North Star Manor (SFF) Abuse and Neglect Attorneys

The state of Minnesota and the Centers for Medicare and Medicaid Services (CMS) regularly conduct routine investigations and surveys of every nursing facility statewide. Through unannounced inspections, the surveyors can identify serious violations and deficiencies that could or have injured residents. At the end of the survey, regulators provide the facility the opportunity to make necessary improvements to the level of care they provide and revise noncompliant policies and procedures.

In the most egregious cases, nursing home regulators for both the state and the federal government will designate a nursing home as a Special Focus Facility (SFF). This undesirable designation places them on the national Medicare watch list. In the months and years ahead, the facility will need to undergo additional surveys, investigations, and inspections until regulators are assured that any improvements made by the nursing staff and administration are permanent.

Nearly four years ago, North Star Manor was designated a Special Focus facility. State and federal regulators added their name to the Federal Watch List. If the facility is unable or unwilling to make significant improvements to the care provided residents and changes to their policies, they will likely face major financial consequences. A few of the serious concerns, violations, and deficiencies involving this nursing home are listed below.

North Star Manor (Good Samaritan Society) – Warren

This Long-Term Care Center is a 45-certified bed ‘for profit’ Home providing services to residents of Warren and Marshall County, Minnesota. The Facility is located at:

410 South Mckinley Street
Warren, MN 56762
(218) 745-5282


In the last three years, North Star Manor (Good Samaritan Society – Warren) has received two monetary penalties levied by state and federal nursing home regulators. These penalties include a $12,199 fine on November 15, 2016, and a $1040 fine on October 15, 2015. Also, there were two formally filed complaints during the same time frame that resulted in citations.

Current Nursing Home Resident Safety Concerns

The state of Minnesota and the CMS routinely update their long-term care home database systems to reflect all opened investigations, dangerous hazards, filed complaints, safety concerns, incident inquiries, and health violations. This information can be found on numerous sites including Many families and individuals use this information to decide the best location to place a loved and who requires the highest level of hygiene assistance and nursing care.

Currently, North Star Manor (Good Samaritan Society – Warren) maintains an overall two out of five stars compared to all nursing homes in the United States. This ranking includes one out of five stars for health inspections, four out of five stars for staffing issues, and three stars for quality measures. Some serious concerns involving deficiencies, violations and citations include:

  • Failure to Report and Investigate Acts or Allegations of Abuse, Neglect or Mistreatment of Residents
  • In a summary statement of deficiencies dated November 15, 2016, the state investigator noted the facility’s failure “to immediately report [an incident] to the State Agency, and thoroughly investigate incidents of potential mistreatment related to significant injuries and bruises of unknown origin for possible mistreatment and neglect of care.” This deficiency involved one resident the facility “who had an unwitnessed fall with serious injury and had bruises of unknown origin.”

    The state investigator also noted that the facility had failed to “timely report to the State Agency incidents of missing money for [another resident] who reported money missing.” Lastly, the facility “failed to ensure [one Licensed Practical Nurse) had a criminal background’s greeting completed.”

  • Failure to Provide an Environment Free of Accident Hazards
  • In a summary statement of deficiencies dated November 15, 2016, the state investigator noted the facility’s failure “comprehensively assess, thoroughly investigate causal factors and implement interventions in order to minimize the risk of falls in injury.” This deficiency affected one resident “who had repeated falls with serious injuries which required medical intervention.” This failure “resulted in an Immediate Jeopardy situation for [the resident].”

    The Immediate Jeopardy “began on November 7, 2016, and was related to the facility’s failure to complete a comprehensive assessment to determine causal factors and implement interventions for [a resident] who sustained significant injuries from two falls which occurred on October 30, 2016, and another fall on November 7, 2016. The lack of assessment placed [the resident] at significant risk for serious injuries or death.”

    Even though the Immediate Jeopardy “was removed on November 15, 2016… the noncompliance remained at a scope and severity of ‘G,’ which indicated actual harm for [the resident] due to a hematoma [swollen blood-clotted tissue] and epistaxis [nosebleed] sustained during a fall which required medical assessment and interventions.”

  • Failure to Develop, Implement and Enforce a Program That Investigates, Controls and Keeps Infection from Spreading
  • In a summary statement of deficiencies dated November 15, 2016, the state investigator noted the facility’s failure “to ensure contact isolation precautions were implemented during the provision of direct resident contact for [a resident] observed during personal care and was in contact precautions [quarantined from other residents].”

    The state surveyor conducted an initial tour at 3:00 PM on November 7, 2016, and observed “an isolation card (plastic container with personal protective equipment] …outside the [resident’s] room.” The cart was observed to contain “a sign which indicated the individual in the room required contact precautions [due to a suspected serious illness that easily transmitted through direct patient contact or in direct contact with the patient’s items].”

    A Licensed Practical Nurse provided care for the resident’s eight of the resident “had tested positive for methicillin-resistant staphylococcal aureus (MRSA) at his suprapubic catheter site.” During the observation, a Nursing Assistant entered the resident’s room “apply gloves and proceeded empty [the resident’s] suprapubic catheter drainage bag.” At that time, the Nursing Assistant “removed her gloves and wash her hands. Without blood hands, [The Nursing Assistant] proceeded to make [the resident’s] bed touching multiple areas of the bed including the covered, bed rails and pillows.”

    When the Nursing Assistant completed their task, they had talked to the resident “while touching his wheelchair and his body, then exited the room.” The Nursing Assistant was then observed “to wash her hands or use sanitizer as she left the room and walked into another resident’s room.” Before the Assistant touched another resident after leaving the room, the State Agency staff member “asked to speak to her.” The Nursing Assistant stated that “she had not washed her hands prior to leaving [the resident’s] room and confirmed the [resident] currently requires precautions related to M.R.S.A.”

  • Failure to Ensure That Every Resident’s Drug Regimen Is Free from Unnecessary Medications
  • In a summary statement of deficiencies dated July 6, 2017, the state investigator noted the facility’s failure to “ensure justification for the continued use of a long-term antibiotic.” This deficiency involved a resident “reviewed for unnecessary medications who received an antibiotic daily.” The surveyor noted that the resident’s July 6, 2017, Care Plan failed to address using the medication and its side effects.

    The resident’s Medical Records revealed that the resident “was most recently seen by a nurse practitioner on June 26, 2017, related to their medical condition. However, there was no documentation indicating that the [antibiotic] use was reviewed. Further review of [the resident’s] medical record revealed that the lack of documentation related to the justification for the continued use of the medication.”

    The state investigator interviewed the Minimum Data Set Coordinator on the morning of July 6, 2017, who confirmed that the resident’s “medical record lacked justification for the continued use of [the antibiotic].”

    In a separate summary statement of deficiencies dated June 30, 2016, the state surveyor noted the facility’s failure “to have the appropriate medical justification and identify targeted behaviors for the continued use of antipsychotic medications. This deficiency involved one resident at the facility who “was reviewed for unnecessary medication use.”

    The resident’s Minimum Data Set (MDS) identified the resident “had moderate cognitive impairment, had no behaviors, wandering or rejection of care and received an antipsychotic medication and anti-anxiety medication on a daily basis.” The resident’s medical record indicated guidance to the nursing staff to give the drug “by mouth one time a day related to an unspecified medical condition not due to the substance.”

    The state investigator reviewed the resident’s December 9, 2015, Consultant Pharmacist Medication Review that identified “recommendations from the Consultant Pharmacist (CP) including [the resident’s medication was] recently started and reduced.” The CP asked the facility to “please clarify targeted behaviors? i.e. (an example) hallucinations, delusions, aggressive behavior, etc.).” However, the doctor “did not provide any target behaviors for the use of [the resident’s] antipsychotic medication as requested by the consultant pharmacist.”

    As a part of the review, the recommendations from the pharmacist included “resident is doing okay with the recent [medication] decrease, consider a trial hold?” The resident’s physician responded to hold the medication but “there was no established period for which to hold the medication or reasons to re-start the medication identified in the …response from the physician.”

    The state investigator reminded the facility of their August 2014 Psychopharmacological Medications and Sedative/Hypnotics Policy that reads in part:

    “To eliminate unnecessary psychopharmacological medications and sedative/hypnotics. The policy directs the staff to conduct a comprehensive assessment to ensure the resident who has not use antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed [that is] documented in the clinical record.”

  • Failure to Ensure That Every Resident Receives an Accurate Assessment by Qualified Health Professional
  • In a summary statement of deficiencies dated June 30, 2016, the state surveyor noted the facility’s failure “to accurately complete the Minimum Data Set (MDS) to reflect a Stage II pressure ulcer.” This deficiency affected one resident at the facility “reviewed for pressure ulcers and to identify falls for [another resident] reviewed for falls.” The resident’s Quarterly Minimum Data Set (MDS) identified the resident “was at risk of developing pressure ulcers, and no unhealed pressure ulcers at Stage I or higher.”

    The resident’s Rev. April 16, 2016, Care Plan identify the resident “was at risk for the development of pressure ulcers related to immobility. Interventions include frequent repositioning and pressure reducing mattress on the bed and a cushion in the chair.” Reviewing the resident’s April 1, 2016, Wound Data Collection report revealed that the resident’s “wound on the coccyx with partial tissue thickness loss, wound bed was a red tone and 100% granulation.”

    The wound measured “1.0 cm x 0.2 cm x 0 cm with no drainage.” The state surveyor interviewed the facility Director of Nursing who stated that the MDS Coordinator “should have consulted the Resident Assessment Instrument prior to completing [the resident’s] MDS. The Director also confirmed that the resident’s Quarterly MDS was incorrectly coded.”

    In a separate incident, the surveyor reviewed a resident’s June 21, 2016, Care Plan that identified this resident “was at risk for falls.” A nursing Assistant verified that the resident “was at risk of falls, had a history of falls … and had fallen recently.”

    As a part of the investigation, the surveyor interviewed with the Director of Nursing who confirmed that the resident “had fallen May 2, 2016, and May 10, 2016.” The Director “confirm that the reference states and the Resident Assessment Instrument manual [states that] the resident’s fall should have been identified on the MDS [that was] completed on June 17, 2016.” The Director stated that the resident’s Minimum Data Set “was coated incorrectly for falls and [the resident’s] falls since the prior assessment should have been identified.”

Ready to File a Nursing Home Abuse Compensation Claim?

If you believe your loved one suffered harm while a patient at North Star Manor, hiring a personal injury law firm can help. With legal representation, your lawyer can build a solid case and file your claim in the appropriate county courthouse before the Minnesota statute of limitations expires.

No upfront payments are necessary because personal injury attorneys accept all nursing home abuse claims for compensation and wrongful death lawsuits through contingency fee agreements. This arrangement allows for immediate legal representation without the need to make any payment until after the case is successfully resolved. Your attorney can negotiate an out of court settlement on your behalf or present evidence in front of a judge and jury at trial. Contact us today!


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Jonathan did a great job helping my family navigate through a lengthy lawsuit involving my grandmother's death in a nursing home. Through every step of the case, Jonathan kept my family informed of the progression of the case. Although our case eventually settled at a mediation, I really was impressed at how well prepared Jonathan was to take the case to trial. Lisa
After I read Jonathan’s Nursing Home Blog, I decided to hire him to look into my wife’s treatment at a local nursing home. Jonathan did a great job explaining the process and the laws that apply to nursing homes. I immediately felt at ease and was glad to have him on my side. Though the lawsuit process was at times frustrating, Jonathan reassured me, particularly at my deposition. I really felt like Jonathan cared about my wife’s best interests, and I think that came across to the lawyers for the nursing home. Eric