Based on record review and staff interview, the facility ' s Quality Assurance and Performance Improvement committee (QAPI) failed to maintain implemented procedures and to monitor the interventions that the committee put into place in February 2017. This was for eight (8) recited deficiencies (self- determination, Minimum Data Set (MDS) accuracy, Activities of daily living (ADL) care for dependent residents, increase/ prevent decrease in range of motion/ mobility, drug regime free from unnecessary drugs, free from unnecessary [MEDICAL CONDITION] medications, free of medication error rate of 5% or more) which were originally cited on 2/9/17 during the recertification/ complaint investigation survey and on the current recertification/ complaint investigation survey on 2/1/18. …
F865 citations in North Carolina
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.
No F865 citations were recorded in North Carolina for 2025. That means none appear in the CMS file for that year — not that the requirement does not apply.
In the surveyor’s words
What North Carolina surveyors wrote
F865 findings written in North Carolina, 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 and Administrator interview, the facility failed to maintain and produce documented evidence of a comprehensive and ongoing Quality Assurance and Performance Improvement program that demonstrated systematic identification, reporting, investigation, analysis, and prevention of adverse events; and the development, implementation, and evaluation of corrective actions or performance improvement activities for calendar year 2025. This deficient practice had the potential to affect all 94 of 94 facility residents. …
Based on record review and staff interviews, the facility failed to maintain documentation and develop a plan that described the process for conducting Quality Assurance and Performance Improvement committee (QAPI) activities. Findings included: Record review of the facility's QAPI records revealed minutes for the prior monthly meetings for the past 12 months. The monthly meeting included notes related to falls, nutrition, and incidents. The QAPI records did not contain a plan that described the process for conducting the facility's QAPI activities. During an interview with the Assistant Director of Nursing (ADON) on 02/06/20 at 11:10 AM, she stated she oversaw the facility's QAPI program. …
What else North Carolina surveyors cite →
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