Cycle 1
Health 2025-05-15 · Fire 2025-05-15
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Aitkin, MN
Aitkin Health Services
3-star overall rating with 3-star inspections with $13,575 in total fines with 5 recent health deficiencies
301 Minnesota Avenue South, Aitkin, MN
(218) 927-5514
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
42
Certified beds
Average residents
36
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
St. Francis Health Services
Operator or chain grouping
Approved since
1967-03-09
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
14 facilities
Chain averages 3 overall / 2 health / 4 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.99
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.27
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
2.64
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
3.90
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
1.26
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.48
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
0.66
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
1.12
CMS adjusted RN staffing hours
Adjusted total hours
4.40
CMS adjusted total nurse staffing hours
Case-mix index
1.21
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
54%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,049
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
37.57
Composite VBP score used to determine payment impact.
Payment multiplier
0.9908
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
1.95
Baseline 67.27% · Performance 56.86% · Measure score 1.95 · Achievement 1.67 · Improvement 1.95
Adjusted total nurse staffing
5.56
Baseline 4.26 hours · Performance 4.66 hours · Measure score 5.56 · Achievement 5.56 · Improvement 2.12
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 17 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 21 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 18 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 11 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 20.34% |
8.2%
12.1 pts better
|
Numerator 12 · Denominator 59 |
| Staff flu vaccination coverage | 35.38% |
42%
6.6 pts worse
|
Numerator 23 · Denominator 65 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 83.7% |
97.3%
13.6 pts worse
|
93.4%
9.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 70.6% · Q2 81.8% · Q3 93.9% · Q4 88.6% · 4Q avg 83.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
96.1%
3.9 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.2% |
3.9%
1.3 pts worse
|
3.3%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 3.0% · Q3 6.1% · Q4 8.6% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 12.3% |
4.3%
8 pts worse
|
11.4%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 9.7% · Q3 12.1% · Q4 8.6% · 4Q avg 12.3% |
| Percentage of long-stay residents who lose too much weight | 2.7% |
4.1%
1.4 pts better
|
5.4%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.4% · Q3 4.0% · Q4 3.8% · 4Q avg 2.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.7% |
12.4%
0.3 pts worse
|
19.6%
6.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 13.3% · Q3 10.3% · Q4 7.1% · 4Q avg 12.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.2% |
17.5%
1.7 pts worse
|
16.7%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 15.4% · Q3 22.2% · Q4 30.0% · 4Q avg 19.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 28.6% |
22.5%
6.1 pts worse
|
16.3%
12.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 28.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.0% |
18.6%
1.6 pts better
|
14.9%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.8% · Q2 14.3% · Q3 33.3% · Q4 7.1% · 4Q avg 17.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.5% |
2.3%
0.8 pts better
|
1.0%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.2% · Q4 3.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.3% |
2.6%
2.7 pts worse
|
1.7%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 0.0% · Q3 6.2% · Q4 9.1% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.6% |
24.8%
0.2 pts better
|
19.8%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.0% · Q2 11.9% · Q3 24.9% · Q4 21.2% · 4Q avg 24.6% |
| Percentage of long-stay residents with pressure ulcers | 5.2% |
5.4%
0.2 pts better
|
5.1%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 3.1% · Q3 0.0% · Q4 14.9% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 45.8% |
88.6%
42.8 pts worse
|
81.7%
35.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q2 43.5% · 4Q avg 45.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.9%
1.9 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 29.2% |
82.7%
53.5 pts worse
|
79.7%
50.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 29.2% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-07 · Fire 2024-03-07
11 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
6 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Cycle 3
Health 2023-02-02 · Fire 2023-02-02
11 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
5 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-03-07
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-04-12
F · Potential for more than minimal harm
2024-03-07
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2024-04-12
F · Potential for more than minimal harm
2024-03-07
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-04-29
F · Potential for more than minimal harm
2024-03-07
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2024-04-15
F · Potential for more than minimal harm
2024-03-07
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-04-15
E · Potential for more than minimal harm
2024-03-07
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-04-15
F · Potential for more than minimal harm
2023-02-02
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-04-12
C · Minimal harm
2023-02-02
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-04-30
C · Minimal harm
2023-02-02
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-04-12
C · Minimal harm
2023-02-02
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2023-04-04
C · Minimal harm
2023-02-02
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-04-12
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-05-15
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-06-18
D · Potential for more than minimal harm
2025-05-15
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-06-18
D · Potential for more than minimal harm
2025-05-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-18
D · Potential for more than minimal harm
2025-04-30
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-03-19
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-04-18
G · Actual harm
2024-12-12
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-12-30
G · Actual harm
2024-07-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-05
D · Potential for more than minimal harm
2024-07-10
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-08-05
D · Potential for more than minimal harm
2024-07-10
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-08-05
D · Potential for more than minimal harm
2024-07-10
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-08-05
D · Potential for more than minimal harm
2024-07-10
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-08-05
D · Potential for more than minimal harm
2024-04-24
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-05-17
D · Potential for more than minimal harm
2024-03-07
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-04-20
D · Potential for more than minimal harm
2024-03-07
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-04-20
D · Potential for more than minimal harm
2024-03-07
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-04-20
D · Potential for more than minimal harm
2024-03-07
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-04-20
D · Potential for more than minimal harm
2024-01-12
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2024-02-16
D · Potential for more than minimal harm
2024-01-12
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-02-16
D · Potential for more than minimal harm
2023-12-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-02
D · Potential for more than minimal harm
2023-12-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-02
D · Potential for more than minimal harm
2023-09-08
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-10-20
D · Potential for more than minimal harm
2023-09-08
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-10-20
D · Potential for more than minimal harm
2023-02-02
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-03-24
D · Potential for more than minimal harm
2023-02-02
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-03-24
D · Potential for more than minimal harm
2023-02-02
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-03-24
D · Potential for more than minimal harm
2023-02-02
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-03-24
D · Potential for more than minimal harm
2023-02-02
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2023-03-24
Penalties and ownership
What sits behind the stars
$13,575
2024-12-12
Fine
Fine · fine $13,575
Fine
Ownership
St. Francis Health Services Of Morris, Inc
5% Or Greater Direct Ownership Interest · Organization
Arnold, Jill
Operational/Managerial Control · Individual
Bach, Curtis
Operational/Managerial Control · Individual
Bach, Curtis
Corporate Director · Individual
Bach, Curtis
Corporate Officer · Individual
Bakke, Christine
Operational/Managerial Control · Individual
Big Stone Therapies Inc
Operational/Managerial Control · Organization
Caspers, Megan
Operational/Managerial Control · Individual
Copeman, Jeffrey
Operational/Managerial Control · Individual
Dionisopoulos, Mary
Operational/Managerial Control · Individual
Dripps, Daniel
Corporate Director · Individual
Ehlers, Douglas
Corporate Director · Individual
Eide Bailly Llp
Operational/Managerial Control · Organization
Flynn, Jennifer
Operational/Managerial Control · Individual
Goodnough, Jennifer
Corporate Director · Individual
Gramm, Timothy
Corporate Director · Individual
Hanneken, Michelle
Operational/Managerial Control · Individual
Hauver, Richard
Operational/Managerial Control · Individual
Hejhal, Roxanne
Operational/Managerial Control · Individual
Henderson, Jeffery
Operational/Managerial Control · Individual
Hofmann, Reed
Operational/Managerial Control · Individual
Huseth, Kendra
Operational/Managerial Control · Individual
Jonas, Carrieann
Operational/Managerial Control · Individual
Lair, Michael
Corporate Director · Individual
Lienemann, Steven
Corporate Director · Individual
Luetmer, John
Corporate Director · Individual
Marlow, Jina
Operational/Managerial Control · Individual
Nelson, Patrick
Corporate Director · Individual
Pegel, Betsy
Operational/Managerial Control · Individual
Peterson-Devries, Camilla
Operational/Managerial Control · Individual
Peterson-Devries, Camilla
Corporate Director · Individual
Peterson-Devries, Camilla
Corporate Officer · Individual
Radaich, Bobbie
Operational/Managerial Control · Individual
Raw, Carol
Operational/Managerial Control · Individual
Raw, Carol
Corporate Director · Individual
Raw, Carol
Corporate Officer · Individual
Rentz, Laura
Corporate Director · Individual
Rentz, Mark
Operational/Managerial Control · Individual
Rentz, Paul
Corporate Director · Individual
Ryan, Benjamin
Operational/Managerial Control · Individual
Sanford, Melinda
Operational/Managerial Control · Individual
Schneider, Todd
Corporate Director · Individual
St. Francis Health Services Of Morris, Inc
Operational/Managerial Control · Organization
Stock, Kelsey
Operational/Managerial Control · Individual
Thompson, Renee
Operational/Managerial Control · Individual
Tomoson, April
Operational/Managerial Control · Individual
Vian, Deanna
Operational/Managerial Control · Individual
Walker, Amy
Operational/Managerial Control · Individual
Wiese, Lorraine
Corporate Director · Individual
Nearby options
Other facilities in reach
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Aicota Health Care Center
Aitkin, MN
2-star overall rating with 3-star inspections with 6 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Heartwood
Crosby, MN
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Good Samaritan Society - Bethany
Brainerd, MN
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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