Based on record review, interview, personnel file review, observation, and review of Quality Assurance and Performance Improvement (QAPI) documentation, the facility failed to implement and maintain an effective QAPI program by failing to identify, monitor, and implement effective corrective actions regarding deficiencies in the facility's activity program. The facility identified concerns related to activity programming and staffing through its QAPI process; however, residents continued to experience limited activity programming and the facility failed to ensure the individual directing the activity program met required qualifications. This had the potential to affect all 74 residents residing in the facility.Findings Included:Interview with the Administrator on 06/08/26 at 2:23 P.M. …
F865 citations in Ohio
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
Ohio cites F865 less often than its own record predicts
0.20 times the national share — cited less often here than elsewhere.
Of every deficiency written in Ohio 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 Ohio surveyors wrote
F865 findings written in Ohio, 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 review of facility documentation and interview with Administrator, the facility failed to participate in at least one quality improvement project. This had the potential to affect all 117 residents residing in the facility. Findings include: Review of the facility's quality improvement files revealed no evidence of participation in a quality improvement project. Interview on 06/13/19 at 8:55 A.M., the Administrator verified the facility had not been participating in a quality improvement project.
The short window
Recent years
| Year | Share of Ohio citations | vs expected |
|---|---|---|
| 2023 | 0.07% | 0.43× |
| 2024 | 0.23% | 1.21× |
| 2025 | 0.05% | 0.20× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Ohio surveyors cite →
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