F865 in New Hampshire. Pick another state for the same tag.
Against expectation — 2024
New Hampshire cites F865 more often than its own record predicts
Versus expected share1.62×
1.62 times the share F865 takes of citations nationally.
Share of New Hampshire citations0.30%
Of every deficiency written in New Hampshire in 2024, this is the portion that was F865.
New Hampshire0.30%
National0.19%
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 New Hampshire surveyors wrote
F865 findings written in New Hampshire, 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.
E · No harm, potential for more than minimal, patternDecember 1, 2023
Based on interview and record review, it was determined that the facility failed to implement and monitor corrective actions for identified gaps in systems.
Findings include:
Review on 11/30/23 of 5 residents for influenza and pneumococcal vaccination revealed that 3 of 5 medical records did not contain documentation that residents were offered and received education for influenza and pneumococcal vaccination. Cross reference F883 Influenza and Pneumococcal Immunizations.
Interview on 11/30/23 at 2:51 p.m. with Staff O (Administrator) revealed that the facility had identified issues offering and educating residents for influenza and pneumococcal vaccinations and the issue was in Quality Assurance. …
C · No harm, potential for minimal, widespreadSeptember 12, 2024
Based on interview and record review, it was determined that the facility failed to develop, implement and maintain an effective comprehensive, data-driven Quality Assurance and Performance Improvement (QAPI) plan.
Findings include:
Interview on 9/12/23 at 2:20 p.m. with Staff A (Administrator) revealed that the facility was unable to provide documentation of a written QAPI plan.
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction