Based on record review, staff interviews, and policy review, the facility failed to ensure that medications were accurately identified and dispensed upon discharge, resulting in one resident (R214) being sent home with another resident's (R221) medications. This failure led to R214 ingesting medications not prescribed to her. This resulted in actual harm when R214 required emergency medical intervention and hospitalization due to hypotension (low blood pressure). Findings include: R214's discharge Minimum Data Set (MDS) dated [DATE], indicated R214 had intact cognition, and had diagnoses of hypertension (high blood pressure), atrial fibrillation (irregular heartbeat that originates in the heart's upper chambers), anemia (low red blood cells) and depression. …
F628 citations in Minnesota
Resident Rights Deficiencies
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Minnesota cites F628 less often than its own record predicts
0.92 times the national share — cited less often here than elsewhere.
Of every deficiency written in Minnesota in 2025, this is the portion that was F628.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Minnesota surveyors wrote
F628 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 send appropriate discharge information for 2 of 3 sampled residents (R39 and R40) including advanced directives, instructions for ongoing care, care plans and goals, or other information to ensure safe and effective transition of care.Findings include: R39's face sheet identified she was admitted to the facility in December 2023 and discharged [DATE]. R39's undated diagnoses sheet identified diagnoses of major depressive disorder, recurrent and severe with psychotic symptoms, generalized anxiety disorder, catatonic disorder due to known physiological condition, schizoaffective disorder, unspecified, neuroleptic induced parkinsonism, bipolar disorder, unspecified, suicidal ideations, age-related cataract, high blood pressure,… …
Based on interview and document review, the facility failed to ensure the Ombudsman was notified of a facility transfer for 1 of 1 resident (R73). Findings include: R73's admission record dated 7/16/26, indicated diagnosis included acute cystitis (medical inflammation of the bladder, usually caused by a bacterial infection) without hematuria (red blood cells in the urine), adult failure to thrive, transient ischemic attack (TIA) and cerebral infarction without residual deficits, other symptoms and signs involving cognitive functions and awareness. R73's provider progress note dated 5/19/26, indicted R73 was being transferred to a memory care center. R73's discharge instructions and summary dated 5/19/26, indicated it was a facility-initiated discharge and must notify the Ombudsman. …
What else Minnesota surveyors cite →
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