Based on observation, interview and document review it was determined that the facility failed to maintain a comprehensive and documented Quality Assurance Program (QAPI) and a process was in place to demonstrate the facility made good faith attempts to identify and prioritize potential issues related to resident care and services, and to track and measure performance at QAPI. The deficient practice affected all residents that resided at the facility and was evidenced by the following: Refer to: F605, F607, F677, F 684, F689, F695, F755, F761, F800, F803, F804, F812, F919 On 05/08/26 at 9:43 AM, the surveyor requested the Quality Assurance Performance Improvement (QAPI) to bring in the documents from the Licensed Nursing Home Administrator (LNHA) so he may discuss with the survey team. …
F865 citations in New Jersey
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
New Jersey cites F865 more often than its own record predicts
1.54 times the share F865 takes of citations nationally.
Of every deficiency written in New Jersey 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 New Jersey surveyors wrote
F865 findings written in New Jersey, 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 New Jersey citations | vs expected |
|---|---|---|
| 2023 | 0.37% | 2.13× |
| 2024 | 0.50% | 2.71× |
| 2025 | 0.37% | 1.54× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else New Jersey 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