Based on record review and interview during survey, the facility failed to implement its Quality Assurance and Performance Improvement (QAPI) program to address a medication diversion event involving unauthorized medication orders and misappropriation of resident medications. Specifically, the facility failed to present the incident to the Quality Assurance and Performance Improvement Committee for review, identify system failures, develop corrective actions, and monitor the effectiveness of interventions to prevent recurrence.Findings include:Cross reference to F-602, F-609.The facility's policy and procedure titled Quality Assurance and Performance Improvement (QAPI) Program dated 01/13/2026 documented the facility shall develop, implement, and maintain an ongoing, facility-wide,… …
F865 citations in New York
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 York cites F865 more often than its own record predicts
1.08 times the share F865 takes of citations nationally.
Of every deficiency written in New York 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 York surveyors wrote
F865 findings written in New York, 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 York citations | vs expected |
|---|---|---|
| 2023 | 0.05% | 0.30× |
| 2024 | 0.25% | 1.32× |
| 2025 | 0.26% | 1.08× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else New York 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