Based on observation, interview and document review the facility failed to ensure care planned interventions were implemented for toileting, resulting in a fall for 1 of 3 residents (R1). This resulted in actual harm to R1 when he fell and sustained a pelvic fracture. The facility had implemented actions to prevent recurrence prior to the survey; therefore, the citation was issued at past non-compliance. Findings include:R1's admission Record indicated R1 admitted to the facility 6/26/26. R1's diagnosis included stroke, spinal stenosis, weakness, blindness in one eye and fracture of left pubis (a break in the pubic bone at the front of the pelvis).R1's admission Minimum data Set (MDS) dated [DATE], identified moderate cognitive impairment and indicated R1 did not display behaviors. …
F656 citations in Minnesota
Comprehensive care plan · Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Minnesota cites F656 less often than its own record predicts
0.91 times the national share — cited less often here than elsewhere.
Of every deficiency written in Minnesota in 2025, this is the portion that was F656.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Minnesota surveyors wrote
F656 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 develop a comprehensive care plan that included bleeding precautions and/or use of diuretics for 4 of 5 sampled residents (R1, R2, R3, and R4). Based on interview and document review, the facility failed to develop a comprehensive care plan that included bleeding precautions and/or use of diuretics for 4 of 5 sampled residents (R1, R2, R3, and R4). Findings include: Review of the 6/6/23, Rx List article, Coumadin (aka Warfarin), located at https://my.clevelandclinic.org/health/treatments/22288-anticoagulants, identified (warfarin) is a blood anticoagulant that inhibits the function of vitamin K dependent coagulation used to inhibit the coagulation (clotting) of blood to reduce or prevent the chance of developing heart… …
The short window
Recent years
| Year | Share of Minnesota citations | vs expected |
|---|---|---|
| 2023 | 2.06% | 0.57× |
| 2024 | 2.52% | 0.74× |
| 2025 | 3.15% | 0.91× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Minnesota surveyors cite →
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