Based on observation, interview and document review the facility failed to complete a thorough investigation of alleged abuse, provide documentation of an investigation and take action to prevent further abuse for 1 of 3 residents (R1) reviewed for abuse. This resulted in an Immediate Jeopardy (IJ) when the administrator and the director of nursing (DON) were notified of a possible sexual relationship between cook-A and R1 but failed to complete a thorough investigation prior to cook-A returning to work. The IJ began on 7/10/26, when the facility failed to conduct a thorough investigation when alleged abuse was reported. The administrator and owner were notified of the immediate jeopardy at 4:45 p.m. on 7/16/26. …
F610 citations in Minnesota
Investigating alleged violations · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Minnesota cites F610 more often than its own record predicts
1.13 times the share F610 takes of citations nationally.
Of every deficiency written in Minnesota in 2025, this is the portion that was F610.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Minnesota surveyors wrote
F610 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 interviews and document review the facility failed to investigation an allegation of mistreatment for 1 of 1 resident (R6) reviewed for mistreatment.Findings include: R6 R6's quarterly Minimum Data Set (MDS) dated [DATE], indicated intact cognition, impairment in both lower extremities, dependence upon staff for assistant with toileting hygiene and activities of daily living (ADL), and an ostomy (a surgical opening on the abdomen that allows stool to leave the body). R6's diagnoses included multiple sclerosis (a chronic disease that affect the nervous system), a neurogenic bladder (nerve damage disrupts communication between the brain, spinal cord and bladder), paraplegia, and depression. …
The short window
Recent years
| Year | Share of Minnesota citations | vs expected |
|---|---|---|
| 2023 | 1.74% | 1.36× |
| 2024 | 1.73% | 1.21× |
| 2025 | 1.71% | 1.13× |
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