facility-wide system to monitor the use of antibiotics for 2 of 2 residents (R5, R16) in the sample who were prescribed antibiotics. The lack of a follow through on a program had the potential to affect all residents prescribed antibiotics. Findings include:R5:R5's progress notes dated 12/25/26 through 12/26/26, identified R5 had confusion and weakness, and on 12/26/26, was sent to the emergency room (ER). Later that same day, R5 returned to the facility with a diagnosis of UTI (urinary tract infection) and new orders for outpatient intravenous (IV) Rocephin (antibiotic). R5's UA (urine analysis) results dated 12/26/25, identified there was no predominant organism, and no further identification or susceptibility would be done.R5's ED notes dated 12/26/25, identified R5 received Rocephin (antibiotic) 1gm IV x 1 dose.R5's progress note dated 1/28/26, identified R5's IV antibiotics were…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2026-03-11 · tag F0882 — widespread
    Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and document review the facility failed to ensure the infection preventionist (IP) had completed specialized training in infection prevention and control and received certification. This had the potential to affect all 29 residents residing in the facility. Findings include:See F880: Based on interview and document review the facility failed to establish and implement a surveillance plan to track, trend and analyze resident actual and potential infections. This had the potential to affect all 29 residents that resided in the facility. See F881: Based on interview and document review, the facility failed to implement their comprehensive antibiotic stewardship program to help reduce unnecessary antibiotic use and infections; and implement a facility-wide system to monitor the use of antibiotics for 2 of 2 residents (R5, R16) in the sample who were prescribed antibiotics. The lack of a follow through on a program had the potential to affect all residents prescribed antibiotics. The infection preventionist infection control certification was requested and not…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-11 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure medications were coded correctly on the Minimum Data Set (MDS) for 2 of 5 residents (R5, R20) reviewed for unnecessary medications. Findings include: The MDS 3.0 Resident Assessment Instrument (RAI) Manual dated 10/25 directs facilities to document how many days the resident received the following classes of medications: antipsychotic, antianxiety, antidepressant, hypnotic, anticoagulant, antibiotic, diuretic, opioid, antiplatelet, hypoglycemic and none of the above. R5: During the MDS observation period from 1/29/26 through 2/4/26, R5's February 2026, medication administration record (MAR), identified R5 was receiving the following medications:Aldactone (a diuretic) (commonly known as a water pill) 25 milligrams (mg) every morning for congestive heart failure.Buspirone (an anti-anxiety medication) 7.5 mg twice a day for anxiety. R5's annual Minimum Data Set (MDS) dated [DATE], identified R5 had diagnoses of congestive heart failure, high…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-06-04 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 2 of 2 residents (R11, R27) reviewed for unnecessary medications; 2 of 2 residents (R8, R17) reviewed for restraints; and 7 of 7 residents (R4, R8, R26, R6, R10, R17, R20, R26) reviewed for grab bars. Findings include: MEDICATIONS: R11 R11's annual Minimum data set (MDS) dated [DATE], identified R11 had a moderate cognitive impairment and had diagnoses that included dementia, major depressive disorder, anxiety, and chronic obstructive pulmonary disease (COPD). R11used antipsychotic, antianxiety, and antidepressant medications. The MDS further identified R11 had not had a gradual dose reduction (GDR) or R11 had documented an indication for use. R11's physician orders identified the following: - buspirone (antianxiety medication) 7.5 milligram (mg) tablet; take 1 tablet by mouth three times a day. - donepezil ((cholinesterase inhibitors) Donepezil is a medication primarily used to treat dementia…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-06-04 · tag F0700 — pattern
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure residents with attached grab bars were comprehensively assessed for use on the bed for 7 of 7 residents (R4, R8, R26, R6, R10, R17, R20) whom had grab bars. Findings include: R4 R4's annual Minimum Data Set (MDS) dated [DATE], identified R4 had a severe cognitive impairment and had diagnoses that included dementia. R4 was nonambulatory, required substantial assistance for eating and was dependent on staff for all other care areas. The MDS did not identify R4 used grab bars. R4's care plan dated 7/7/22, identified R4 was contracted at bilateral knees to 90 degrees flexion (bent). R4 had pain with some stretching into extension more in left knee than in right knee but was able to complete range of motion (ROM) at ankles and hips with no difficulties. Res. also has tightness noted in left ring and pinky finger, no other tightness or difficulties noted with ROM in bilateral upper extremities. The care plan did not identify R4 used…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-04 · tag F0604 — failed to not use physical restraints improperly — isolated
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure residents were free from physical restraints while in bed for 2 of 2 residents (R8, R17) reviewed for restraints. Findings include: R8: R8's quarterly Minimum Data Set (MDS) dated [DATE], identified R8 had a mild cognitive impairment and had diagnoses that included history of a stroke, hallucinations, disorientation, restlessness and agitation, hemiplegia (one sided paralysis) and hemiparesis (one sided weakness). R8 was nonambulatory and required touching/supervision assistance for eating and was dependent on staff for all other care areas. The MDS identified no restraints were used for R8. R8's Activities of Daily Living (ADLs) Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 2/20/25, identified R9 was dependent on staff for most ADLs and R8 had left sided neglect from a stroke. R8's care plan revised 5/22/25, identified R8, on admit, did seem to be a low risk for falls/elopement. R8 was chair fast and could…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-24 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to develop and implement interventions to reduce fall risks for 1 of 3 residents (R3) reviewed for accidents. Findings include: R3's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition, socially isolated self often, and no behaviors identified. R3 had functional impairment upper extremity on one side. R3 required supervision or touching assistance with personal hygiene, sit to stand, ambulation, toilet transfers, toileting hygiene, shower/bath, upper body dressing, and putting on and taking off footwear. R3 required partial to moderate assistance with lower body dressing. R3 was frequently incontinent of bladder and occasionally incontinent of bowel. R3 had diagnoses of anemia (low red blood cell that carry oxygen to the body and can cause fatigue and shortness of breath), CHF (congestive heart failure), diabetes mellitus (DM), depression, and asthma (chronic lung disease affecting of the lungs and can cause shortness…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 5 citations
  • Potential for harm · Ecited before2024-03-14 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and document review, the facility failed to ensure soiled and potentially contaminated resident laundry was sorted in a manner to reduce the risk of cross contamination and subsequent infection spread. These findings had the potential to affect all 30 residents residing in the nursing home. Findings include: On 3/12/24, at 10:40 a.m. a laundry tour was completed with laundry aide (LA)-A present. LA-A stated the nursing assistants brought the resident's personal laundry down to the laundry room in blue bags and put the bags in large yellow bins. The process was to sort the resident's laundry into three separate bins of colored items, whites and heavy such as blankets. Any laundry that was contaminated would come down in a red bag, and that bag would be opened into the soaker sink and be soaked. LA-A put on gloves and removed one of the blue bags from the bin and tore it open into a laundry cart; however, did not put on a gown to protect LA-A clothes. LA-A always put disposable gloves on but had never been instructed to wear a disposable gown to…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-03-14 · tag F0883 — failed to offer flu and pneumonia vaccines — pattern
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to provide pneumococcal conjugate vaccine 20 variant (PVC20) education as directed by the Centers for Disease Control (CDC) for 4 of 5 residents (R6, R7, R8, R11) reviewed for immunizations. Findings include: R6's significant change Minimum Data Set (MDS) dated [DATE], identified R6 was [AGE] years of age with diagnoses hemiplegia following a cerebral infarction, and diabetes. The facility's Preventive Health Care Report dated 4/1/23 to 3/12/24, identified R6 received the pneumococcal polysaccharide vaccine (PPSV23) on 8/5/15, and the pneumococcal conjugate vaccine (PCV13) on 12/16/16. R6's medical record failed to provide evidence the PCV20 was offered and/or education was provided in conjunction with the provider to R6/R6's representative. R7's quarterly MDS dated [DATE], identified R7 was 78 with diagnoses atrial fibrillation, Raynaud's syndrome, and diabetes. The facility's Preventive Health Care Report dated 9/1/23 to 3/12/24, identified R7 had…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-14 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to re-assess and implement interventions to keep residents free from sexual abuse following resident to resident abuse involving residents (R16 and R21) for 1 of 1 incidents of abuse reviewed. Findings include: R16's annual Minimum Data Set, dated [DATE], identified R16 had severe cognitive impairment. R16 had not displayed physical, verbal, or other behavioral symptoms directed towards other. R21's quarterly MDS dated [DATE], identified R21 had severe cognitive impairment. R16's care plan updated 6/29/21, identified R16 had known physical affection toward others such as holding hands and touching arms/shoulders. Interventions directed staff to stop the behaviors, remind R16 the behaviors were not appropriate and remove R16 or other residents from the situation. R21's progress note dated 1/28/24, identified R21 was in the common area and R16 came up to R21 and placed his hand on R21's shoulder started rubbing, then moved down the arm and across R21's…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-14 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure an allegation of sexual abuse was reported to the facility administrator and state agency (SA) within 2 hours for resident to resident potential sexual abuse involving (R16 and R21) for 1 of 1 incidents reviewed for abuse. Findings include: R16's quarterly Minimum Data Set (MDS) dated [DATE] identified R16 had severe cognitive impairment. R21's quarterly MDS dated [DATE], identified R21 had severe cognitive impairment. R21's progress note dated 1/28/24, identified R21 was in the common area and R16 came up to R21 and placed his hand on R21's shoulder started rubbing, then moved down the arm and across R21's breast, and then R16 tried to placed his hand down R16's shirt. R21 refused and R16 gently lifted R21's chin and kissed her on her mouth. R21 seemed a little startled and asked to to her room. The was no report submitted to the SA regarding the observation of potential sexual abuse. The facilities undated investigation report identified on…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-14 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure a Level I Pre-admission Screening and Resident Review (a requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) was completed, retained in the medical record, and readily available to ensure continuity of care with mental health needs for 1 of 1 residents (R6) reviewed for PASARR. Findings include: R6's significant change Minimum Data Set (MDS) dated [DATE] identified R6 had moderate cognitive impairment and a diagnoses of psychotic disorder (other than schizophrenia) and depression. R6's undated face sheet, received on 3/14/24, identified R6 was admitted to the facility on [DATE], and diagnoses included dependent personality disorder and major depressive disorder. During an interview on 3/13/24 at 11:30 a.m., the social services designee (SSD) stated R6 was a direct admit from a nursing home which was closing and called Senior Linkage Line (a help line for PASARR). The Senior Linkage…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$12,534 in federal fines across 1 penalty.

  • $12,534 — penalty dated 2024-02-06

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

Owner / managerTypeRoleShareSince
CITY OF MAHNOMENOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST22%since 07/01/2006
MAHNOMEN COUNTYOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST78%since 07/01/2006
GUENTHER, LORIIndividualW-2 MANAGING EMPLOYEEsince 10/01/2015
KRUGER, DALEIndividualCORPORATE OFFICERsince 09/08/2015

2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

What families pay in MN

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Minnesota Medicaid page.

Typical monthly cost in Minnesota
$10,646/mo
Nursing home (semi-private)
$13,870/mo
Nursing home (private)
$6,573/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 245238. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-11, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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