Based on observation, interview, and document review the facility failed to ensure residents had a fitted sheet on their bed for 2 of 2 residents (R15, R53) with bariatric beds.Findings include: R15 R15's quarterly Minimum Data Set (MDS) dated [DATE], indicated intact cognition and diagnoses of chronic respiratory failure with hypoxia, morbid obesity, and chronic pain. It further included R15 had bilateral impairment of his lower extremities, was dependent on staff for toileting and transfers. During observation and interview on 6/1/26 at 11:58 a.m., R15 was in bed (bariatric) on top of a blanket that had been laid across the bed where large areas of the bare mattress were exposed. R15 stated the facility never put a fitted sheet on his bed because they didn't have any sheets that fit. …
F917 citations in Minnesota
Environmental Deficiencies
Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2023
Minnesota cites F917 more often than its own record predicts
3.08 times the share F917 takes of citations nationally.
Of every deficiency written in Minnesota in 2023, this is the portion that was F917.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Minnesota surveyors wrote
F917 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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