Based on review of the facility's Quality Assurance Performance Improvement (QAPI) meeting sign in sheets, and staff interview, the facility failed to ensure all required members attended meetings at least quarterly for 2 of 4 quarters (November 2025 and February 2026) reviewed. Failure to have the medical director participate in the facility's quality assurance activities may result in an ineffective QAPI program and deprives the committee of the physician's unique contributions for analysis of quality concerns and assisting with decision making based on identified concerns.Findings include:Review of the QAPI meeting sign-in sheets, from March 2025 to February 2026 showed the medical director failed to attend any meetings since August 2025.During an interview on 03/18/26 at 3:30 p.m., an… …
F868 citations in North Dakota
Quality assurance committee · Administration Deficiencies
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
North Dakota cites F868 more often than its own record predicts
3.58 times the share F868 takes of citations nationally.
Of every deficiency written in North Dakota in 2025, this is the portion that was F868.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What North Dakota surveyors wrote
F868 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 |
|---|---|---|
| 2023 | 0.70% | 2.74× |
| 2025 | 0.83% | 3.58× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else North Dakota surveyors cite →
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