Based on observations, interviews and record review, the facility failed to develop, implement, monitor and reevaluate its quality assurance performance improvement (QAPI) program to ensure the unique care and services the facility provided were maintained at acceptable levels of performance and continuously improved. Specifically, the facility's QAPI program failed to systematically self-identify, investigate, analyze and correct problems relating to resident safety and resident rights. This failure contributed to serious adverse outcomes and the likelihood of further serious adverse outcome. Cross-reference F604 for physical restraints, F605 for chemical restraints,F689 for accident/hazards and F744 for treatment and services for dementia care. Findings include: I. …
F865 citations in Colorado
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 — 2024
Colorado cites F865 less often than its own record predicts
0.40 times the national share — cited less often here than elsewhere.
Of every deficiency written in Colorado in 2024, 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 Colorado surveyors wrote
F865 findings written in Colorado, 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 and interviews, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented in order to facilitate improvement in the lives of nursing home residents through continuous attention to quality of care, quality of life, and resident safety.Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to its infection prevention program.Findings include:I. Cross-referenced citationsCross-reference F880: The facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection. …
What else Colorado surveyors cite →
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