Based on interview, record review, and policy review, the facility failed to conduct and provide evidence of QAPI meeting in order to mitigate and pull all resources together to stop the spread of COVID 19, and implement process changes to improve outcomes. Currently the facility has 10 residents which are negative (-) for COVID 19 and since the facility was identified to have a failure in the screening process, not having a QAPI meeting to mitigate the risk further place the residents and staff at risk for contracting the COVID-19 virus. There were 77 residents and 37 staff members infected with the COVID-19 virus. Twenty-seven (27) resident deaths were related to the COVID-19 outbreak. Findings include: 1. A prior SA visit revealed IJ #1 at F880 Infection Control. …
F865 citations in Hawaii
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 — 2023
Hawaii cites F865 more often than its own record predicts
2.45 times the share F865 takes of citations nationally.
Of every deficiency written in Hawaii in 2023, 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 Hawaii surveyors wrote
F865 findings written in Hawaii, 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 interview, the facility failed to develop, implement, and maintain an effective, comprehensive, data-driven Quality Assurance and Performance Improvement (QAPI) program that focuses on indicators of the outcomes of care and quality of life. The facility does not have a system to collect and use data to identify areas of improvement. Therefore, there is no evidence of performance improvement projects with monitoring of the efficacy of the project. This deficient practice has the potential to affect the quality of life and quality of care of all residents to maintain or attain their highest practicable physical, mental, and psycho-social well-being. Findings include: On 09/15/23 at 12:50 PM an interview was conducted with the Administrator. …
What else Hawaii surveyors cite →
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