Based on record review and interview the facility failed to maintain a Quality Assurance and Process Improvement (QAPI) committee that developed and implemented appropriate plans of action to correct quality deficiencies they identified or should have identified. Without sufficiently identifying or adequately addressing and communicating about areas of deficient practice, systematic correction could not be achieved and maintained throughout the facility. This failed practice, to achieve or maintain corrective action, resulted in: 1) physical harm to residents who developed stage II, III, and IV pressure ulcers and 2) psychosocial harm to residents affected by isolation and inadequate care to meet physical, social, and emotional needs, due to staffing shortages, during room-based care (RBC)… …
F865 citations in Alaska
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
Alaska cites F865 more often than its own record predicts
2.23 times the share F865 takes of citations nationally.
Of every deficiency written in Alaska 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 Alaska surveyors wrote
F865 findings written in Alaska, 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 record review, interview, and observation, the facility failed to develop, implement, and maintain an effective Quality Assurance and Performance Improvement (QAPI) program that identified, analyzed, and corrected systemic quality deficiencies. The facility failed to use available data to identify trends, failed to prioritize high-risk issues, and failed to implement and sustain corrective actions.Specifically, the facility failed to identify and/or address ongoing patterns of deficient practice related to staffing, grievance process, clinical care, activities, medication management, therapy services, discharge planning, environmental conditions, and care planning. …
What else Alaska surveyors cite →
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