Based on observation, interview and record review the facility failed to consistently identify quality of care deficiencies or develop an action plan to correct known deficiencies requiring quality assessment and assurance interventions. Failure to conduct an effective program that timely identified and developed action plans to respond to quality care deficiencies placed residents at risk for reduced quality of care and quality of life. Findings included . Refer to the following deficiencies: F600, F607, and F610 related to immediate jeopardy of abuse F686 related to the development of a facility acquired pressure ulcer causing harm to the resident F908 related to unsafe functionality of a resident's bed causing harm to the resident F697 related to an ineffective pain management program… …
F865 citations in Washington
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
Washington cites F865 more often than its own record predicts
1.17 times the share F865 takes of citations nationally.
Of every deficiency written in Washington 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 Washington surveyors wrote
F865 findings written in Washington, 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, the facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program to correct identified noncompliance and ensure changes were maintained to ensure ongoing compliance. This failure placed residents at risk of lacking quality medical care, abuse/neglect, foodborne illness, preventable infections, and a diminished quality of life. Findings included.Review of the CASPER Report 0003D Provider History Profile, run dated 11/25/2025, showed the facility had the following repeated noncompliance on previous Long-Term Care Surveys/Complaint Investigations and continued to be out of compliance on the current 12/02/2025 Long-Term Care Survey:1. …
Based on interview and record review, the facility failed to develop a Quality Assurance and Performance Improvement program (QAPI) that contained all required components in regulation. This failure placed all residents at risk of unidentified and/or unmet needs. Findings included: On 08/31/18 at 8:19 AM, Staff A, Director of Nursing Services, provided a binder entitled QAPI Program. She reported staff was working on reducing the number of [MEDICAL CONDITION] medications in their resident population. The facility designated this material as their QAPI plan. The QAPI document showed the ongoing work by facility staff to address the use of [MEDICAL CONDITION] medications. This also included the prn (as-needed) use of antipsychotic medications. …
The short window
Recent years
| Year | Share of Washington citations | vs expected |
|---|---|---|
| 2023 | 0.16% | 0.94× |
| 2024 | 0.06% | 0.33× |
| 2025 | 0.28% | 1.17× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Washington surveyors cite →
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