:Based on interview and record review, the facility's Quality Assessment and Assurance committee failed to develop and implement appropriate plans of action to correct deficient practices related to food safety requirements and infection control. This has the potential to affect all 61 residents.The facility failed to follow infection control standards of practice and proper sanitation of dishware during a Gastrointestinal illness outbreak. Evidenced by: The facility's Quality Assurance/Assessment and Performance Improvement (QAPI) Plan policy, dated 9/4/24, states, in part: Purpose: The QAPI Program is to utilize an on-going, data driven, pro-active approach to advance to the quality of life and quality of care for all residents at the facility. …
F865 citations in Wisconsin
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
Wisconsin cites F865 less often than its own record predicts
0.15 times the national share — cited less often here than elsewhere.
Of every deficiency written in Wisconsin 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 Wisconsin surveyors wrote
F865 findings written in Wisconsin, 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.
Based on staff interview and record review, the facility did not have a Quality Assurance and Performance Improvement (QAPI) Plan. This had the potential to affect all 14 residents at the facility. The facility did not create a QAPI plan. Findings include: On 5/9/22, Surveyor requested QAPI plan during entrance conference. On 5/10/22, Surveyor noted QAPI plan was not provided to survey team. On 5/10/22 at 12:07 PM, Surveyor interviewed Corporate Consultant (CC)-E regarding QAPI plan. CC-E confirmed the facility did not have a QAPI plan. Nursing Home Administrator (NHA)-A verified the facility did not have a QAPI plan.
What else Wisconsin surveyors cite →
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