Based on observation, interview and document review, the facility failed to ensure the emergency call system remained accessible and functional for 4 of 4 residents (R9, R30, R52, and R64) who used the shared bathroom by failing to ensure the bathroom emergency call light pull cord was long enough to be reached by a resident from the floor creating the potential for delayed staff response during an emergency.Findings include:R9's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated R9 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15, was independent with personal hygiene and toileting, and had experienced one fall with minor injury.R52's quarterly MDS assessment dated [DATE] indicated R52 had severe cognitive impairment with a BIMS score of 4… …
F919 citations in Minnesota
Call system · Environmental Deficiencies
Make sure that a working call system is available in each resident's bathroom and bathing area.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Minnesota cites F919 more often than its own record predicts
1.39 times the share F919 takes of citations nationally.
Of every deficiency written in Minnesota in 2025, this is the portion that was F919.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Minnesota surveyors wrote
F919 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.
The short window
Recent years
| Year | Share of Minnesota citations | vs expected |
|---|---|---|
| 2023 | 0.52% | 1.18× |
| 2024 | 0.28% | 0.62× |
| 2025 | 0.62% | 1.39× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Minnesota surveyors cite →
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