Based on review of facility documentation, facility policy and interviews, the facility failed to ensure that the QAPI plan included ensuring good faith efforts to correct the water management deficiencies cited during the previous recertification survey. The findings include:Review of the findings from the previous annual recertification survey on 11/19/24 identified issues related to implementation of measures to prevent the growth of Legionella and other opportunistic waterborne pathogens in the building water systems.Following review of the infection prevention program on 6/1/26, ongoing issues were identified related the implementation of measures to prevent the growth of Legionella and other opportunistic waterborne pathogens in the building water systems.Interview with the… …
F865 citations in Connecticut
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
Connecticut cites F865 less often than its own record predicts
0.26 times the national share — cited less often here than elsewhere.
Of every deficiency written in Connecticut 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 Connecticut surveyors wrote
F865 findings written in Connecticut, 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 review of facility policy, facility documentation, and interview for the Quality Assurance and Performance Improvement (QAPI) and Quality Assessment and Assurance (QAA) programs, the facility failed to implement a QAPI plan related to management of the infection prevention and control program . The findings include: Interview and review of facility documentation with the Administrator on 1/21/26 at 3:31 PM identified the QAA committee met monthly to review current QAPI plans and needs for additional quality improvement. …
The short window
Recent years
| Year | Share of Connecticut citations | vs expected |
|---|---|---|
| 2023 | 0.25% | 1.46× |
| 2024 | 0.06% | 0.30× |
| 2025 | 0.06% | 0.26× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Connecticut 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