Aftenro Home
510 West College Street, Duluth, MN 55811 · St. Louis County · 54 certified beds · avg 51 residents/day · certified since Nov 12, 1981
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
All citations in the current public record (24)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Mar 19, 2026 | F · Potential for harm, facility-wide | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Mar 19, 2026 | F · Potential for harm, facility-wide | The facility did not employ enough qualified food and nutrition staff, including a qualified dietician, to properly run its food service. · from a complaint |
| Mar 19, 2026 | F · Potential for harm, facility-wide | The facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives. · from a complaint |
| Mar 19, 2026 | F · Potential for harm, facility-wide | The facility did not serve meals and snacks at times that fit residents' needs, preferences, and requests, or did not offer nourishing alternatives for residents who want to eat outside scheduled meal times. · from a complaint |
| Mar 19, 2026 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Mar 19, 2026 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Mar 19, 2026 | E · Potential for harm, repeated | The facility did not honor residents' right to form and take part in resident or family groups, such as a resident council. |
| Mar 19, 2026 | E · Potential for harm, repeated | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Mar 19, 2026 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. · from a complaint |
| Mar 19, 2026 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Mar 19, 2026 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Mar 19, 2026 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. · from a complaint |
| Mar 19, 2026 | C · Minimal risk, facility-wide | The facility did not give residents the required written notice of their rights, the facility's rules, the services offered, and what those services cost. |
| Mar 19, 2026 | B · Minimal risk, repeated | The facility did not honor residents' right to manage their own money and financial affairs. |
| Jan 9, 2025 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jan 9, 2025 | F · Potential for harm, facility-wide | The facility did not regularly inspect bed frames, mattresses, and bed rails for safety, or the rails and mattresses were not attached safely to the frames. |
| Jan 9, 2025 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Jan 9, 2025 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Jan 9, 2025 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Jan 9, 2025 | D · Potential for harm, one-off | The facility did not make sure special medical diets — like low-sodium or diabetic diets — were properly ordered by the resident's doctor or managed by a qualified dietitian as state law allows. |
| Oct 25, 2023 | F · Potential for harm, facility-wide | The facility did not electronically submit complete and accurate staffing information to the government, based on payroll and other verifiable records. |
| Oct 25, 2023 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Oct 25, 2023 | D · Potential for harm, one-off | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. |
| Oct 25, 2023 | D · Potential for harm, one-off | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (6 → 14).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 4 | 0 | F |
| 2025 | 6 | 0 | F |
| 2026 | 14 | 0 | F |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
No fines or payment denials in the published 3-year window.
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Minnesota avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 4.24 | 4.83 | 3.95 | bottom 26% in Minnesota; top 31% in the U.S. |
| Registered Nurse hours | 1.21 | 1.22 | 0.69 | top 42% in Minnesota; top 9% in the U.S. |
| Weekend total nurse staffing | 3.50 | 4.27 | 3.50 | bottom 15% in Minnesota; top 42% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.57 | 0.69 | 0.48 | bottom 47% in Minnesota; top 25% in the U.S. |
| Total nursing staff turnover (%) | 26.4 | 42.2 | 45.8 | top 12% in Minnesota; top 9% in the U.S. |
| RN turnover (%) | 0.0 | 38.6 | 42.9 | top 1% in Minnesota; top 1% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.52, RN 1.00, weekend 2.90. Staffing rating: 5/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 1/5 · long-stay residents: 1/5 · short-stay residents: —/5
Who owns this facility
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Ownership Data Not Available |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
- "Do you have a qualified dietician on staff, and how involved are they in each resident's nutrition plan?"
- "How do you track each resident's food allergies and preferences, and what happens if they don't like what's served?"
- "What happens if a resident is hungry between meals or misses a mealtime — what food options are available?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "Does your facility have an active resident council, and how does management respond to its concerns?"
- "Who is on the team that builds each resident's care plan, and how quickly is it in place after admission?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Benedictine Health Center | 0.4 mi | Duluth, MN | ★☆☆☆☆ | 1/5 | abuse |
| Hilltop Healthcare Rehabilitation and Skilled Nurs | 1.7 mi | Duluth, MN | ★★☆☆☆ | 2/5 | |
| Ecumen Lakeshore | 2.4 mi | Duluth, MN | ★★★★★ | 5/5 | |
| Bayshore Residence and Rehabilitation Center | 3.3 mi | Duluth, MN | ★★☆☆☆ | 2/5 | |
| Viewcrest Health Center | 3.9 mi | Duluth, MN | ★★★☆☆ | 3/5 | |
| Franciscan Health Center | 5.2 mi | Duluth, MN | ★☆☆☆☆ | 2/5 | |
| Dove Healthcare - Superior | 7.0 mi | Superior, WI | ★★☆☆☆ | 2/5 | |
| Villa Marina Health and Rehabilitation Center | 7.5 mi | Superior, WI | ★★★★☆ | 3/5 | |
| The North Shore Estates LLC | 8.0 mi | Duluth, MN | ★★☆☆☆ | 2/5 | |
| Twin Ports Health Services | 8.3 mi | Superior, WI | ★★★★★ | 4/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 24E355.