Based on facility policy review, facility document review, medical record review, observation and interview, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to reassess and monitor ongoing concerns with falls (Residents #149, #253, and #74) and elopement (Resident #252). The facility failed develop an effective QAPI program that recognized concerns related to safe smoking by Resident's (#202, #61, #16, and #48) and failed to ensure systems and processes were in place and consistently followed by staff to prevent an elopement, falls and an unsafe smoking environment. The failure of the QAPI Committee to ensure a safe environment for smoking and to develop corrective actions for elopement and falls, placed all residents in Immediate Jeopardy (IJ). …
F865 citations in Tennessee
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 — 2023
Tennessee cites F865 more often than its own record predicts
3.83 times the share F865 takes of citations nationally.
Of every deficiency written in Tennessee in 2023, 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 Tennessee surveyors wrote
F865 findings written in Tennessee, 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 facility policy review, medical record review, facility documentation review, and interview, the Quality Assurance Performance Improvement (QAPI) committee continued with the same approach to each resident-to-resident sexual abuse interaction, failed to identify the resident's activity as sexual abuse activity, and resident abuse was continually repeated. The resident-to resident altercations had occurred on multiple occasions between on 11/11/2025 and 3/28/2026 between 3 residents (Resident #49, Resident #15, and Resident #99) which resulted in abuse for Resident #49. …
What else Tennessee surveyors cite →
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