Based on interview and document review, the facility failed to ensure the Minimum Data Set (MDS) was accurately coded, with the potential for inaccurate federal reimbursement and resident care planning for 2 of 3 residents (R23, R46) reviewed for MDS accuracy. Findings include: R23's quarterly MDS dated [DATE], indicated R23 did not get an injection or a hypoglycemic (medication that decreases blood sugar levels) medication during the look back period (LBP). R23's Medication Administration Record (MAR) dated 7/1/26 to 7/30/26, indicated R23 received 500 milligrams (mg) of metformin daily during the LBP. The MAR indicated R23 received one, five mg injection of tirzepatide (a hypoglycemic medication also used for weight loss) during the LBP. …
F641 citations in Minnesota
Accuracy of assessments · Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Minnesota cites F641 more often than its own record predicts
1.18 times the share F641 takes of citations nationally.
Of every deficiency written in Minnesota in 2025, this is the portion that was F641.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Minnesota surveyors wrote
F641 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 observation, interview, and document review, the facility failed to ensure the completed Minimum Data Set (MDS) was accurately coded to reflect actual restraint use for 4 of 4 residents (R2, R15, R26, R41) reviewed for MDS accuracy. In addition, the facility failed to accurately complete a Brief Interview for Mental Status (BIMS) assessment for 1 of 4 residents (R17) reviewed for MDS accuracy. Findings include: Restraint Use The Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, dated 10/2023, outlined a section labeled, SECTION P: RESTRAINTS AND ALARMS, which directed to record the frequency a resident was restrained by any of the listed devices during the seven-day look-back period. …
The short window
Recent years
| Year | Share of Minnesota citations | vs expected |
|---|---|---|
| 2023 | 1.48% | 0.87× |
| 2024 | 1.42% | 0.84× |
| 2025 | 2.17% | 1.18× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Minnesota surveyors cite →
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