F865 in Texas. Pick another state for the same tag.
Against expectation — 2025
Texas cites F865 less often than its own record predicts
Versus expected share0.09×
0.09 times the national share — cited less often here than elsewhere.
Share of Texas citations0.02%
Of every deficiency written in Texas in 2025, this is the portion that was F865.
Texas0.02%
National0.24%
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 Texas surveyors wrote
F865 findings written in Texas, 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.
H · Actual harm, patternMay 7, 2025
Based on observations, interviews, and record review, the facility failed to ensure the facility's quality assurance and performance improvement (QAPI ) program identified and prioritized problems and opportunities that reflect organizational process, functions, and services provided to residents.
The facility failed to identify inconsistencies regarding ostomy care and documentation before such concerns were identified by surveyor during survey from ,d+[DATE]-[DATE].
The failure could place residents at risk of emotional distress and inadequate ostomy care. …
E · No harm, potential for more than minimal, patternMay 14, 2026
Based on interview and record review the facility failed to develop a QAPI (Quality Assurance and Performance Improvement) plan that described the process for conducting quality assessment and assurance activities, including the process on how the committee would identify and correct quality deficiencies. The facility failed to have documentation and evidence of its QAPI plan being ongoing and comprehensive.This failure could affect all residents and result in quality deficiencies not being recognized and corrected.Findings included: Record review of the Nursing Facility's QAPI plan, the Nursing Facility's meeting template documents for 02/2026, 03/2026, and 04/2026, revealed the areas documented: Goal, Interventions, and Progress, were blank. …
C · No harm, potential for minimal, widespreadJuly 27, 2023
Based on interview and record reviews the facility failed to maintain documentation and demonstrate evidence of its ongoing QAPI program for 1 of 1 facility's reviewed for QAPI.
The facility failed to maintain documentation of QAPI meetings prior to February of 2023.
This failure placed residents at risk of maintaining and improving safety and quality of life.
Findings included:
Record review of QAPI meetings revealed: Facility had maintained QAPI meeting minutes from 02/2023 to 07/2023. No previous meeting documentation was available.
During an interview on 07/25/23 at 10:30AM with ADM and RRN, ADM said he had been scouring the ADM office for evidence of previous QAPI meetings with no success. He said he became the ADM in March of 2023. …
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