Based on observation, interview, and document review, the facility failed to appropriately assess, monitor, and intervene when 1 of 1 resident (R1) with known increasing physical behaviors caused by dementia, physically abused 5 of 35 residents (R2, R3, R5, R6 and 1 unknown resident) resulting in skin tears, a lacerated lip, and 2 puncture wounds caused by biting. R1 was also at risk for abuse when 1 of 1 resident (R4) threatened to harm R1 with his oxygen tank. This resulted in an immediate jeopardy (IJ). The IJ began on 5/9/21, when R1 had physically assaulted R3 by grabbing R3's arm and pinching her and the facility failed to assess R1's dementia and behaviors and develop interventions to manage behaviors and prevent further resident to resident altercations. …
F744 citations in Minnesota
Dementia care · Quality of Life and Care Deficiencies
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Minnesota cites F744 less often than its own record predicts
0.59 times the national share — cited less often here than elsewhere.
Of every deficiency written in Minnesota in 2025, this is the portion that was F744.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Minnesota surveyors wrote
F744 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 comprehensively assess, and implement behavior management interventions for 1 of 1 residents (R13) who exhibited escalating physical and verbal behaviors with frequent aggressions toward staff causing distress. This resulted in actual psychosocial harm for R13 who had repeated behaviors of hitting, kicking, grabbing, and use of vulgar language that required hospitalization and subsequent intramuscular (IM) medication to alleviate these unassessed, escalating behaviors. Findings include: R13's Resident Face Sheet dated 11/26/18, included [DIAGNOSES REDACTED]. R13's admission Minimum Data Set ((MDS) dated [DATE], indicated R13 was severely cognitively impaired, and had [DIAGNOSES REDACTED]. …
Based on observation, interview and document review, the facility failed to assess and evaluate wandering behaviors, including entering other residents' rooms and going through personal belongings, for 1 of 3 residents (R13) reviewed for behavioral symptoms.Findings include:R13's quarterly Minimum Data Set (MDS) dated [DATE], identified R13 had severe cognitive impairment and diagnoses that included Alzheimer's disease, dementia and anxiety. R13 exhibited wandering daily. R13 used a bed alarm and a wander/elopement alarm. …
The short window
Recent years
| Year | Share of Minnesota citations | vs expected |
|---|---|---|
| 2023 | 0.39% | 1.82× |
| 2024 | 0.24% | 1.13× |
| 2025 | 0.12% | 0.59× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Minnesota surveyors cite →
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