Based on interview and document review, the facility failed to have evidence of measurable goals and documentation of an analysis and evaluation of the data, submitted to the QAPI committee to ensure Performance Improvement Projects (PIPS) areas identified had oversight and a documented action plan. This had the potential to affect all 38 residents living in the facility. Findings include: Review of QAPI meeting minutes provided from October 2025 through July 2026, identified department heads were bringing data forth to QAPI on various topics such as; infection control with an upward trend of skin infections, data analysis of employee illnesses, resident booster vaccinations, identified requirement of consents needed for psychotropic medication use, prevalence of pressure sore in high-risk… …
F867 citations in Minnesota
QAPI improvement activities · Administration Deficiencies
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Minnesota cites F867 more often than its own record predicts
3.19 times the share F867 takes of citations nationally.
Of every deficiency written in Minnesota in 2025, this is the portion that was F867.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Minnesota surveyors wrote
F867 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.
Based on interview and document review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee identify, investigate, analyze and respond to freezer maintenance (i.e., prevent ice buildup) by developing and implementing action plans for the process improvement identified to be a current concern with past identified non compliancy. This had potential to affect all 45 residents, staff and visitors who consumed food at the care center. Findings include: Facilities QAPI (Quality Assessment and Performance Improvement) Plan, identified the purpose of QA (Quality Assessment) would be to take a proactive approach to continually improve the way we provide care, with each employee to participate in the ongoing QAPI efforts. …
The short window
Recent years
| Year | Share of Minnesota citations | vs expected |
|---|---|---|
| 2023 | 0.77% | 1.32× |
| 2024 | 0.98% | 2.19× |
| 2025 | 1.05% | 3.19× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Minnesota 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