Based on observation, interview, and document review the facility failed to ensure the care plan was updated timely and accurately and failed to monitor effectiveness of interventions and modify the care plan as needed for 1 of 1 resident (R151) reviewed for falls.Findings include:R151's significant change in status minimum data set (MDS) dated [DATE], indicated R151 had impaired cognitive status, required assist from staff for transfers, and had a history of multiple falls. R151's diagnoses included osteoarthritis, weakness, history of falling with fractures, generalized anxiety disorder, major depressive disorder, and age-related physical debility.R151's care plan dated 8/25/26, indicated R151 was at risk for and had a history of falling. …
F657 citations in Minnesota
Care plan timing and revision · Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Minnesota cites F657 more often than its own record predicts
1.35 times the share F657 takes of citations nationally.
Of every deficiency written in Minnesota in 2025, this is the portion that was F657.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Minnesota surveyors wrote
F657 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 ensure nursing staff had been in attendance at care conferences conducted for 3 of 3 residents (R3, R28, R96 ) reviewed for care planning. Findings include: R28's facesheet printed on 6/15/23 included diagnoses of rhabdomyolysis (breakdown of muscle tissue), pressure ulcers and repeated falls. R28's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated R28 was cognitively intact; had clear speech, was understood and could understand. R28 did not walk and required extensive assistance of one or two staff for activities of daily living. …
The short window
Recent years
| Year | Share of Minnesota citations | vs expected |
|---|---|---|
| 2023 | 1.48% | 0.69× |
| 2024 | 1.65% | 0.86× |
| 2025 | 2.52% | 1.35× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Minnesota surveyors cite →
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