F865 in Louisiana. Pick another state for the same tag.
Against expectation — 2025
Louisiana cites F865 more often than its own record predicts
Versus expected share1.58×
1.58 times the share F865 takes of citations nationally.
Share of Louisiana citations0.38%
Of every deficiency written in Louisiana in 2025, this is the portion that was F865.
Louisiana0.38%
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 Louisiana surveyors wrote
F865 findings written in Louisiana, 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.
D · No harm, potential for more than minimal, isolatedJuly 1, 2026
Based on interviews and record reviews, the facility failed to provide surveyor staff during the survey with the requested complete Quality Assurance and Performance Improvement (QAPI) documentation, including the facility's identified quality concerns necessary to evaluate the effectiveness of the facility's QAPI program as evidenced by the removal of identified quality concerns from the document produced to surveyors. Findings: Review of the facility's undated QAPI Program policy and procedure, revealed, in part, the facility shall develop, implement, and maintain an effective, comprehensive, data-driven QAPI program which identified systems and processes that may have led to avoidable negative outcomes. …
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