Based on interview, video/audio recording review and document review, the facility administration directed staff not to report or document a resident elopement. The administration's direction not to report, prevented immediate identification and correction of failures in supervision, alarm response, staff training, and elopement prevention, leaving residents exposed to continued risk of elopement and serious injury and demonstrated a breakdown of the facility's governing systems for resident protection, quality assurance, and promoted an ongoing culture of fear of the facility being shut down, retaliation and regulatory noncompliance. …
F835 citations in Minnesota
Administration · Administration Deficiencies
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Minnesota cites F835 less often than its own record predicts
0.40 times the national share — cited less often here than elsewhere.
Of every deficiency written in Minnesota in 2025, this is the portion that was F835.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Minnesota surveyors wrote
F835 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 provide oversight and management for the facility when there was a severe rodent infestation, lack of food, and the facility was in disrepair. This had the potential to affect all 13 residents currently residing at the facility as well as all staff and visitors.Findings include:A pest control service invoice, dated 6/8/26, indicated on 6/14/24 immediate repairs recommended for hole in siding or foundation larger than two inches and front patio deteriorated. No suggested repairs have been made at this time. Pest control service was provided. It indicated heavy rodent activity in the basement. …
The short window
Recent years
| Year | Share of Minnesota citations | vs expected |
|---|---|---|
| 2023 | 0.26% | 0.90× |
| 2024 | 0.04% | 0.12× |
| 2025 | 0.12% | 0.40× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Minnesota surveyors cite →
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