This pertains to intake M 6435 and MI 589. Based on interviews and record review, the facility failed to demonstrate its QAPI program identified and implemented appropriate plans of action to correct quality deficiencies necessary to assure residents attain and maintain the highest practicable level of well-being, resulting in the potential for serious negative physical and psychosocial outcomes for all 106 residents residing at the facility. Findings include: Review of facility provided policy Quality Assurance and Performance Improvement (QAPI) with a last revised dated of 7/28/2020 revealed: It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life. …
F865 citations in Michigan
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
Michigan cites F865 more often than its own record predicts
1.11 times the share F865 takes of citations nationally.
Of every deficiency written in Michigan 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 Michigan surveyors wrote
F865 findings written in Michigan, 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 develop and maintain a Quality Assistance and Process Improvement (QAPI) program which identified and prioritized quality deficiencies, systematically analyzed the underlying causes, and implemented effective corrective action or performance improvement activities to remedy those deficiencies. Findings Included:On 06/26/2026 at 02:07 p.m. an interview was conducted with Nursing Home Administrator (NHA) A regarding concerns identified during the current Recertification Survey. NHA A' explained that during the last year the QAPI committee had identified areas of concerns for Performance Improvement Plans (PIPS). …
Based on observation, interview, and record review the facility Quality Assurance and Quality Improvement (QAPI) program failed to identify issues with multiple areas of infection control and implement their QAPI plan to address these high-risk issues, potentially affecting the health, safety and quality of life for all 105 residents residing in the facility. Findings include: During the survey, the facility was in a current COVID 19 outbreak with 14 residents being symptomatic with positive COVID 19 test results. …
The short window
Recent years
| Year | Share of Michigan citations | vs expected |
|---|---|---|
| 2023 | 0.18% | 1.04× |
| 2024 | 0.02% | 0.12× |
| 2025 | 0.27% | 1.11× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Michigan surveyors cite →
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