F865 in Kentucky. Pick another state for the same tag.
Against expectation — 2025
Kentucky cites F865 more often than its own record predicts
Versus expected share2.93×
2.93 times the share F865 takes of citations nationally.
Share of Kentucky citations0.70%
Of every deficiency written in Kentucky in 2025, this is the portion that was F865.
Kentucky0.70%
National0.24%
Share of all citations that were F865.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Kentucky surveyors wrote
F865 findings written in Kentucky, 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.
K · Immediate jeopardy, patternMay 17, 2025
Based upon interview, review of medical records, review of the facility's policy/procedures, the facility failed to ensure that its Quality Assurance and Performance Improvement Plan (QAPI) provided overall guidance to the facility; to provide excellence in quality of care and support quality of life through patient-centered care. The facility failed to implement an effective QAPI program to guide its operations and ensure the appropriate allocation of resources. As a result, the facility did not operate effectively or efficiently to achieve the highest practicable level of physical, mental, and psychosocial well-being for residents. This systemic failure caused or was likely to cause serious injury, impairment, or death to the resident. …
Based on observation, interview, record review, review of the facility's fall report documentation and Quality Assurance Performance Improvement (QAPI) Policy, the facility failed to maintain an effective, comprehensive, data driven QAPI program which focused on criteria for outcomes and quality of life related to falls for 8 of 10 sampled residents, (Residents (R)10, R15, R27, R57, R75, R93, R111, and R274.
Review of the facility's Incidents by Incident Type, documentation dated 02/28/2024 through 08/28/2024, revealed the facility had a total of 346 resident falls during that six-month timeframe. Review of the facility's QAPI documentation however, revealed no documented evidence the facility brought the issue of multiple residents' falls to the QAPI Committee prior to August 2024. …
D · No harm, potential for more than minimal, isolatedMarch 10, 2026
Based on staff interviews, policy, and record review, the facility failed to ensure it developed, implemented, and maintained an effective, comprehensive Quality Assurance and Performance Improvement (QAPI) system that focused on the development, implementation, and evaluation of adverse events to ensure necessary corrective action was taken regarding its pharmacy program. The findings include: Review of the undated facilities policy document with identification at the bottom of the page, as follows: Quality Assurance Performance Improvement (QAPI) Policy, Page 32, R/3-2025, revealed that the QAPI program committee was responsible for implementing and maintaining an ongoing systemwide process of quality improvement. …
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