Based on observation, interview and document review the facility failed to ensure fluids were provided in a consistency/thickness to meet the needs for 1 of 1 resident (R1) reviewed for liquid consistency. This resulted in an immediate jeopardy for R1 who was served thin liquids, not in accordance with recommendations by the speech language pathologist (SLP).The IJ began on 8/1/26, when facility staff provided R1 with thin liquids despite an order for nectar thickened liquids. The IJ was identified on 8/18/26, the administrator was notified of the immediate jeopardy at 3:00 p.m. on 8/18/26. The immediate jeopardy was removed on 8/2/26, the deficient practice was corrected prior to the start of the survey and was therefore issued at past noncompliance. …
F805 citations in Minnesota
Food in a form residents can eat · Nutrition and Dietary Deficiencies
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Minnesota cites F805 more often than its own record predicts
1.02 times the share F805 takes of citations nationally.
Of every deficiency written in Minnesota in 2025, this is the portion that was F805.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Minnesota surveyors wrote
F805 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 ensure beverages were provided in the appropriate consistency for 1 of 1 resident (R20) reviewed who required modified liquids.Findings include:R20's admission minimum data set (MDS) dated [DATE], indicated R20 had intact cognition, required supervision for intake, received mechanically altered diet of pureed texture food and mildly thickened liquids, and received speech therapy. R20's diagnoses included stroke, dysphagia (difficulty swallowing), coronary artery disease, high blood pressure, and risk for malnutrition related to therapeutic diet of altered consistency.R20's nutrition care area assessment (CAA) dated 8/8/26, indicated R20 required a mechanically altered diet and thickened liquids due to dysphagia… …
The short window
Recent years
| Year | Share of Minnesota citations | vs expected |
|---|---|---|
| 2023 | 0.13% | 0.36× |
| 2024 | 0.12% | 0.33× |
| 2025 | 0.31% | 1.02× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Minnesota surveyors cite →
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