On 02/25/26 at 3:03 p.m., an IJ situation was determined to exist related to the facility's failure to have an effective quality assurance program that acted on identified concerns and developed a plan of action to correct identified quality of care issues. On 02/26/26 at 3:26 p.m., the Oklahoma State Department of Health verified the existence of an IJ situation.On 02/26/26 at 3:48 p.m., the administrator was notified of the IJ situation and the IJ template was provided.Administrator was educated on having an effective QAPI program that identifies and implements corrective action for quality-of-care issues that include but not limited to reporting allegations of misappropriation of controlled medications to the Oklahoma State Department of Health and Law Enforcement. …
F865 · 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.
Every F865 citation surveyors wrote nationally that year.
Distinct nursing homes with at least one F865 finding.
The harm level
How severely F865 is cited
2.8% of citations found actual harm or worse (level G and above).
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J40.5% | K30.3% | L70.8% |
| Actual harm | G60.7% | H40.5% | I10.1% |
| No harm, potential for more than minimal | D18220.7% | E23927.2% | F40846.4% |
| No harm, potential for minimal | A— | B40.5% | C212.4% |
In the surveyor’s words
What an F865 citation says
One finding from each severity level, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Licensure Reference Number 175 NAC 12-006.07(C) Based on record review and interview, the facility failed to ensure the Quality Assurance Performance Improvement Program (QAPI - a facility process that identifies problems in the facility and works to correct the concerns) identified and addressed concerns related to deficient practice identified on the annual survey 2026 ( F550, F605, F641, F677, F684, F686, F688, F692, F695, F712, F756, F761, F835, F838, F843, F880, and F865 ) This had the potential to affect 74 residents who resided in the facility. …
Based on interview and record review it was determined the facility failed to ensure a Quality Assurance and Performance Improvement (QAPI) program implemented action plans to correct identified quality deficiencies. This placed all residents at risk for not receiving the care and services for optimal resident outcomes. Findings include: The facility's 4/25/26 QAPI policy indicated the facility was to develop, implement and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life and addresses all the care and unique services the facility provides.A review of the 6/26/26 Facility QAPI plan failed to recognize or address the following:-Lack of sufficient staffing based on acuity.-Lack of CNA annual performance… …
Based on review of the Certification and Survey Enhanced Report (CASPER) from the Centers for Medicare & Medicaid Services (CMS), facility policy review, and staff interviews, the facility failed to ensure an effective QAPI program to address previously cited deficiencies which resulted in five deficiencies being re-cited during the current Health Recertification survey. The facility reported a census of 89 residents.Findings include:A review of the facilities 4/21/25 Statement of Deficiencies and Plan of Correction revealed the following citations: F641 (Accuracy of Assessments); F684 (Quality of Care); F689 (Free of Accident Hazards/Supervision/Devices); F812 (Food Procurement, Store/Prepare/Serve-Sanitary); F880 (Infection Prevention and Control)The Health Recertification survey… …
By state — 2025
Where F865 is cited more, and less, than expected
Each state is measured against its own expected share, not against other states.
- Iowa7.79× · 44 citations
- California0.98× · 37 citations
Co-occurrence
Cited alongside F865
Of the 2025 surveys that cited F865, these tags appeared in the same inspection more often than chance would predict.
- F86814.0% of F865 surveys · 14.5× chance
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
- F83513.6% of F865 surveys · 11.1× chance
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
- F86713.6% of F865 surveys · 10.0× chance
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
- F88711.6% of F865 surveys · 7.7× chance
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
- F88114.7% of F865 surveys · 7.4× chance
Implement a program that monitors antibiotic use.
Cited in the same inspection, not caused by one another.
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