On 02/25/26 at 3:03 p.m., an IJ situation was determined to exist related to the facility's failure to have an effective quality assurance program that acted on identified concerns and developed a plan of action to correct identified quality of care issues. On 02/26/26 at 3:26 p.m., the Oklahoma State Department of Health verified the existence of an IJ situation.On 02/26/26 at 3:48 p.m., the administrator was notified of the IJ situation and the IJ template was provided.Administrator was educated on having an effective QAPI program that identifies and implements corrective action for quality-of-care issues that include but not limited to reporting allegations of misappropriation of controlled medications to the Oklahoma State Department of Health and Law Enforcement. …
F865 citations in Oklahoma
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
Oklahoma cites F865 less often than its own record predicts
0.68 times the national share — cited less often here than elsewhere.
Of every deficiency written in Oklahoma 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 Oklahoma surveyors wrote
F865 findings written in Oklahoma, 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 observation, record review, and interview, the facility failed to maintain an effective Quality Assessment and Performance Improvement (QAPI), as evidenced by failure to demonstrate systematic identification, reporting, investigation, analysis, and prevention of adverse events and documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities. The facility had systematic problems with identification of abuse allegations, reporting abuse allegations to OSDH, development of comprehensive care plans/revision of care plans, and adequate supervision to prevent accident hazards related to smoking.The administrator identified 34 residents who resided in the facility.Findings: Please refer to CMS form 2567 with exit… …
The short window
Recent years
| Year | Share of Oklahoma citations | vs expected |
|---|---|---|
| 2023 | 0.23% | 1.31× |
| 2024 | 0.05% | 0.27× |
| 2025 | 0.16% | 0.68× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Oklahoma surveyors cite →
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