Based on observation, interview, and record review, the facility failed to ensure an effective Quality Assessment and Performance Improvement (QAPI) and Quality Assessment and Assurance (QAA) plan was in placed for identifying and responding to resident care concerns, by implementing, monitoring, and evaluating action plans for pain management, respiratory care, and answering call lights. This failure put multiple residents' health and safety at risk including delayed and inappropriate provision of care and treatment for [REDACTED]. Findings: During the course of the facility survey on December 11-19, 2017, multiple residents with care concerns were observed regarding appropriate provision of respiratory care, pain management and answering call light promptly. …
F865 citations in California
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
California cites F865 less often than its own record predicts
0.98 times the national share — cited less often here than elsewhere.
Of every deficiency written in California 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 California surveyors wrote
F865 findings written in California, 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 record review, the facility failed to ensure the Quality Assessment and Assurance (QAA- process used to systematically evaluate care delivery, identify quality deficiencies, and develop corrective action plans) and Quality Assurance Performance Improvement (QAPI- process to continuously monitor and elevate the safety and quality of care) committee established an effective system to monitor residents at risk for developing or acquiring pressure injury (injury to skin and underlying tissue resulting from prolonged pressure on the skin) or wound.This deficient practice placed residents at risk for not receiving the quality of care and treatment necessary to meet their highest practicable well-being.Findings:During an interview on 7/23/2026 at 3:52 p.m., with the… …
Based on interview and facility document review, the facility failed to implement their QAPI plan and their past Recertification Survey POC for F759. * The facility failed to ensure the Pharmacy Nurse Consultant conducted medication pass observations for licensed nurses as per facility's QAPI plan. This failure had the potential for ongoing non-compliance and incomplete data being reviewed by the QAPI committee. Findings: Review of the facility's 2024 Recertification Survey POC accepted by the Department on 1/17/25, included the following for F769:- The Pharmacy Nurse Consultant will conduct medication pass observations for all newly hired licensed nurses;- The Pharmacy Nurse Consultant will conduct medication pass observations with three licensed nurses per month; and- The DON will report… …
The short window
Recent years
| Year | Share of California citations | vs expected |
|---|---|---|
| 2023 | 0.14% | 0.80× |
| 2024 | 0.17% | 0.89× |
| 2025 | 0.23% | 0.98× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else California surveyors cite →
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