Based on interview and document review, the facility failed to implement an effective compliance and ethics program with sufficient monitoring and auditing mechanisms to detect and prevent potential violations and ensure the integrity of the data reported to the Centers for Medicare and Medicaid services (CMS). The facility further failed to ensure employees could report, without fear of retaliation, a high-level personnel's suspected violations. These failures resulted in documentation and minimum data set (MDS) irregularities with unsupported or inconsistently reported diagnosis for 4 of 4 residents (R31, R39, R40, R61) reviewed. Findings include: R31's admission Record identified an admission date of 1/25/23. …
F895 citations in Minnesota
Administration Deficiencies
Have a Compliance and Ethics Program.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2024
Minnesota cites F895 more often than its own record predicts
3.20 times the share F895 takes of citations nationally.
Of every deficiency written in Minnesota in 2024, this is the portion that was F895.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Minnesota surveyors wrote
F895 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.
What else Minnesota surveyors cite →
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