Based on observation, interview and document review, the facility failed to establish a communication process between the facility and the hospice provider to ensure that the needs of a resident were addressed and met for 1 of 3 residents (R1) reviewed for hospice services. This resulted in an immediate jeopardy (IJ) when R1 did not receive the necessary care and services for the treatment of pressure ulcers and pain management. R1's pressure ulcer went untreated for approximately six weeks and R1's pain was not controlled, limiting staff's ability to perform activities of daily living for R1. In addition, the facility failed to have a designated member of the interdisciplinary team who was responsible to work with hospice to ensure residents receiving hospice services needs were met. …
F849 citations in Minnesota
Administration Deficiencies
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Minnesota cites F849 less often than its own record predicts
0.86 times the national share — cited less often here than elsewhere.
Of every deficiency written in Minnesota in 2025, this is the portion that was F849.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Minnesota surveyors wrote
F849 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 ensure there was a communication process between the long-term care (LTC) facility and the hospice provider to ensure the needs of the resident were met for 1 of 1 resident (R6) reviewed for hospice services. Findings include:R6's quarterly Minimum Data Set (MDS) assessment, dated 6/12/26, indicated R6 was cognitively intact and received hospice services. The High-Risk Drug Classes: Use and indication section of the MDS indicated R6 received antipsychotic medications (medications used to treat mood disorders).R6's diagnoses list included dementia with agitation, stroke, mode disturbances, depression, palliative care, and mental/behavioral disordersR6's care plan indicated R6 was on hospice and had history of anxiety, agitation,… …
The short window
Recent years
| Year | Share of Minnesota citations | vs expected |
|---|---|---|
| 2023 | 0.19% | 0.61× |
| 2024 | 0.20% | 0.64× |
| 2025 | 0.23% | 0.86× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Minnesota surveyors cite →
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