Based on record review, interview, and facility policy review, the facility failed to utilize its Quality Assurance and Performance Improvement (QAPI) process to identify and correct quality deficiencies that posed a likelihood of immediate jeopardy to the health and safety of its residents. The facility failed to report and appropriately respond to a fire event, with prior knowledge that the sprinkler system was not functioning at full operational capacity, placing residents at increased risk for serious harm during an emergency. The findings include:A tour of the facility was conducted on 1/12/2026 by the Life Safety surveyor at 12:00 PM. …
F865 citations in Florida
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
Florida cites F865 more often than its own record predicts
1.10 times the share F865 takes of citations nationally.
Of every deficiency written in Florida 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 Florida surveyors wrote
F865 findings written in Florida, 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 record reviews and interviews the facility failed to maintain an effective, comprehensive Quality Assurance and Performance Improvement program (QAPI) related to the development and implementation of corrective actions or performance improvement activities as evidence by the continued absence of daily skilled assessments for residents receiving skilled services.Findings included:Review of Resident #7's admission Record showed the resident was admitted on [DATE]. The record included diagnoses not limited to paroxysmal atrial fibrillation, hypertensive heart disease without heart failure, generalized muscle weakness, adult failure to thrive, and Encounter for surgical aftercare following surgery on the circulatory system.Review of Resident #7's active physician orders revealed the… …
The short window
Recent years
| Year | Share of Florida citations | vs expected |
|---|---|---|
| 2023 | 0.23% | 1.34× |
| 2024 | 0.19% | 1.04× |
| 2025 | 0.26% | 1.10× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Florida surveyors cite →
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