Based on interview and document review, 1 of 1 Governing Body failed to provied appropriate oversight to ensure deficient practice had been corrected and coompliance achieved. Refer to F636, F656, F684, F758, F812, F842, F865, F880, F882, and F944. Findings include: Review of the QAPI meeting minute attendance from the 3/25/25 QAPI Meeting (meetings are held monthly) identified attendees present were the administrator, the director of nursing (DON) the assistant director of nursing (ADON), the infection preventionist (IP) the social services designee (SSD) and the pharmacist. The medical director was absent for this meeting. During the meeting, topics discussed were as follows: 1) Pressure Ulcers: There were 14 active pressure ulcers involving 5 residents. …
F837 citations in Minnesota
Administration Deficiencies
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Minnesota cites F837 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 F837.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Minnesota surveyors wrote
F837 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 failed to establish and implement a policy related to the responsibility of the administrator to report to and being held accountable by the Governing Body. This had the potential to affect all 69 residents residing in the facility. Findings include: On 9/6/24, facility policies were reviewed and documentation was requested from the facility to demonstrate the facility had current policies and procedures related to the Governing Body. On 9/6/24 at 5:22 p.m., the administrator stated the facility did not have a policy about the Governing Body.
The short window
Recent years
| Year | Share of Minnesota citations | vs expected |
|---|---|---|
| 2024 | 0.08% | 0.86× |
| 2025 | 0.04% | 0.71× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Minnesota surveyors cite →
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