Based on survey findings, review of facility policy, professional reference, and staff interview, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to develop a Performance Improvement Project (PIP) to decrease or prevent the likelihood of problems or occurrences of adverse events, and ensure compliance with federal requirements related to a resident choking incident. Findings include:Review of the facility Quality Assurance and Performance Improvement Plan occurred on 05/28/26. The undated policy stated, . Scope . we provide comprehensive clinical care to residents . all care is resident-centered and focuses on choice and Individualized plans of care . Implementation . …
F865 citations in North Dakota
QAPI program · Administration Deficiencies
Have a plan that describes the process for conducting QAPI and QAA activities.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
North Dakota cites F865 more often than its own record predicts
3.48 times the share F865 takes of citations nationally.
Of every deficiency written in North Dakota in 2025, this is the portion that was F865.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What North Dakota surveyors wrote
F865 findings written in North Dakota, 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 North Dakota citations | vs expected |
|---|---|---|
| 2024 | 0.25% | 1.33× |
| 2025 | 0.83% | 3.48× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else North Dakota surveyors cite →
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction