Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around March 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 Essentia Health Homestead during CMS and state inspections, most recent first.
Glucose monitor not disinfected between resident uses. An RN used the same point of care glucose monitor on two residents with DM and insulin orders, placing it on a resident’s overbed table and then on the med cart without disinfecting it. The RN stated she only disinfected the monitor at the end of her shift, while the DON stated it was to be cleaned between each resident use; the facility policy also required disinfection after each patient use.
A resident with severe cognitive impairment, impaired mobility, and high fall risk was care planned to have wheelchair footrests in place at all times, with staff ensuring proper positioning and monitoring for leaning during transport. A NA transported the resident in a manual wheelchair from the shower without the footrests, and while going through the doorway the wheelchair struck the door frame, causing the resident, who was leaning forward, to fall out. The resident sustained a T12 fracture, head injury with concussion, abrasions and contusions, and multiple right-hand lacerations requiring sutures, and the DON confirmed the care plan had not been followed.
An unlicensed nursing student administered medications, including insulin and controlled substances, to several residents without direct supervision or verified competencies. The NS was unclear about her permitted duties and lacked required certification, while the supervising RN was not present during medication administration. Facility staff and program leadership were inconsistent in their understanding of supervision requirements, resulting in unsupervised medication administration to residents with complex medical needs.
A resident with mobility limitations and recent injury reported care concerns, including a painful transfer incident, repeated unmet requests for assistance, and a missing pillow, directly to the DON and administrator. Despite these communications, the facility did not acknowledge or process the concerns as a grievance according to policy, resulting in a lack of timely response or resolution.
Staff failed to use the correct sling sizes during mechanical lift transfers for multiple residents with mobility impairments, resulting in at least one resident sustaining a significant bruise. Care plans did not specify sling sizes, and staff demonstrated uncertainty about proper sling selection, leading to the use of slings inconsistent with manufacturer recommendations and resident assessments.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
The facility did not have clear or detailed policies and procedures for reporting suspected crimes to law enforcement. The existing policy lacked examples of reportable crimes and did not specify timeframes for notification. Both the DON and administrator were uncertain about which incidents required law enforcement reporting, and the policy only specifically addressed drug diversion reporting to the state agency and Board of Nursing.
The facility failed to deliver mail and packages to residents on Saturdays, affecting two residents who reported delays. Mail was delivered to the hospital, sorted, and then picked up by nursing home staff, but the sorting area was not staffed on weekends, causing delays. The facility's policy states residents have the right to promptly receive mail and packages.
The facility inaccurately submitted PB&J staffing data to CMS, indicating low weekend staffing and lack of 24-hour licensed nursing coverage, which was contradicted by payroll and schedules showing adequate staffing. The DON and an RN confirmed consistent nurse presence, and the administrator acknowledged a corporate-wide issue with data entry. No policy on PB&J data submission was provided.
A facility failed to identify a diagnosis for a prescribed medication for a resident with dementia, bipolar disorder, and manic depression. The resident was receiving escitalopram without a specified diagnosis or indication for use. A nurse admitted to omitting the diagnosis when entering the order, and the DON confirmed the expectation for all medications to have a diagnosis to prevent unnecessary administration.
A resident with COPD was administered an inhaler that lacked proper labeling, including instructions for use. The LPN acknowledged the missing label and relied on physician orders for administration instructions. The DON confirmed that all medications should be properly labeled, as per the facility's Medication Management policy.
The facility did not consistently post daily nurse staffing information, affecting all 20 residents, staff, and visitors. On one occasion, the posting was outdated, and on another, it was missing. The DON indicated that the night nurse was responsible for updating the postings, but they were not completed for two consecutive days, contrary to the facility's policy.
The facility failed to provide hand sanitization opportunities for residents dining in the main dining room, as observed during multiple meal times. Staff did not offer hand sanitization to residents, despite sanitizing their own hands between tasks. Interviews confirmed that hand hygiene was not consistently offered in the dining room, contrary to the expectations of the infection preventionist and DON.
The facility failed to limit PRN antipsychotic medication use to 14 days or ensure provider evaluations for two residents with severe cognitive impairments. One resident received PRN Haldol and Risperdal without bi-weekly evaluations, while another received PRN quetiapine without timely assessments. The facility lacked processes to ensure compliance with their policy requiring provider evaluations and order renewals every 14 days.
Glucose Monitor Not Disinfected Between Resident Uses
Penalty
Summary
The facility failed to disinfect a point of care glucose monitor between uses for two residents who required blood glucose checks. R5 had a diagnosis of diabetes mellitus and received insulin on a regular basis; R5’s care plan directed blood glucose monitoring per orders, and the orders required blood sugar checks three times a day. R18 also had a diagnosis of diabetes mellitus and received insulin on a regular basis; R18’s care plan directed blood sugar monitoring per order, and the orders required blood sugar checks four times a day. During observation on 4/20/26 at 4:37 p.m., RN-A used the glucose monitor to obtain R5’s blood sugar, then placed the monitor on R5’s overbed table while administering insulin and other medications. After leaving the room, RN-A placed the monitor on the medication cart and returned to the nurse’s station, where it remained undisinfected. R18 then requested a blood glucose check before supper, and RN-A sanitized her hands, put on gloves, and used the same glucose monitor to obtain R18’s blood sugar without disinfecting it first. RN-A stated she only disinfected the glucose monitor at the end of her shift and had not been disinfecting it between residents. The interim DON stated glucose monitors were to be cleaned between use with each resident to prevent spread of infections. The facility’s policy stated staff were to clean and disinfect the glucose monitor after each patient use.
Failure to Follow Wheelchair Transport Care Plan Leads to Fall With Injuries
Penalty
Summary
The deficiency involves the facility’s failure to implement care-planned fall prevention interventions for a resident at high risk for falls, resulting in a fall with injury. The resident had diagnoses including aphasia, dysphagia, muscle weakness, traumatic brain injury, and impaired mobility, with severe cognitive impairment documented on the MDS and dependence on staff for transfers and wheelchair transport. A care plan addressing wheelchair transport safety and positioning directed staff to ensure the resident was fully positioned and supported in the wheelchair prior to transport, verify footrests were in place prior to transport, and monitor for leaning, sliding, or unsafe positioning. An additional care-planned approach required wheelchair pedals to be on at all times. On the date of the incident, a nursing assistant transported the resident in a manual wheelchair from the shower room to the resident’s room without the foot pedals in place, contrary to the care plan. While being wheeled through the doorway, the wheelchair struck the door frame, causing the chair to stop and the resident, who had begun leaning forward, to fall out of the wheelchair onto the floor. Progress notes and ED documentation identified that the resident sustained a T12 vertebral fracture, a head injury with concussion, an abrasion and contusion to the head, a bruise to the left knee, and multiple lacerations to the right hand requiring sutures. The nursing assistant later acknowledged awareness that the foot pedals should have been on but did not apply them because the transport was only from the shower to the room. The DON confirmed that the resident’s care plan had not been followed when the fall occurred.
Unsupervised Medication Administration by Unlicensed Nursing Student
Penalty
Summary
The facility failed to ensure that an unlicensed nursing student (NS) was properly supervised during the administration of medications, including high-risk medications such as insulin, liquid morphine, and other controlled substances. The NS, who did not possess a nursing license, competencies, or the required certification for medication administration, was observed administering medications independently to multiple residents without direct supervision by a licensed nurse. Observations included the NS administering insulin via pen and performing blood glucose checks without oversight, while the assigned RN was not present in the immediate area. Documentation and interviews revealed that the NS administered controlled substances and other medications to residents with complex medical histories, including diagnoses such as respiratory disease, dementia, chronic pain, diabetes, and hypertension. The NS was not a trained medication aide and was unclear about the scope of tasks she was permitted to perform, lacking immediate access to competency documentation. The NS stated she typically checked with a nurse before administering insulin but did not do so during observed instances. The RN on duty confirmed she had not seen the NS's completed competencies and was not acting as the NS's preceptor at the time. Further interviews with facility staff and the nursing program director indicated confusion and lack of clarity regarding the supervision and competency requirements for the NS. The apprenticeship program guidelines required direct supervision for medication administration, but this was not followed. The NS was allowed to work on the floor and administer medications without the necessary oversight or verification of competencies, affecting several residents who received medications from the NS during this period.
Removal Plan
- Review the nurse apprenticeship program.
- Provide re-education to nurse apprentice on program expectations prior to returning to work.
- Educate all staff responsible for administering medications and/or supervising a nurse apprentice on the apprentice program and review the orientation education agenda.
- Review all resident records for medication errors.
Failure to Implement Grievance Process for Resident Care Concerns
Penalty
Summary
The facility failed to implement its grievance process for one resident who expressed care concerns. The resident, who had intact cognition and diagnoses including fractures and heart disease, was care planned to require mechanical lift transfers due to mobility issues. The resident reported via email to the DON and administrator that he sustained a painful bruise during a transfer to a shower chair, which resulted in significant pain and limited his ability to get out of bed for over two weeks. He also reported repeated denials of requests to be transferred to his recliner for lunch and concerns about a missing pillow needed for proper positioning. Despite these concerns being communicated directly to facility leadership, the resident did not receive a response from the DON or administrator. Interviews confirmed that the resident's concerns were not formally documented or processed as grievances, as required by facility policy. The administrator acknowledged receipt of the resident's email and stated that the DON was supposed to handle the issue, but no grievance was written up. The facility's grievance policy requires prompt acknowledgment, investigation, and communication of findings to the resident, none of which occurred in this case. The lack of response and failure to follow the grievance process resulted in the resident's concerns not being addressed in a timely or appropriate manner.
Failure to Ensure Proper Sling Size Use During Mechanical Lift Transfers
Penalty
Summary
The facility failed to ensure that staff utilized the proper sling sizes when performing transfers via mechanical lift for four out of five residents who required such assistance. Observations, interviews, and document reviews revealed that care plans for these residents did not specify the appropriate sling size, and staff often used slings that did not correspond to the residents' weights or manufacturer recommendations. For example, one resident with a history of lumbar spine fracture, obesity, and heart disease was transferred using a sling that was not indicated in the care plan, resulting in a significant bruise on the inner thigh, which the resident attributed to the lift sling. Further review showed that other residents with conditions such as respiratory disease, dementia, Parkinson's disease, and above-knee amputation were also transferred using slings of incorrect sizes. In several cases, the slings observed in use did not match the sizes recommended by the residents' assessments or the sizing charts. Staff interviews indicated a lack of knowledge regarding how to determine the correct sling size, and care plans consistently lacked documentation of the required sling size for each resident. The facility's policy required that care be provided in accordance with the care plan and manufacturer recommendations for sling size. However, there was no evidence that the facility assessed or addressed the use of incorrect sling sizes after injuries occurred, nor was there documentation of staff training or corrective measures to prevent recurrence. The interim DON and other staff acknowledged uncertainty about sling selection and the absence of root cause analysis following resident injury.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Develop Clear Policies for Reporting Suspected Crimes to Law Enforcement
Penalty
Summary
The facility failed to develop and implement comprehensive policies and procedures for reporting suspected crimes to law enforcement, as required. The existing Abuse, Neglect, Mistreatment and Misappropriation of Resident Property policy stated that local law enforcement should be notified of any reasonable suspicion of a crime against a resident and that suspected crimes or alleged sexual abuse must be immediately reported to law enforcement for investigation. However, the policy did not provide further examples of crimes that should be reported or specify the timeframe for reporting. During interviews, both the DON and the administrator were unclear about which crimes should be reported to law enforcement and when, with the administrator acknowledging that the policy was vague and lacked necessary detail. The policy only specifically mentioned reporting drug diversion to the state agency and the Board of Nursing, but did not address broader requirements for law enforcement notification.
Mail Delivery Delays on Saturdays
Penalty
Summary
The facility failed to ensure that residents received their mail and packages on Saturdays, affecting two residents who expressed concerns about the delivery process. Both residents were cognitively intact, as identified in their quarterly Minimum Data Set (MDS) assessments. During a resident meeting, one resident stated that mail and packages arriving late Friday or early Saturday were not delivered until Monday. Another resident confirmed receiving notifications of package arrivals on Saturdays but did not receive them until Monday. The mail and packages were initially delivered to the main hospital, sorted there, and then delivered to the nursing home, which contributed to the delay. Interviews with facility staff, including the activities director, director of nursing, registered nurse, licensed social worker, and health unit coordinator, revealed that the mail delivery process had changed since the onset of COVID-19. The mail was now delivered to the hospital, where it was sorted and placed in a mailroom for nursing home staff to pick up. However, the sorting area was not staffed on weekends, resulting in delays for any mail or packages arriving on Saturdays. The facility's Patient Rights and Responsibilities policy stated that residents have the right to promptly receive mail and packages, which was not being upheld in this case.
Inaccurate PB&J Staffing Data Submission
Penalty
Summary
The facility failed to accurately submit payroll-based journal (PB&J) staffing data to the Centers for Medicare and Medicaid Services (CMS) for the fourth quarter, covering the period from July 1, 2024, to September 30, 2024. The submitted data indicated excessively low weekend staffing and a lack of licensed nursing coverage 24 hours a day for all days in July, August, and September 2024. Additionally, the report showed no registered nurse (RN) coverage for eight consecutive hours on multiple days throughout the same period. However, upon review of the facility's payroll and working schedules, it was found that there was licensed nursing staff available 24 hours a day for all 92 days, and RN coverage was present for all 54 days identified in the PB&J report. During interviews, the Director of Nursing (DON) and an RN confirmed that there was always a nurse present in the facility, and in cases of nurse call-ins, the previous shift was mandated to stay. The administrator stated that the nursing hours were entered by an off-site corporate staff member and acknowledged a corporate-wide issue with how the information was pulled, although the administrator did not know how to correct it. The facility did not provide a policy or procedure regarding PB&J data submission when requested.
Failure to Identify Diagnosis for Prescribed Medication
Penalty
Summary
The facility failed to identify a diagnosis for a medication prescribed to one of the residents reviewed for unnecessary medications. The resident, who had diagnoses of dementia with behavioral disturbance, bipolar disorder, and manic depression, was receiving an antidepressant. The order summary report for the resident included an order for escitalopram, but it did not specify a diagnosis or indication for its use. During an interview, a registered nurse admitted to forgetting to include the diagnosis when entering the medication order after a change. The director of nursing confirmed that it was expected for all medications to have a diagnosis or indication for use to ensure medications were not administered unnecessarily. The facility's policy required medication orders to include the medication, dose, frequency, route, and diagnosis or indication for use.
Improper Medication Labeling Leads to Potential Error
Penalty
Summary
The facility failed to ensure that medications were properly labeled, which could lead to medication errors. During a medication pass, an LPN was observed administering an inhaler to a resident with chronic obstructive pulmonary disease (COPD). The inhaler, identified as anoro ellipta, was not labeled with instructions for administration. The LPN acknowledged that the inhaler should have been labeled with the resident's information and instructions from the pharmacy, but stated that the box containing this information was likely discarded. The LPN relied on checking the physician's orders for current instructions before administering the medication. The Director of Nursing confirmed that all medications should have a label with the medication name, pharmacy, date of order, expiration date, resident's name, and instructions for use. The facility's Medication Management policy requires staff to compare the medication and dosage schedule on the medication administration record (MAR) to the medication label, ensuring the right patient, medication, dose, time, and route of administration. The lack of proper labeling on the inhaler was a deviation from this policy, as the medication should have been removed from the cart and the pharmacy contacted if the label was incomplete.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to consistently post required nurse staffing information on a daily basis, which had the potential to affect all 20 residents, staff, and visitors who may wish to view the information. On March 10th, the nurse staff posting was observed to be dated for the previous day, March 9th, and on March 11th, the posting was missing entirely. The Director of Nursing (DON) stated that the night nurse was responsible for completing the daily staff posting for the following day, but postings for March 10th and 11th were not completed. The facility's policy, revised in February 2024, required that staffing hours be posted daily in a prominent place, including details such as the facility name, current date, total number, and actual hours worked by RNs, LPNs, and NAs, excluding certain managerial roles.
Failure to Provide Hand Sanitization Before Meals
Penalty
Summary
The facility failed to ensure that residents dining in the main dining room were given an opportunity to sanitize their hands prior to meal consumption. During observations of dinner, breakfast, and lunch meals, it was noted that none of the tables had hand sanitizing products available, and staff did not offer hand sanitization to residents either as they entered the dining room or while they were seated. Although staff were observed sanitizing their own hands between tasks, they neglected to extend this practice to the residents, which is crucial for infection prevention. Interviews with nursing assistants revealed that while hand hygiene was offered to residents in their rooms, it was not consistently offered in the dining room. The infection preventionist and the director of nursing both confirmed that it was their expectation for residents to be offered hand sanitization prior to meals to prevent the spread of infection. The facility's standards of care also instructed that all residents should be offered hand hygiene before meals, indicating a lapse in adherence to established protocols.
Failure to Limit PRN Antipsychotic Medication Use
Penalty
Summary
The facility failed to ensure that PRN antipsychotic medication use was limited to 14 days or supported by notes from a provider face-to-face visit for two residents. Resident 16, who had severe cognitive impairment and diagnoses of Alzheimer's and dementia, was receiving PRN antipsychotic medications Haldol and Risperdal without documented stop dates or evidence of bi-weekly provider evaluations to justify continued use. Interviews with facility staff, including a registered nurse and the director of nursing, revealed a lack of clarity on who was responsible for ensuring these evaluations and reorders were completed. The facility's policy required PRN antipsychotic medications to be renewed every 14 days following a provider evaluation, which was not adhered to in this case. Similarly, Resident 20, who had severe cognitive impairment and non-Alzheimer's dementia, was receiving PRN quetiapine without evidence of in-person assessments every 14 days. The resident's electronic medical record did not show any provider response to pharmacist recommendations for continued use of the medication. The director of nursing confirmed that the resident had not been evaluated in person since admission for the continued use of PRN quetiapine. The facility lacked processes to ensure timely provider assessments and order renewals or discontinuations for PRN antipsychotic medications, as required by their policy.
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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 Deer River
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Grand Village | 12.7 mi | — | 0 | 0 |
| The Emeralds At Grand Rapids Llc | 15.6 mi | — | 1 | 0 |
| Bigfork Valley Communities | 28.7 mi | — | 8 | 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.