F865 in Minnesota. Pick another state for the same tag.
Against expectation — 2025
Minnesota cites F865 more often than its own record predicts
Versus expected share1.79×
1.79 times the share F865 takes of citations nationally.
Share of Minnesota citations0.43%
Of every deficiency written in Minnesota in 2025, this is the portion that was F865.
Minnesota0.43%
National0.24%
Share of all citations that were F865.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Minnesota surveyors wrote
F865 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.
F · No harm, potential for more than minimal, widespreadJuly 16, 2026
Based on interview and record review, the quality assurance and performance improvement (QAPI) committee failed to identify resident call light wait time concerns prior to survey, nor make a good faith attempt to correct the deficiency. This deficient practice had the potential to affect all 42 residents residing in the facility.
Findings include:
QAPI meeting minutes dated 3/31/25, indicated, Call lights tend to be #1 issue. Call light response times had not been included/mentioned again in the subsequent six QAPI meeting minutes. …
C · No harm, potential for minimal, widespreadOctober 19, 2022
Based on interview and document review, the facility failed to develop and implement a Quality Assurance and Performance Improvement (QAPI) plan assuring care and services were identified to maintain acceptable levels of performance and continual improvement. This deficient practice had the potential to affect all 12 residents residing in the facility.
Findings include:
The facility's QAPI plan was requested however one was not provided.
When interviewed on 10/19/22, at 5:31 p.m. the administrator stated current practice for the QAPI meetings included a review of old business and new business. The administrator indicated the QAPI committee had been working on pharmacy recommendations and communication with the medical director. …
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