Based on observation, interview and document review, the facility failed to ensure an un-licensed nursing student (NS) was supervised during resident medication administration, including significant medication such as insulin, liquid morphine and other controlled substances. In addition, NS did not possess a nursing license, competencies, or skills set to provide necessary resident nursing services nor other certification required for medication administration. This had the likelihood for a serious adverse outcome and placed 4 of 4 residents (R2, R3, R6, R7) in immediate Jeopardy (IJ). The IJ began on 12/12/25, when the NS was observed administering insulin to a resident without direct supervision by a licensed nurse. The administrator was notified of the immediate jeopardy at 5:05 p.m. …
F726 citations in Minnesota
Competent nursing staff · Nursing and Physician Services Deficiencies
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Minnesota cites F726 more often than its own record predicts
1.10 times the share F726 takes of citations nationally.
Of every deficiency written in Minnesota in 2025, this is the portion that was F726.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Minnesota surveyors wrote
F726 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 have the knowledge, competencies and skill sets to provide care, and respond to each resident's individualized assessed needs safely in a manner that promotes each person centered care, basic nursing skills, infection control and identification of changes in condition, mental and psychosocial well-being. This practice was evident for director of nursing (DON), 2 of 12 registered nurses (RN-C & RN-D) and 3 of 10 licensed practical nurse (LPN-A, LPN-D & LPN-E). Finding include: Refer to 554: LPN-A left medications at bedside for a resident who was deemed not safe to do so. …
Based on interview and document review, the facility failed to ensure nursing staff were appropriately oriented and trained for safe medication administration. This resulted in widespread medication administration errors affecting 16 of 25 residents (R4, R7, R10, R12, R16, R18, R20, R23, R25, R27, R29, R30, R31, R37, R39, and R46) on 7/15/26.Findings include:(Cross-reference: Refer to F-760 for the specific medical record data and medication error details for residents R4, R7, R10, R12, R16, R18, R20, R23, R25, R27, R29, R30, R31, R37, R39, and R46.)Review of the facility policy Change in Condition, dated 11/13/24, showed requirements to notify the provider and responsible party of any change in resident physical, psychosocial, or mental status. …
The short window
Recent years
| Year | Share of Minnesota citations | vs expected |
|---|---|---|
| 2023 | 0.58% | 0.95× |
| 2024 | 0.63% | 0.96× |
| 2025 | 0.66% | 1.10× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Minnesota surveyors cite →
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