Based on observation, interview, and document review, the facility failed to ensure resident advance directives were accurately and consistently documented between the physician orders in the resident's electronic health record (EHR) and the Provider Order for Life-Sustaining Treatment (POLST) in the hard chart to ensure the resident's wishes would be followed in the event of a cardiac arrest. This resulted in immediate jeopardy for 2 of 13 residents (R2, R6) whose code statuses were not accurately documented, with an additional resident (R1) discrepancy found in a facility-wide audit.The immediate jeopardy began on [DATE], when interviews with the direct care nurse and director of nursing indicated they would implement incorrect procedures and not started CPR on R2 if found without a… …
F578 citations in Minnesota
Advance directives · Resident Rights Deficiencies
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Minnesota cites F578 less often than its own record predicts
0.94 times the national share — cited less often here than elsewhere.
Of every deficiency written in Minnesota in 2025, this is the portion that was F578.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Minnesota surveyors wrote
F578 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.
Based on interview and document review the facility failed to comply with resident rights to refuse treatment for 1 of 4 residents (R1) reviewed when staff proceeded with a urinary straight catheterization while R1 verbally and physically refused the procedure. R1 has had increased anxiety since the straight catheterization procedure. Findings include: R1's Minimal Data Set (MDS) dated [DATE] indicated R1 admitted to the facility on [DATE]. R1's pertinent primary medical conditions indicated on the MDS included anxiety disorder, morbid obesity, metastatic breast cancer, pathological fracture of the left tibia (shin bone) and generalized muscle weakness. R1 had no cognitive deficits. R1 was dependent upon staff with toileting and lower body dressing and transfers. …
Based on interview and document review the facility failed to ensure 1 of 1 resident's (R5) Provider Orders for Life Sustaining Treatment (POLST) was completed timely.Findings include:R5's admission Minimum Data Set (MDS) dated [DATE], identified R5 had diagnoses which included heart failure (a medical condition where the heart does not pump blood effectively), dementia, diabetes mellitus, hyperlipidemia, and heart disease. In addition, R5's MDS identified they were moderately cognitively intact and required partial to moderate assistance with activities of daily living.R5's POLST identified R5 signed their POLST document on 5/6/26, R5's provider did not sign the document until 7/30/26, after it was brought to the facility's attention that the document had not been signed by the… …
The short window
Recent years
| Year | Share of Minnesota citations | vs expected |
|---|---|---|
| 2023 | 1.03% | 0.96× |
| 2024 | 0.98% | 1.00× |
| 2025 | 0.89% | 0.94× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Minnesota surveyors cite →
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