Based on staff interviews, record review, and policy review, the facility failed to identify issues prior to their identification by the survey team and failed to implement and maintain an effective, ongoing Quality Assurance and Performance Improvement (QAPI) program that addressed identified concerns and ensured corrective actions were implemented and sustained. Specifically, the facility was unable to provide any Performance Improvement Plans (PIPs) completed in the last year and failed to address ongoing physical and verbal abuse by one resident toward other residents, allowing the abuse to continue.Findings include: Review of the facility documentation indicated QAPI meetings were held, but there was no data/trending, no root cause analysis for problems identified, no interventions… …
F865 citations in Georgia
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
Georgia cites F865 less often than its own record predicts
0.36 times the national share — cited less often here than elsewhere.
Of every deficiency written in Georgia 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 Georgia surveyors wrote
F865 findings written in Georgia, 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.
The short window
Recent years
| Year | Share of Georgia citations | vs expected |
|---|---|---|
| 2023 | 0.26% | 1.48× |
| 2024 | 0.07% | 0.36× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Georgia 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