Based on staff interview, record review, and facility policy review, the facility failed to use its Quality Assurance and Performance Improvement (QAPI) program to identify, analyze, and correct systemic failures in infection prevention and control and staffing during an influenza (flu) outbreak for 59 of 59 residents residing in the facility from 10/8/25 through 10/12/25.The facility's failure to use its QAPI program to evaluate and address the lack of outbreak recognition including failure to initiate droplet precautions, failure to notify the local health department, failure to ensure antiviral medications were administered as prescribed, and failure to monitor staff illness and infection control compliance resulted in continued exposure and spread of influenza within the facility. …
F865 citations in Mississippi
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
Mississippi cites F865 more often than its own record predicts
2.83 times the share F865 takes of citations nationally.
Of every deficiency written in Mississippi 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 Mississippi surveyors wrote
F865 findings written in Mississippi, 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 review, staff interview, and facility policy review, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to sustain corrective actions to prevent recurrence of previously cited deficiencies, specifically, the facility was cited for failing to provide the residents with a homelike environment during an annual recertification survey on 01/09/2025 and was cited again for the same deficiency during the current survey, demonstrating that QAPI failed to sustain ongoing monitoring and oversight to prevent recurrence for one (1) of seven (7) deficiencies cited. …
The short window
Recent years
| Year | Share of Mississippi citations | vs expected |
|---|---|---|
| 2023 | 0.54% | 3.13× |
| 2024 | 0.81% | 4.35× |
| 2025 | 0.67% | 2.83× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Mississippi 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