Based on interview and record review, the facility failed to develop and implement a comprehensive, competency-based nursing orientation program, failed to maintain required competency records in newly hired employee files. This failure resulted in a new graduate nurse working independently without verified competencies, leading to a widespread medication error incident. This deficient practice had the potential to impact all residents who received nursing care at the facility.Findings include:Review of the facility's personnel records for four nurses hired within the last seven months revealed a complete absence of role-specific training documentation:Licensed Practical Nurse (LPN)-A was hired on 6/25/26. …
F940 citations in Minnesota
Administration Deficiencies
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Minnesota cites F940 less often than its own record predicts
0.40 times the national share — cited less often here than elsewhere.
Of every deficiency written in Minnesota in 2025, this is the portion that was F940.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Minnesota surveyors wrote
F940 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 | 0.19% | 2.42× |
| 2024 | 0.12% | 1.25× |
| 2025 | 0.04% | 0.40× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Minnesota surveyors cite →
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