Based on interview and document review, the facility failed to ensure the head of bed was elevated for 1 of 3 residents (R1) who utilized a tube feeding to meet their nutritional needs. This resulted in an immediate jeopardy (IJ) situation for R1 who had an emesis when left flat in bed, while their tube feeding was running, which lead to aspiration and subsequent hospitalization . The IJ began on 1/15/22, at 3:10 p.m. while R1 was found laying flat in bed and covered in emesis when her tube feeding was actively running and was subsequently hospitalized due to an aspiration pneumonia. The administrator and director of nursing (DON) were notified of the IJ for R1 on 1/21/22, at 12:15 p.m. …
F693 citations in Minnesota
Tube feeding · Quality of Life and Care Deficiencies
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Minnesota cites F693 less often than its own record predicts
0.28 times the national share — cited less often here than elsewhere.
Of every deficiency written in Minnesota in 2025, this is the portion that was F693.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Minnesota surveyors wrote
F693 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 record review, the facility failed to ensure staff checked gastrostomy tube (G-tube) (a feeding tube inserted through the abdomen) placement prior to administration of medications, water flushes and feedings for 1 of 1 resident (R1) observed for medication administration via gastrostomy tube. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had no cognitive impairment and was dependent or maximal assistance with activities of daily living (ADLs). Diagnoses included progressive bulbar palsy (a motor neuron disease that affects the nerves controlling speech, swallow and facial muscles), dysarthria (speech disorder), diverticulosis of intestine, esophagitis and gastritis. On 9/8/26, at 8:17 a.m. …
The short window
Recent years
| Year | Share of Minnesota citations | vs expected |
|---|---|---|
| 2023 | 0.64% | 0.86× |
| 2024 | 0.24% | 0.34× |
| 2025 | 0.19% | 0.28× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Minnesota surveyors cite →
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