F865 in Pennsylvania. Pick another state for the same tag.
Against expectation — 2025
Pennsylvania cites F865 less often than its own record predicts
Versus expected share0.70×
0.70 times the national share — cited less often here than elsewhere.
Share of Pennsylvania citations0.17%
Of every deficiency written in Pennsylvania in 2025, this is the portion that was F865.
Pennsylvania0.17%
National0.24%
Share of all citations that were F865.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Pennsylvania surveyors wrote
F865 findings written in Pennsylvania, 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.
E · No harm, potential for more than minimal, patternJuly 9, 2026
Based on a review of facility documentation, cited deficiencies from a previous survey, review of plans of correction documentation, and staff interview, it was determined that the facility's Quality Assurance and Performance Improvement (QAPI) program failed to correct previously cited deficiencies. Findings include:Review of the facility policy, Quality Assurance and Performance Improvement (QAPI)Program dated 1/6/26, indicated it is a proactive systematic approach to improving the quality of care, quality of life and services in the facility. …
C · No harm, potential for minimal, widespreadMay 1, 2023
Based on review of select facility documents and staff interview, it was determined that the facility failed to develop a QAPI (Quality Assurance and Performance Improvement) Plan to reflect the complexities, unique care, and services that the facility provides.
Findings include:
Review of Facility QAPI Plan updated April 2023, revealed the scope of services outlines the type of care and services our organization provides.
Review of the QAPI plan included in the services provided
-Ventilator Care: We provide a ventilator care program that includes social services, nursing, activities, dietary, and rehabilitative support for those who are ventilator dependent. …
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