Based on observation, interview and document review, the facility failed to ensure medications were administered safely for 1 of 2 residents (R139) who had medications left at the bedside and had been assessed as not safe to self administer those medications.Findings Include:R139's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified R139 had moderate cognitive impairment with diagnoses which included arthritis, adjustment disorder with depressed mood and chronic pain. …
F554 citations in Minnesota
Resident Rights Deficiencies
Allow residents to self-administer drugs if determined clinically appropriate.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Minnesota cites F554 more often than its own record predicts
3.29 times the share F554 takes of citations nationally.
Of every deficiency written in Minnesota in 2025, this is the portion that was F554.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Minnesota surveyors wrote
F554 findings written in Minnesota, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
The short window
Recent years
| Year | Share of Minnesota citations | vs expected |
|---|---|---|
| 2023 | 2.45% | 4.42× |
| 2024 | 2.64% | 4.82× |
| 2025 | 1.86% | 3.29× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Minnesota surveyors cite →
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