Based on interview and document review, the facility failed to allow 1 of 1 residents (R1) to return to the facility after a non-medically recommended leave of absence (LOA). When R1 returned to the facility, she was notified she was discharged , and had no safe discharge plan in place. This resulted in an immediate jeopardy (IJ) for R1 who was homeless, subsequently relapsed on substances, and was hospitalized on four separate occasions for intoxication, suicidal ideation, and mental health concerns. The IJ began on 7/27/21, at 2:00 p.m. when R1 was discharged without notice against medical advice (AMA) after she went on a leave of absence (LOA) that was determined by the facility to be AMA. R1's commitment case manager was not notified of R1's LOA or subsequent AMA discharge. …
F622 citations in Minnesota
Transfer and discharge · Resident Rights Deficiencies
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Minnesota cites F622 less often than its own record predicts
0.67 times the national share — cited less often here than elsewhere.
Of every deficiency written in Minnesota in 2025, this is the portion that was F622.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Minnesota surveyors wrote
F622 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 provide complete information upon transfer to the receiving facility for 1 of 2 residents (R18) reviewed for hospitalization and discharge. Findings include: R18's quarterly Minimum Data Set (MDS) dated [DATE], indicated R18 had impaired cognition and was noted to exhibit inattention and disorganized thinking. R18 was also noted to have intermittent behavioral symptoms including physical behavioral symptoms directed towards others, verbal behaviors, and other symptoms not directed at others. R18 was noted to receive assistance with activities of daily living, although was able to ambulate independently. …
The short window
Recent years
| Year | Share of Minnesota citations | vs expected |
|---|---|---|
| 2023 | 0.58% | 2.30× |
| 2024 | 0.12% | 0.37× |
| 2025 | 0.08% | 0.67× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Minnesota surveyors cite →
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