Based on interview and record review, the facility failed to demonstrate evidence of maintaining an ongoing effective, comprehensive, data-driven Quality Assurance Performance Improvement (QAPI) program that focuses on indicators of the outcomes of care and quality of life. This had the potential to affect all residents residing in the facility. The facility's census was 147.Review of the facility's policy titled, QAPI Program, revised February 2020, showed:- This facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents;- The objectives of the QAPI program are to provide a means to measure current and potential indicators for outcomes of care and quality of… …
F865 citations in Missouri
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
Missouri cites F865 more often than its own record predicts
1.56 times the share F865 takes of citations nationally.
Of every deficiency written in Missouri 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 Missouri surveyors wrote
F865 findings written in Missouri, 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 interview and record review, facility staff failed to develop a Quality Assurance and Performance Improvement Plan (QAPI) (written plan containing the process that will guide the nursing home's efforts in assuring care and services are maintained at acceptable levels of performance and continually improved). The facility census was 73. 1. Review of the facility's records showed the facility did not have a QAPI plan containing the necessary policies and protocols describing how they would identify and correct their quality deficiencies, track and measure performance, and establish goals and thresholds for performance measurements. …
The short window
Recent years
| Year | Share of Missouri citations | vs expected |
|---|---|---|
| 2023 | 0.23% | 1.34× |
| 2024 | 0.33% | 1.78× |
| 2025 | 0.37% | 1.56× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Missouri surveyors cite →
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