Based on interview and document review the facility failed to report an allegation of suspected abuse to the State Agency immediately (with in 2 hours) for 1 of 1 resident (R84) who reported rough handling by 1 of 1 staff (nursing assistant (NA)-A) during the provision of personal cares. Findings include: Review of the 1/22/26 at 4:23 p.m., report to the State Agency (SA) identified facility staff became aware of an incident of potential physical abuse on 1/21/26 during the provision of toileting after the supper meal. The incident was reported by R48 to an unidentified staff member following the incident on 1/21/26. The director of nursing (DON) became aware of the incident on 1/22/26 at 12:30 p.m. and updated the administrator of the reported incident. …
F609 citations in Minnesota
Reporting alleged violations · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Minnesota cites F609 more often than its own record predicts
1.08 times the share F609 takes of citations nationally.
Of every deficiency written in Minnesota in 2025, this is the portion that was F609.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Minnesota surveyors wrote
F609 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 | 3.87% | 1.95× |
| 2024 | 3.62% | 1.59× |
| 2025 | 2.64% | 1.08× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Minnesota surveyors cite →
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction