Aitkin Health Services

In the surveyor’s words

From the most serious findings on record at Aitkin Health Services, in the surveyor’s own words.

• Immediate jeopardy, isolatedF700Dec 29, 2022

  Based on interview and record review, the facility failed to assess and/or re-assess and review for risks and benefits of the use of assistive devices including bed rails resulting in risk of potential serious harm, injury, impairment, or death for 1 of 4 (R1) residents who had a bed rail in place despite being at risk and was found with head between the mattress and bed rail. This resulted in an Immediate Jeopardy for R1. Additionally, the facility failed to assess and/or re-assess and review for risks and benefits of the use of assistive devices including bed rails for 3 of 4 residents (R2, R3, R4) reviewed for safety. The immediate jeopardy began on 10/12/22, when bed rails were placed on R1's bed prior to an assessment being completed to determine safe for use. […]

• Immediate jeopardy, isolatedF880Oct 15, 2021

  Based on observation, interview and document review, the facility failed to implement the Centers for Disease Controls (CDC) guidance for individualized transmission-based precautions including appropriate personal protective equipment (PPE) and isolation precautions to prevent the spread of COVID-19 for 1 of 1 resident (R3) who displayed symptoms of COVID-19. This practice resulted in an immediate jeopardy (IJ) situation which had the high likelihood to cause serious illness and/or death In addition, the facility failed to ensure proper hand hygiene was performed during dining for 2 of 5 (R9, R34) residents reviewed for dining; failed to ensure shared equipment was cleaned and disinfected for 2 of 3 (R9, R39) residents reviewed for shared equipment use; and failed to ensure soiled laundry… […]

• Actual harm, isolatedF689Dec 12, 2024

  Based on interview and document review, the facility failed to supervise, implement, and assess fall interventions to reduce the risk of falls for 1 of 3 residents (R1) reviewed for falls. This resulted in actual harm when R1 fell and sustained a laceration to the middle of her forehead which required an emergency department (ED) visit and sutures. Findings include: R1's Face Sheet dated 4/29/24, indicated R1 had arthritis in both hips, spinal stenosis (abnormal narrowing of the spinal canal), and mild cognitive impairment. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had mild impaired cognition, had two or more falls without injury and one fall with minor injury, and needed extensive assistance with transfers, toileting and bed mobility. […]

• Actual harm, isolatedF684Jul 10, 2024

  Based on interview and document review, the facility failed to ensure treatment and care in accordance with professional standards of practice for 1 of 3 residents (R1) reviewed who did not receive the necessary care and monitoring related to multiple incorrect insertion attempts of an indwelling catheter which resulted in bleeding, blood clots, pain, discomfort, low urine output, and low blood pressure, leading to a diagnosis of sepsis and admission to the Intensive Care Unit (ICU) via ambulance. This resulted in actual harm for R1. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified severely impaired cognition and no behaviors noted. […]

• No harm, potential for more than minimal, widespreadF880Jun 4, 2026

  Based on observation, interview, and document review the facility failed to ensure linens were handled properly to help prevent the spread of infection. In addition, the facility failed to maintain a water management program which identified potential areas for water-borne bacteria and maintain records of water management activities. Findings include:Linen HandlingDuring an observation on entrance on 6/1/26 at 1:50 p.m., in an alcove next to the elevator down to the conference room, stood a three-shelved unit storing clean linens, the cover was observed up over the top of the unit and there were items stored up on top of the cover which was folded back. A sign on the cart indicated please close the cover. […]