Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Aftenro Home during CMS and state inspections, most recent first.
The facility lacked a comprehensive infection prevention and control program with an annual review, affecting all 54 residents. The provided document was only a policy manual, not a full program. Interviews with the DON and ADON confirmed the absence of an annually reviewed program, highlighting the need for formal procedures to manage infection risks.
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails, potentially affecting all residents using beds. Interviews revealed that while assessments were conducted when a resident requested a side rail, there was no routine inspection program. Maintenance confirmed they did not perform regular checks, and the director of nursing acknowledged this gap. Despite a policy requiring routine checks, maintenance records were not provided, leading to the deficiency.
The facility failed to develop comprehensive care plans for two residents, leading to deficiencies in addressing their specific medical needs. One resident's care plan did not adequately address diabetic care, despite fluctuating blood sugar levels, while another resident's plan lacked details on assistance needed for ADLs. The DON confirmed the care plans were incomplete, contrary to the facility's policy for person-centered care.
A resident with severe cognitive impairment and multiple diagnoses experienced a significant weight loss of 9.4 pounds in one month, dropping from 173 to 163.6 pounds. Despite the care plan's directive to notify the RD and provider with significant weight changes, there was no follow-up nutritional assessment or intervention documented. Interviews with staff revealed a failure in communication and follow-up, as the resident's significant weight loss was not addressed with appropriate interventions or reassessment.
The facility exceeded the acceptable medication error rate with a 6.7% error rate during medication passes involving two residents. One resident with acute respiratory failure did not rinse their mouth after using a Symbicort inhaler, and another with COPD drank water instead of rinsing after using a Wixela inhaler. The TMAs involved were either inconsistent or unaware of the proper procedure.
Two residents with diabetes were not provided with their prescribed therapeutic diets, leading to inappropriate meal service. Staff were unclear about dietary codes and failed to follow meal tickets, resulting in residents receiving regular meals instead of consistent carbohydrate diets. Observations and interviews revealed a lack of understanding and communication among dietary staff regarding the dietary needs of diabetic residents.
Inadequate Infection Control Program
Penalty
Summary
The facility failed to develop an infection prevention and control program with an annual review, which included written standards, policies, and procedures. These procedures should have specified when and to whom possible incidents of communicable diseases or infections should be reported, as well as when and how transmission-based precautions (TBP) and enhanced barrier precautions (EBP) should be implemented to prevent infections. Additionally, the program should have included hand hygiene procedures for staff involved in direct resident care. This deficiency had the potential to affect all 54 residents residing in the facility. During the survey, the infection control program was requested, and a document titled 'Nursing Services Policy and Procedure Manual for Long-Term Care Infection Control' dated 10/2023 was provided. However, this document was merely a policy and procedure manual, not a comprehensive infection control program. Interviews with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) confirmed that they did not have an infection control program that was reviewed annually. The DON acknowledged the absence of a formal written program for infection control and recognized the benefit of such a program in identifying necessary changes for infection prevention on a yearly basis.
Failure to Conduct Regular Bed Inspections
Penalty
Summary
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails, which could potentially affect all residents using beds. Interviews revealed that while the assistant director of nurses (ADON) involved physical therapy and conducted assessments when a resident requested a side rail, there was no clear responsibility for regular inspections. The registered nurse (RN-B) responsible for assessments followed FDA guidelines but only involved maintenance if issues were identified. Maintenance worker (MW-A) confirmed that they assembled beds and performed initial measurements but did not conduct routine inspections. The director of nursing (DON) acknowledged the absence of a routine inspection program for beds, and the administrator recognized the importance of such a system to prevent entrapment. Despite a policy in place for monitoring and evaluating side rail use, which required routine checks, maintenance records for bed inspections were not provided. This lack of a systematic approach to inspecting and maintaining beds led to the deficiency identified by the surveyors.
Deficiencies in Comprehensive Care Planning for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, leading to deficiencies in addressing their specific medical needs. For one resident, identified as R32, the care plan did not adequately address diabetic care despite the resident's diagnosis of diabetes mellitus and fluctuating blood sugar levels. The resident's care plan, last revised in September 2024, focused on nutritional issues but lacked specific interventions for managing diabetes, such as monitoring blood sugar levels and responding to high or low readings. The Director of Nursing (DON) confirmed that the care plan should have included directions for diabetes care to alert staff to the signs and symptoms of blood sugar fluctuations. Another resident, identified as R17, had a care plan that failed to specify the level of functioning, assistance needed for activities of daily living (ADLs), or the number of staff required to assist. This resident had diagnoses including hemiplegia, hemiparesis, type 2 diabetes mellitus, and congestive heart failure, which necessitated detailed care planning to address ADL deficits. The DON acknowledged that care plans are typically reviewed quarterly but was unsure how R17's care plan was incomplete. The facility's policy emphasizes the importance of comprehensive, person-centered care plans, yet these deficiencies indicate a failure to adhere to this policy, resulting in inadequate care planning for the residents involved.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to comprehensively reassess and develop interventions to address continued weight loss for a resident with severe cognitive impairment and multiple diagnoses, including dementia, chronic kidney disease, and type 2 diabetes mellitus. The resident's care plan, last revised in November, identified a potential nutritional problem with a goal of maintaining weight within 5% of 178 pounds. However, the resident experienced a significant weight loss of 9.4 pounds, or 5.4%, in one month, dropping from 173 pounds to 163.6 pounds. Despite the care plan's directive to notify the registered dietician and provider with significant weight changes, there was no follow-up nutritional assessment or intervention documented after the resident's weight loss. Interviews with facility staff, including nursing assistants and the director of nursing, revealed that while weights were recorded in the resident's chart, there was an expectation to notify the provider of significant weight changes. However, the deficiency indicates a failure in communication and follow-up, as the resident's significant weight loss was not addressed with appropriate interventions or reassessment. The director of nursing confirmed the expectation for staff to notify the provider with significant weight changes, highlighting a lapse in the facility's protocol to ensure the resident's nutritional needs were met.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 6.7 percent. This was observed during medication passes involving two residents. The first resident, with a diagnosis of acute respiratory failure with hypoxia, was observed taking two puffs of Symbicort inhaler close together without rinsing their mouth afterward, as per the provider's order. The trained medication aid (TMA) stated that the resident sometimes rinsed their mouth, indicating inconsistency in following the prescribed instructions. The second resident, diagnosed with chronic obstructive pulmonary disease (COPD), was observed taking one puff of Wixela inhaler and then drinking water instead of rinsing their mouth as required. The TMA involved was initially unaware of the need to rinse the mouth after using the inhaler, only confirming the requirement after reviewing the order. The assistant director of nursing (ADON) expressed that it was expected for TMAs to encourage residents to rinse their mouths to prevent complications. The facility's policy on inhaled medication administration was requested but not provided.
Failure to Follow Therapeutic Diets for Diabetic Residents
Penalty
Summary
The facility failed to ensure that therapeutic diets prescribed by physicians were followed for two residents, both of whom had specific dietary needs due to their medical conditions. One resident, who was cognitively intact and had diabetes mellitus, was not receiving the prescribed consistent carbohydrate diet. Despite having active orders for a specific diet and insulin regimen, the resident reported receiving meals similar to those of other residents, which did not align with her dietary needs. Observations confirmed that her meals included items not suitable for a diabetic diet, such as regular dressing and ice cream, and her meal ticket was marked with a diet code that was not understood by the staff. Another resident, also cognitively intact and with a history of diabetes and chronic kidney disease, was not receiving the consistent carbohydrate diet as ordered. This resident reported having to self-regulate her diet due to fluctuations in blood sugar levels. Observations showed that her meals included high-carbohydrate items like regular jello and juice, which were not sugar-free, contrary to her dietary requirements. The dietary staff, including dietary aides and cooks, were unclear about the dietary codes and did not consistently follow the meal tickets, leading to the residents receiving inappropriate meals. Interviews with various staff members, including dietary aides, cooks, and the registered dietician, revealed a lack of understanding and communication regarding the dietary needs of diabetic residents. The dietary manager and administrator acknowledged the expectation that therapeutic diets should be followed based on orders, but there was no consistent practice in place to ensure this. The facility's dietary management system lacked clear definitions for the diet codes used, contributing to the confusion and failure to provide appropriate meals for residents with specific dietary needs.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Duluth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Benedictine Health Center | 0.4 mi | — | 22 | 2 |
| Hilltop Healthcare Rehabilitation And Skilled Nurs | 1.7 mi | — | 17 | 0 |
| Ecumen Lakeshore | 2.4 mi | — | 0 | 0 |
| Bayshore Residence And Rehabilitation Center | 3.3 mi | — | 2 | 0 |
| Viewcrest Health Center | 3.9 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.