Citations in Minnesota
Statistics, citations and compliance trends for long-term care facilities in Minnesota.
Statistics for Minnesota (Last 12 Months)
Financial Impact (Last 12 Months)
Latest citations in Minnesota
Failure to use beard restraints during food prep and meal service was observed when two cooks with visible facial hair handled and checked food without beard coverings. One cook said he was unsure a beard restraint was required, and the other said staff never wore them. The KL stated beard restraints were required, but none were available on the hygiene supply shelf, which contained gloves, hair restraints, and aprons.
The facility failed to ensure that NA-M completed the required Alzheimer's and dementia care training. During record review and interview, the administrator could not locate training documentation for the NA, who had a start date of 9/9/25, and no policy related to the training was provided.
A resident with moderate unspecified dementia and Sjogren syndrome with keratoconjunctivitis complained that the room lights were too white, bright, and harsh and asked for softer, more yellow lighting. Staff repeatedly responded by turning the lights off, but no work order was submitted to maintenance for the requested lighting change, despite staff stating that lighting concerns should be forwarded to maintenance.
PRN Antipsychotic Order Not Limited or Reassessed: A resident with advanced dementia, Alzheimer’s disease, agitation, and hospice services received PRN haloperidol for agitation and delirium under an open-ended order rather than a 14-day limit. Physician documentation continued the medication but did not show an evaluation of its ongoing need or an adequate rationale for renewal, and nursing notes did not document non-pharmacological interventions before one PRN dose was given.
Missing Written Transfer and Bed-Hold Notices: A resident with severe cognitive impairment and nonverbal status was transferred by ambulance to the ED for labored respirations and a change in LOC. The chart lacked evidence that written transfer and bed-hold notices were sent with the resident or provided to the resident’s representative, and staff stated these notices were not routinely sent with the resident.
A resident with severe cognitive impairment, Type I DM, and Alzheimer’s disease had an MDS that incorrectly identified 2 DTIs and pressure-reducing devices despite EMR and wound documentation showing both heel wounds had healed. Staff confirmed the wounds were healed and stated the ongoing wound care was preventative, and the RN who completed the MDS acknowledged the DTIs were entered in error.
Failure to Use Beard Restraints During Food Preparation
Penalty
Summary
The facility failed to ensure the proper use of beard restraints during food preparation and meal service. During observation and interview, one cook was seen taking the temperatures of oatmeal and scrambled eggs while having gray whiskers covering his chin and lower cheeks, and he was not wearing a beard restraint. When asked about beard restraints, he stated he was not sure he was supposed to wear one and said no one in the kitchen wore beard coverings and he would not know where to find one if required. A second cook was observed stirring separate pots of vegetables and chicken to be used in soup while having black whiskers covering his chin and cheeks and not wearing a beard restraint. He stated kitchen staff never wore beard coverings and the facility had never required this, adding that they probably should be wearing them. The kitchen lead stated he thought beard restraints were required and identified a shelf for hygiene supplies, but the shelves contained disposable gloves, hair restraints, and aprons and did not contain beard restraints. He stated the facility did not appear to have any beard coverings and that he would include them on his next order. A policy dated 6/19/19 directed staff to wear hair coverings and keep mustaches, sideburns, and beards neatly trimmed.
Failure to Document Required Alzheimer's and Dementia Care Training
Penalty
Summary
The facility failed to ensure that 1 of 8 staff members, NA-M, had completed the required Alzheimer's and dementia care training program. During the survey, a request was made for Alzheimer's and/or dementia care training records for eight employees, and the administrator later stated that training could not be found for NA-M, whose start date was 9/9/25. The administrator stated it was the expectation that all staff receive Alzheimer's and/or dementia care training before working with residents and that documentation of the training be maintained. A policy related to Alzheimer's and dementia care training was requested, but none was provided.
Failure to Honor Resident Request for Different Room Lighting
Penalty
Summary
The facility failed to honor a resident’s request for different room lighting and did not facilitate the resident’s stated preference for softer, more yellow light. The resident had a quarterly MDS indicating a diagnosis of moderate unspecified dementia, and the care plan identified Sjogren syndrome with keratoconjunctivitis, a condition that can cause pain, impaired eyesight, and light sensitivity. During observation and interview, the resident was cognitively alert and able to answer questions appropriately, and stated she really hated the lights in her room because they were too white, bright, and harsh. She identified the circular overhead light between the two resident spaces and the rectangular wall light above her bed as the most bothersome. When the resident complained, a NA responded by turning the lights off, and the resident stated that staff always did that whenever she complained. RN-B stated she would normally complete a work order for lighting complaints but had not done so for this resident, and she said she usually responded by turning off the lights. The DOM stated nursing staff were expected to send a maintenance request for room lighting concerns and that he could change bulbs if lights were too bright, but he had not received any recent requests for different lighting or bulbs. RN-A also stated staff were expected to submit a work order if a resident wanted a different type of light, and she was not aware of the resident’s request. The DON stated nursing staff were expected to contact maintenance if a resident complained about lighting or requested a different type of lighting, and a policy regarding resident choices was requested but not received.
PRN Antipsychotic Order Not Limited or Reassessed
Penalty
Summary
The facility failed to ensure a PRN antipsychotic medication was limited to 14 days and that continued use of the medication was evaluated by the attending physician or prescribing practitioner for one resident. The resident had severe cognitive impairment, Alzheimer’s disease, dementia, and received hospice services. The resident’s care plan addressed behavioral problems including refusing care and wandering, and staff were directed to administer medications as ordered, monitor for side effects, explain care before starting, and use calming and diversion techniques as needed. The resident’s medication orders showed haloperidol solution ordered PRN for agitation and delirium, with an order written on 7/10/26 as open-ended rather than limited to 14 days. The resident received PRN haloperidol multiple times in July and once in August. A physician progress note described advanced dementia, disorientation, inability to make needs known, a history of agitation, and continued use of haloperidol PRN along with structured environment and safety precautions, but the note did not document an evaluation of the appropriateness or continued need for the PRN antipsychotic medication or an adequate rationale for renewal. Nursing documentation showed a PRN dose was given for restlessness and was effective, but the note did not identify non-pharmacological interventions attempted before administration. The DON stated the resident should have had a 14-day face-to-face evaluation to ensure the ongoing need for the PRN antipsychotic medication. The pharmacist stated the medication had been reviewed and that PRN antipsychotic medications required a face-to-face medical provider evaluation every 14 days, and also noted the indication was not appropriate and that the medication was later discontinued.
Missing Written Transfer and Bed-Hold Notices
Penalty
Summary
The facility failed to ensure written transfer notices were provided as soon as practicable for 1 resident who was transferred to the emergency department by ambulance for labored respirations and a change in level of consciousness. The resident had severe cognitive impairment on the comprehensive MDS, was noted in a progress note to sleep most of the time, have a decreased level of consciousness, and be nonverbal, and her daughter was designated as her legal representative. The transfer note documented that verbal consent was obtained by phone from the daughter for a bed hold. A review of the resident’s medical record found no evidence that written transfer and bed-hold notices were sent with the resident to the hospital or provided to the resident’s representative. During interviews, nursing staff stated that paperwork sent with residents included items such as a face sheet, diagnoses, POLST, medications, immunizations, vital signs, and progress notes, and that bed holds were handled on a paper form kept at the facility and scanned into the chart. Staff also stated that written transfer notices and bed-hold forms were not sent with the resident or provided to the resident’s representative, and the DON stated she did not know whether a written transfer notice and/or written bed-hold notice was required to be sent with the resident or provided to the resident’s representative.
MDS inaccurately reflected healed heel wounds
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) accurately reflected R77’s status. R77’s quarterly MDS identified severe cognitive impairment, diagnoses of Type I Diabetes and Alzheimer’s disease, and indicated that she had 2 deep tissue injuries (DTIs) and used a pressure reducing device for her bed and chair. However, the electronic medical record showed that R77’s DTIs were healed on 6/9/26, and weekly wound documentation also identified that the DTIs on both heels had healed. The physician order dated 6/9/26 to 7/7/26 directed wound care for the left heel unstageable DTI, including daily skin prep, but staff stated this ongoing care was a preventative measure after the wounds had healed. During interviews, RN-E confirmed the heel areas had healed and the weekly wound notes reflected that status. RN-F, who completed the MDS, stated she was unsure why 2 DTIs were entered, later said she had entered them because the resident had been receiving wound care until 7/7/26, and then acknowledged the DTIs should not have been identified on the MDS and were entered in error. The DON stated MDS accuracy affected the resident care plan and should reflect the resident’s current needs.
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Compliance trends in Minnesota
Data through Jul 2026Comparisons below measure the most recent period Aug 2025 – Jul 2026 against the prior period Aug 2024 – Jul 2025 (two equal 12-month windows). The most recent 1 months are excluded because CMS is still publishing them.
Top tags by month · last 24 months
dashed = still reportingMonthly citation counts for the 5 most-cited tags. The dashed tail is the 1-month reporting lag.
Frequency movers
Biggest change in how often each tag is cited, as a rate per 100 inspections (so it isn't skewed by survey volume): Aug 2025 – Jul 2026 vs the prior period Aug 2024 – Jul 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: Aug 2025 – Jul 2026 vs the prior period Aug 2024 – Jul 2025. The number is the average severity on the A–L scale (A=0…L=11); the letter is the band it falls in. A rise means the same tag is being cited at a more serious level — note the average can move enough to rank here while staying within the same letter. Same 20-citation minimum applies.
Care domain movers
Citations grouped into CFR care domains — F-tags by their §483 regulatory section (CMS State Operations Manual, Appendix PP) — measured as a rate per 100 inspections: Aug 2025 – Jul 2026 vs the prior period Aug 2024 – Jul 2025. Share is the domain's portion of citations this period; avg severity is the mean scope/severity letter and immediate jeopardy the percentage cited at J–L, both over the current period. Domains with at least 20 citations in both periods are shown; the sparkline tracks the last 12 months (left = oldest).
Immediate jeopardies · this period
Citations at the most serious scope/severity — J–L, immediate jeopardy, residents placed at risk of serious harm or death — over Aug 2025 – Jul 2026 vs the prior period Aug 2024 – Jul 2025. "Surveys with an IJ" counts distinct health inspections that had at least one.
Survey activity · by month
faded/dashed = still reportingCitations each month split into complaint-driven (unscheduled, triggered by grievances) vs standard surveys — bars, left axis — with the number of inspections as a line on the right axis. Rising inspections signal more scrutiny; a rising complaint share means more off-cycle surveys. The most recent 1 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. Aug 2025 – Jul 2026 vs the prior period Aug 2024 – Jul 2025; the most recent 1 months are still being reported (dashed).
Penalties · by month
faded = still reportingTotal civil money penalty dollars imposed on the state's facilities each month — how hard the state is enforcing. The most recent 1 months are still being reported, and penalties often lag citations by several months.
Emerging tags
Tags that weren't established last period but surged — an early warning, distinct from movers (which track already-common tags). Criteria: fewer than 20 citations in the prior period, but at least 10 this period and 2.5× their prior volume. The sparkline shows monthly counts over the last 12 months (left = oldest).
Trusted data from CMS and state health departments
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