Based on observation, record review, policy review, review of grievances, review of I&A Reports, review of staffing schedules, review of Quality Assessment and Performance Improvement (QAPI) meeting minutes, and interviews with residents and staff, it was determined the facility failed to ensure the QAPI program was effectively implemented. This failure directly impacted 40 out of 40 residents (#4, #7, #8, #13, #14, #17, #18, #19, #20, #23, #24, #25, #28, #31, #32, #35, #36, #38, #46, #49, #53, #54, #57, #59, #61, #62, #65, #72, #75, #130, #131, #134, #180, #231, #333, #380, #430, #4311, #480, and #481) who were reviewed, and affected the other 57 residents in the facility. …
F865 citations in Idaho
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
Idaho cites F865 more often than its own record predicts
1.40 times the share F865 takes of citations nationally.
Of every deficiency written in Idaho 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 Idaho surveyors wrote
F865 findings written in Idaho, 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, policy review, and staff interview, it was determined the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) Committee effectively identified, monitored, and corrected ongoing systemic issues related to the Restorative Nursing Program. This failure resulted in continued inability to meet the facility's established benchmark for restorative service (RA) completion and documentation across multiple consecutive quarters from 2024 through 2026. These findings demonstrate the QAPI Committee did not ensure the implementation of effective corrective actions or sustained performance improvement as required. …
What else Idaho surveyors cite →
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