Mahnomen Health Center
Mahnomen Health Center in MAHNOMEN, MN — inspection on March 11, 2026.
Found 6 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview on 3/11/26 at 8:29 a.m., registered nurse (RN)-A, unit coordinator/MDS nurse, stated when they were completing a MDS they reviewed the residents' chart during the observation period and completed the MDS using that data.
When the MDS for R5 and R20 were completed, RN-A stated the medications were missed and did not get entered into the MDS.
During an interview on 3/11/26 at 11:09 a.m., the director of nursing (DON) stated it was the expectation each portion of the MDS would be completed correctly. It is important because it can affect care plans, payment and quality measures. A facility policy related to MDS accuracy was requested but not received.
and other verifiable and auditable data.
journal system (PBJ) staffing data to Centers for Medicare and Medicaid Services (CMS).
This had
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 Medicare and Medicaid (CMS) was requested but not received.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
245238 03/11/2026
Mahnomen Health Center 414 West Jefferson Avenue Mahnomen, MN 56557
meeting minutes going back to eight months did not identify attendance by the medical director and
the medical director stated he attended the QAPI meetings sometimes but could not clearly recall the
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 also F-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 facility's Quality Assurance and Improvement Plan for Long Term Care policy dated 1/22/26, identified the QAPI committee was to be attended by the medical director.
245238 03/11/2026
Mahnomen Health Center 414 West Jefferson Avenue Mahnomen, MN 56557
facilities Infection Control Surveillance Plan dated 5/22/25, identified infection control was used to
providing information to members of the health care team to assist in improving outcomes.The
Program (IPCP) to prevent infections in patients and employees.
The Infection Preventionist was responsible and accountable for IPCP.
The priority services included prevention strategies, managing data and information and policies and procedures to prevent infections in patients and employees, and referred to the Infection Control Surveillance Plan.
245238 03/11/2026
Mahnomen Health Center 414 West Jefferson Avenue Mahnomen, MN 56557
implement a facility-wide system to monitor the use of antibiotics for 2 of 2 residents (R5, R16) in the
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 discontinued and R5 started sulfamethoxazole-trimethoprim (antibiotic) 800-160 mg twice daily for 3 days on 12/27/25.The facility continued to treat R5 for a UTI even though the lab results showed no predominant bacterial growth.R16:R16's progress note dated 1/25/26, identified R16 was frequently requesting to use the bathroom. UA was sent to lab.R16's UA dated 1/25/26, identified no predominant organism and UC (urine culture) was not completed.R16's orders report dated 1/18/26 through 2/13/26, identified an order for Macrobid 100 mg take 1 capsule twice daily x 5 days for UTI dated 1/26/26.R16's 72-hour antibiotic time-out dated 1/28/26, identified R16 was prescribed Macrobid 100 mg twice daily for 5 days, end date 1/31/26.
The facility continued to treat R16 for a UTI even though the lab results showed no predominant bacterial growth.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 tracking system to quickly identify resident symptoms or infections and reviewed the residents' medical record.On 3/11/2026 at 1:22 p.m., the DON stated for the most part the providers over prescribed antibiotics and many of the residents had not met Loeb's criteria for UTI.
The DON stated Loeb's criteria was important to follow because they want to be able to treat an infection when the resident needed it.
The medical director returned a phone call after facility exit on 3/11/26 at 4:48 p.m. and stated he oversaw the review of the facility policies and procedures for resident care.
The medical director was uncertain how the facility tracked antibiotic use and one of the nurses would know more.
Further, the facility uses an algorithm and communicates to the provider and either sends the resident to the emergency room or schedule an appointment with their provider; a lot of the mid-level practitioners prescribed 3-day antibiotics, and he and the physicians usually prescribed 5-day antibiotics.
The facilities Antibiotic Stewardship Program revised 3/4/25, identified the facility would promote the appropriate use of antibiotics (right dose, drug, and duration) to treat infections that result in the best outcome with the least amount of toxicity and resistance.
Antibiotic Stewardship actions included assessment of residents suspected of having an infection by considering the Loeb Criteria when considering initiation of antibiotics.
Key Components of the Loeb Criteria for Urinary Tract Infection (UTI) - No Catheter included acute dysuria OR fever (100.2 F or greater) plus one of the following: urgency, frequency, suprapubic pain, gross hematuria, or costovertebral tenderness. A 72-hour antibiotic time-out is performed after initiation of antibiotic or first dose in the facility.
The 72-hour timeout includes resident assessment for consideration of antibiotic need, duration, selection of antibiotic/change, and de-escalation potential.
245238 03/11/2026
Mahnomen Health Center 414 West Jefferson Avenue Mahnomen, MN 56557
During interview on 3/10/26 at 4:50 p.m., the director of nursing (DON), who also worked as the facility infection preventionist (IP), stated she had worked as the IP nurse for two years.
The DON stated she had completed the on-line courses for infection control last year; however, had not taken the certification test.
The DON was unable to provide any documentation or certificate of completion of an approved infection prevention course.A copy of the facilities Infection Preventionist job description was requested and not received.
245238 03/11/2026
Mahnomen Health Center 414 West Jefferson Avenue Mahnomen, MN 56557