Based on interview and document review, the facility failed to ensure physician-ordered vision services were arranged and provided by failing to schedule and follow through with a routine referral to a retinal specialist for 1 of 1 resident (R31) reviewed for vision services. This failure had the potential for more than minimal harm by delaying evaluation and treatment of reported vision symptoms and potential diabetes-related eye conditions. Findings include: R31's annual Minimum Data Set (MDS) assessment, dated 4/1/26, indicated R31 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. Diagnoses included diabetes mellitus, protein-calorie malnutrition, depression, and post-traumatic stress disorder (PTSD). …
F685 citations in Minnesota
Quality of Life and Care Deficiencies
Assist a resident in gaining access to vision and hearing services.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Minnesota cites F685 more often than its own record predicts
2.08 times the share F685 takes of citations nationally.
Of every deficiency written in Minnesota in 2025, this is the portion that was F685.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Minnesota surveyors wrote
F685 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.
The short window
Recent years
| Year | Share of Minnesota citations | vs expected |
|---|---|---|
| 2023 | 0.58% | 2.18× |
| 2024 | 0.55% | 1.94× |
| 2025 | 0.50% | 2.08× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Minnesota surveyors cite →
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