Mahnomen Health Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF886May 26, 2021

  Based on observation, interview and document review, the facility failed to test all active staff for COVID-19 prior to working, after an identified COVID-19 outbreak, as directed by the Centers for Disease Control (CDC). This practice resulted in an immediate jeopardy (IJ) situation which had the high likelihood to cause serious illness and/or death for 3 of 26 residents (R13, R15, R20) who resided at the facility and were not fully vaccinated against COVID-19. The IJ began on 3/24/21, when a staff member tested positive for COVID-19 and the facility failed to ensure all active staff were immediately tested for COVID-19 prior to working; along with following ongoing outbreak testing to ensure no more active cases were circulating within the facility. […]

• Actual harm, isolatedF689Apr 12, 2022

  Based on interview and document review, the facility failed to ensure interventions were developed and implemented to prevent falls for 3 of 3 residents (R1, R2, R3) who had a history of falls. This resulted in actual harm to R1 who sustained a [CONDITION(S)] following a fall, actual harm to R2 who required 7 staples in her head following a fall, and actual harm to R3 who sustained a compression fracture following a fall. Findings include: R1 R1's admission Minimal Data Set (MDS) dated [DATE], indicated R1 was cognitively intact with a diagnosis of stroke. The MDS indicated R1 required extensive assist of two staff for bed mobility, transfers, ambulation in room, and toileting. In addition, the MDS indicated R1 had two or more falls since admission. […]

• Actual harm, isolatedF697Apr 12, 2022

  Based on observation, interview, and document review, the facility failed to ensure complaints of worsening low back pain were comprehensively assessed and treated in a timely manner to provide comfort and reduce risk of complications for 1 of 1 residents (R3) who voiced concerns about pain management. This resulted in actual harm when staff failed to follow physician ordered lumbar xrays, collaborate with other health professionals and address ongoing severe pain for several weeks which resulted in a decline in R3's activities of daily living (ADLs). Findings include: R3's significant change Minimal Data Set (MDS) dated [DATE], indicated R3 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF851Mar 11, 2026

  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. […]

• No harm, potential for more than minimal, widespreadF868Mar 11, 2026

  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. […]