Based on staff interview and review of the facility policy titled, Quality Assurance and Process Improvement Committee , the facility failed to maintain minutes of all QAPI meetings to document its ongoing Quality Assurance and Performance Improvement (QAPI) program. This had the potential to affect all 53 residents of the facility. The findings include: A review of a facility policy titled, Quality Assurance and Process Improvement Committee , with an updated date 8/4/22, revealed: .The committee shall maintain minutes of all regular and special meetings that include at least the following information: . b. The names of committee members present and absent; . During an interview with the Administrator on 04/25/24 at 08:16 a.m., the Administrator stated the facility had a QAPI policy. …
F865 citations in Alabama
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 — 2024
Alabama cites F865 more often than its own record predicts
1.97 times the share F865 takes of citations nationally.
Of every deficiency written in Alabama in 2024, 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 Alabama surveyors wrote
F865 findings written in Alabama, 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.
What else Alabama surveyors cite →
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction