Based on observation, interview, and record review the facility failed to ensure effective pharmacy services for availability in opioid pain medication for 1 of 3 residents (R1) reviewed for pharmacy services. As a result of the facility's failures pain medications were not administered to R1 due to prolonged medication unavailability which caused escalating severe unmanaged pain that was more than transient and possible early opioid withdrawal symptoms without alternate treatment or monitoring. …
F755 citations in Minnesota
Pharmacy services · Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Minnesota cites F755 less often than its own record predicts
0.71 times the national share — cited less often here than elsewhere.
Of every deficiency written in Minnesota in 2025, this is the portion that was F755.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Minnesota surveyors wrote
F755 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 implement a system to ensure medications were consistently acquired, received, and administered as ordered for 3 of 3 residents (R20, R4, R22) reviewed. As a result, R20 did not receive hydromorphone (synthetic opioid/narcotic) for seven days and pregabalin (anticonvulsant to treat nerve pain) for four days. This resulted in actual harm when R20 experienced severe withdrawal symptoms.Findings include: R20 R20's annual Minimum Data Set (MDS), dated [DATE], indicated R20 was cognitively intact. …
Based on observation, interview, and document review, the facility failed to follow provider orders for medication and failed to ensure medication administration was correctly documented for 3 of 3 residents (R4, R5, and R6) reviewed for medication administration.Findings include: R4 R4's annual Minimum Data Set (MDS) dated [DATE], identified R4 had intact cognition. R4's medical diagnoses include progressive neurological conditions, Parkinson's, anemia (low iron), thyroid disorder, anxiety, depression, and malnutrition. R4's orders identified:Nutren 1.5 (nutritional supplements) liquid; 0.07 gram (gr) - 1.5 kilocalorie (kcal) /milliliters (ml); 250 ml bolus; feeding tube. …
The short window
Recent years
| Year | Share of Minnesota citations | vs expected |
|---|---|---|
| 2023 | 2.00% | 0.95× |
| 2024 | 2.01% | 0.94× |
| 2025 | 1.67% | 0.71× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Minnesota surveyors cite →
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