Based on observation, interview, and record review the facility failed to implement appropriate interventions and supervision, monitor and assess changes in mood and mental status, coordinate care with psychiatric providers, and notify the providers of changes in mood/behavior for 1 of 3 residents (R1) who had a significant history of suicidal ideation and suicide attempts. These failures resulted in Immediate Jeopardy (IJ) when R1 attempted suicide after a progressive decline in mood and behavior following the discontinuation of two psychotropic medications without increased monitoring, provider notification, or revision of interventions. …
F740 citations in Minnesota
Behavioral health services · Quality of Life and Care Deficiencies
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Minnesota cites F740 more often than its own record predicts
1.33 times the share F740 takes of citations nationally.
Of every deficiency written in Minnesota in 2025, this is the portion that was F740.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Minnesota surveyors wrote
F740 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 develop and implement individualized non-pharmacological interventions to manage behaviors for 2 of 2 residents (R1, R3) who had mental health disorders with behaviors. The facility's failures resulted in harm for R1 when she sustained burns from using hot towels to self-soothe to relieve anxiety symptoms and had multiple hospitalization for mental health stabilization. Findings include: R1's face sheet identified R1 was admitted to facility October of 2022 with diagnoses including, borderline personality disorder, generalized anxiety disorder, unspecified mood [affective] disorder, and major depressive disorder, single episode, severe without psychotic features. …
Based on observation, interview, and document review the facility failed to ensure the behavioral health service provider was updated with symptoms and the need for a psychological visit for 1 of 1 resident (R151) reviewed for mood and behavior.Findings include:R151's quarterly minimum data set (MDS) dated [DATE], indicated R151 had impaired cognition, and was dependent on staff for most activities of daily living (ADL's). R151's diagnoses included major depressive disorder, dementia, multiple sclerosis, mood disturbance, and chronic pain.R151's care plan dated 8/25/26, indicated R151 had potential for mood concerns related to major depressive disorder, multiple sclerosis, chronic pain, and insomnia and had reported feeling down, depressed, and hopeless. …
The short window
Recent years
| Year | Share of Minnesota citations | vs expected |
|---|---|---|
| 2023 | 0.58% | 2.20× |
| 2024 | 0.32% | 1.27× |
| 2025 | 0.35% | 1.33× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Minnesota surveyors cite →
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