Based on interview and record review it was determined the facility failed to address QAPI (Quality Assurance and Performance Improvement) identified concerns regarding sufficient staff for 1 of 1 QA (Quality Assurance) committees reviewed for QAPI. This resulted in the failure to provide timely care and assistance to residents. Findings include: The 4/19/22 Annual Survey identified nurse staffing as an area requiring correction in order to provide adequate care to residents. A 2/12/23 complaint investigation identified nurse staffing as an area requiring continued correction with deficient practice identified from 8/2022 through 12/2022. Review of QAPI Meeting Minutes from 1/2023 identified nurse staffing as an area to address and review in future QAPI meetings. …
F865 citations in Oregon
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
Oregon cites F865 less often than its own record predicts
0.88 times the national share — cited less often here than elsewhere.
Of every deficiency written in Oregon 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 Oregon surveyors wrote
F865 findings written in Oregon, 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 it was determined the facility failed to ensure a Quality Assurance and Performance Improvement (QAPI) program implemented action plans to correct identified quality deficiencies. This placed all residents at risk for not receiving the care and services for optimal resident outcomes. Findings include: The facility's 4/25/26 QAPI policy indicated the facility was to develop, implement and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life and addresses all the care and unique services the facility provides.A review of the 6/26/26 Facility QAPI plan failed to recognize or address the following:-Lack of sufficient staffing based on acuity.-Lack of CNA annual performance… …
The short window
Recent years
| Year | Share of Oregon citations | vs expected |
|---|---|---|
| 2023 | 0.31% | 1.80× |
| 2024 | 0.08% | 0.41× |
| 2025 | 0.21% | 0.88× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Oregon surveyors cite →
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