Based on observation, interview and document review, the facility failed to provide sufficient nursing staff to ensure residents' safety and overall care and needs were maintained by ensuring scheduled medications to treat pain, blood sugar (insulin), blood thinners, blood pressure, and [MEDICAL CONDITION] were administered, and failed to ensure wound dressings were completed for 14 of 41 residents (R3, R6, R8, R14, R29, R15, R13, R33, R24, R20, R27, R12,R15, and R18). The facility also failed to ensure breakfast was provided for 17 of 38 residents (R31, R30, R5, R33, R32, R38, R28, R11, R17, R40, R7, R12, R8, R21, R25, R9, R23) between the dates of [DATE] and [DATE], and failed to ensure repositioning was completed to prevent pressure ulcers for 1 of 1 resident (R28). …
F725 citations in Minnesota
Sufficient nursing staff · Nursing and Physician Services Deficiencies
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Minnesota cites F725 less often than its own record predicts
0.80 times the national share — cited less often here than elsewhere.
Of every deficiency written in Minnesota in 2025, this is the portion that was F725.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Minnesota surveyors wrote
F725 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 provide sufficient staffing to ensure residents received the care and assistance they needed in a timely manner for 4 of 5 residents (R5, R1, R3, & R6) reviewed for call lights. This caused actual harm to R5 when she waited nearly three hours for her call light to be answered causing her to experience increased anxiety, distress, fear, and feelings of worthlessness and helplessness. Findings include: R5 R5's Minimum Data Set (MDS) assessment dated [DATE], indicated she had intact cognition and no behaviors or rejections of care. R5 had diagnoses including multiple sclerosis (chronic disease affecting the central nervous system), anxiety disorder, major depressive disorder, and morbid obesity. …
Based on observation, interview and document review, the facility failed to ensure there were sufficient numbers of staff to ensure all resident cares were completed timely or as ordered. This affected activities of daily living (ADLs) for 4 of 5 residents (R52, R66, R50, R2), positioning for meals for 1 of 1 resident (R9), toileting program schedules and check and changes for 3 of 5 residents (R66, R8, R9), timely pain medication delivery timely for 1 of 3 resident (R62), dialysis care for 1 of 1 resident (R11). This also affected timely meal service for 9 of 9 residents (R56, R30, R44, R26, R2, R8, R72, R10, R73). …
The short window
Recent years
| Year | Share of Minnesota citations | vs expected |
|---|---|---|
| 2023 | 0.71% | 0.88× |
| 2024 | 0.51% | 0.64× |
| 2025 | 0.62% | 0.80× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Minnesota surveyors cite →
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