Based on observation, interview and record review, the facility failed to ensure medications were secured, allowing a resident (R1) to have access to medication that was ingested for a suicide attempt. These practices resulted in an immediate jeopardy (IJ) for R1, whom was hospitalized and then intubated (insertion of a tube into the airway) as a result of the adverse effects of the medication overdose. The immediate jeopardy began on 12/15/20, when trained medication aid (TMA)-A failed to secure medication that was left unattended. The facility administrator and Licensed Practical Nurse (LPN)-B were notified of the immediate jeopardy on 12/17/20, at 2:45 p.m. …
F761 citations in Minnesota
Drug labeling and storage · Pharmacy Service Deficiencies
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Minnesota cites F761 less often than its own record predicts
0.53 times the national share — cited less often here than elsewhere.
Of every deficiency written in Minnesota in 2025, this is the portion that was F761.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Minnesota surveyors wrote
F761 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 refrigerated medications categized as controlled substance were properly stored with a two-lock system in 3 of 4 medication rooms reviewed for safe medication storage. In addition, the facility failed to ensure stock supply lab specimen collection supplies were not outdated. Findings include: On [DATE] at 1:35 p.m., a review of the Lakeside TCU medication room was completed with registered nurse RN-A. RN-A used a key to gain access to the medication room. The medication room fridge was not locked. There was an unlocked black box on the shelf inside the fridge. There was a bottle of Ativan inside the box. RN-A was not able to find a key that would lock the box. …
The short window
Recent years
| Year | Share of Minnesota citations | vs expected |
|---|---|---|
| 2023 | 2.13% | 0.67× |
| 2024 | 1.81% | 0.59× |
| 2025 | 1.71% | 0.53× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Minnesota surveyors cite →
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