Aftenro Home
Duluth, Minnesota · CCN 24E355
20 surveys since 2011, 7 of them producing a finding at harm level or worse.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
- Citations on record
- 151
- Surveys
- 20
- Harm or worse
- 7
- Immediate jeopardy
- 3
Findings at the most serious level CMS records.
Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.
The facility
- Certified beds
- 54
- Ownership
- Non profit - Corporation
- Chain
- Independent
- County
- St. Louis
- Medicare-certified since
- 1981
CMS ratings
- Overall
- 1
- Health inspection
- 1
- Staffing
- 5
- Quality measures
- 1
CMS’s own Five-Star ratings.
Compared with similar facilities
Since 2021, this facility recorded more weighted findings than most of its peer group.
Weighted by harm level, against 123 not-for-profit facilities with fewer than 66 beds in Minnesota.
Last survey on record
Mar 19, 2026
235 days ago.
Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.
Staffing
| Measure | This facility | Peer median |
|---|---|---|
| Nurse hours per resident day | 3.52 | 4.22 |
| Registered-nurse hours per resident day | 1.00 | — |
| Annual nurse turnover | 26.4% | 42.1% |
As reported by the facility to CMS, beside the peer-group median.
Enforcement
No fines, payment denials or special-focus designation on the current CMS record.
Severity of recent findings
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J— | K— | L— |
| Actual harm | G— | H— | I— |
| No harm, potential for more than minimal | D1145.8% | E28.3% | F937.5% |
| No harm, potential for minimal | A— | B14.2% | C14.2% |
Most frequently cited here
In CMS’s current monthly file.
- F6562×
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- F6922×
Provide enough food/fluids to maintain a resident's health.
- F8802×
Provide and implement an infection prevention and control program.
- F5651×
Honor the resident's right to organize and participate in resident/family groups in the facility.
- F5671×
Honor the resident's right to manage his or her financial affairs.
In the surveyor’s words
From the most serious findings on record at Aftenro Home, in the surveyor’s own words.
- Immediate jeopardy, isolatedF678Sep 27, 2021
Based on observation, interview and document review, the facility failed to ensure documentation of each resident's advance directive/code status was consistent throughout their records to ensure the code status reflected resident current resuscitation preferences and physician orders. The facility's failure resulted in an immediate jeopardy, risk of serious harm, injury, impairment, or death for 1 of 16 residents (R27) reviewed for advance directives. The immediate jeopardy began on [DATE], when R27 changed her preference from requesting cardiopulmonary resuscitation (CPR) to do not attempt resuscitation (DNR). […]
- Actual harm, isolatedF689Jan 19, 2021
Based on interview and document review, the facility failed to perform a comprehensive root cause analysis which identified individualized risk factors to reduce the likelihood of subsequent falls, and failed to develop a comprehensive care plan which identified fall risk factors and/or implement resident centered interventions to reduce the risk of falls for 2 of 4 residents (R1, R4) reviewed for accidents. This resulted in actual harm for R1 who fell and suffered a head injury which required medical intervention. Findings include: R1's Admission Record printed [DATE], indicated R1's [DIAGNOSES REDACTED]. R1's significant change Minimum Data Set ((MDS) dated [DATE], indicated R1 had moderate cognitive impairment. […]
- No harm, potential for more than minimal, widespreadF755Mar 19, 2026
Based on observation, interview and document review, the facility failed to ensure the narcotic emergency kit was tracked to prevent potential theft and diversion of medications. This had the potential to affect all residents residing on the nursing unit.Findings include:On 3/18/26 at 1:05 p.m., a tour of the locked medication room was conducted with registered nurse (RN)-D. The medication room had one emergency kit that contained controlled substances, was locked in a cupboard and had a plastic numbered lock on it. RN-D stated the emergency kit containing narcotics was swapped out weekly by pharmacy. If the emergency kit was used they would fill out a slip identifying what was used and for which resident. […]
- No harm, potential for more than minimal, widespreadF801Mar 19, 2026
Based on interview and document review, in the absence of a full-time registered dietician the facility failed to designate a qualified person to serve as the director of food and nutrition services. This deficient practice had the potential to affect any resident in the facility.Findings include:During an interview on 3/16/26 at 8:22 a.m., the dietary manager (DM) stated she didn't have a certified dietary manager (CDM) certificate, and didn't think anyone here did, but the dietician was here several times a month. During an interview on 3/18/26 at 2:27 p.m., the administrator stated the DM didn't have a CDM certificate and wasn't enrolled in the program yet but had been at a previous employment. […]
- No harm, potential for more than minimal, widespreadF806Mar 19, 2026
Based on observation, interview, and document review the facility failed to ensure a reliable system for identifying ingredients containing food allergens, and to ensure residents were not served items they were allergic to. In addition, the facility failed to have pre-planned menus for therapeutic diet types for 2 of 2 residents (R5, R35) reviewed for nutrition and food concerns.Findings include:R5's quarterly minimum data set (MDS) dated [DATE], identified R5 had intact cognition, a diagnosis of diabetes mellitus (DM), unplanned weight loss and needed set-up assistance with eating.R5's care plan dated 1/8/25, identified a focus statement related to DM and included interventions to have a dietary consult for nutritional regimen and ongoing monitoring, to discuss mealtimes, portion sizes,… […]
Read 27 findings in full →The most serious and the most recent: 27 of 151 on record.
Every survey on record
FindingsAt actual harm or above
- Mar 19, 2026Standard and complaint14 findings
- Jan 9, 2025Standard6 findings
- Oct 25, 2023Standard4 findings
- Dec 1, 2022Standard and complaint4 findings
- Dec 23, 2021Complaint1 finding
- Sep 27, 2021Standard17 findings · 1 harm
- Jan 19, 2021Complaint1 finding · 1 harm
- Apr 1, 2020Infection control1 finding
Show the 12 earlier surveys
- Dec 12, 2019Standard11 findings · 1 harm
- May 15, 2019Complaint3 findings
- Oct 4, 2018Standard8 findings
- Feb 8, 2018Standard8 findings
- Apr 27, 2017Standard9 findings · 1 harm
- Mar 18, 2016Standard11 findings
- Jan 30, 2015Standard9 findings
- Jun 11, 2014Standard2 findings
- Jun 13, 2013—2 findings
- Apr 24, 2013Standard19 findings · 3 harm
- Jul 18, 2012—9 findings
- Jun 9, 2011—12 findings
Surveys that found no deficiencies are not in CMS’s files and do not appear here.
Comparable facilities
The nearest facilities to this one in the same peer group, by weighted findings.
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction