F865: Have a plan that describes the process for conducting QAPI and QAA activities
F865 is one of the federal requirements every Medicare and Medicaid certified nursing home must meet. CMS describes it as: Have a plan that describes the process for conducting QAPI and QAA activities.
It sits in CMS's administration category.
CMS Health Deficiencies file, data as of September 1, 2026. The files hold each home's last three standard inspections and three years of complaint visits.
How seriously inspectors rate it
Every citation gets a letter for how much harm inspectors found and how many residents it touched (how to read the letters). 23.5% of F865 citations came from a complaint visit rather than a routine inspection.
By letter: B 4, C 20, D 174, E 232, F 392, G 4, H 4, I 1, J 4, K 3, L 6.
What inspectors wrote
Three recent F865 citations from different states, quoted from the inspectors' statements of deficiencies (CMS form 2567). Names are removed by CMS.
Inspectors wrote, July 16, 2026, scope and severity FBased on interview and record review, the quality assurance and performance improvement (QAPI) committee failed to identify resident call light wait time concerns prior to survey, nor make a good faith attempt to correct the deficiency. This deficient practice had the potential to affect all 42 residents residing in the facility.
Lakeshore Rehabilitation Center LLC, Waseca, MN
Inspectors wrote, July 16, 2026, scope and severity DBased on review of Quality Assurance and Performance Improvement(QAPI) meeting documentation, policy review, and staff interview, the facility failed to carry out Quality Assurance(QA) activities to obtain feedback, use data, and take action to conduct structured, systematic investigations and analysis of underlying causes or contributing factors of problems affecting facility-wide processes that impact quality of care, quality of life, and resident safety. The facility reported a census of 68 residents.
Crystal Heights Care Center, Oskaloosa, IA
Inspectors wrote, July 13, 2026, scope and severity DBased 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.
Delhi Rehabilitation and Nursing Center, Delhi, NY
Most recent F865 citations at the harm or jeopardy level
Newest first, all 22 in the current files. Each home's page shows the citation in full context, with its correction status.
| Inspection | Home | Town | Letter | Visit |
|---|---|---|---|---|
| May 26, 2026 | Good Samaritan Society - Millard | Omaha, NE | H | Standard |
| March 16, 2026 | Provo Rehabilitation and Nursing | Provo, UT | G | Complaint |
| March 5, 2026 | Wewoka Healthcare Center | Wewoka, OK | L | Standard |
| January 9, 2026 | Award Care at Beneva | Sarasota, FL | L | Standard |
| November 13, 2025 | Barre Gardens Nursing and Rehab, LLC | Barre, VT | L | Complaint |
| October 28, 2025 | Sunplex Sub-Acute Center | Ocean Springs, MS | L | Complaint |
| September 11, 2025 | Aviata at Big Bend | Perry, FL | L | Complaint |
| May 17, 2025 | Salyersville Nursing and Rehabilitation Center | Salyersville, KY | K | Standard |
| February 11, 2025 | Vantage at Worcester LLC | Worcester, MA | K | Complaint |
| February 7, 2025 | Summit Square | Waynesboro, VA | G | Complaint |
| September 30, 2024 | Barbourville Health and Rehabilitation Center | Barbourville, KY | H | Complaint |
| February 20, 2024 | Courtyards Comm Living Center | Fulton, MS | J | Standard |
| November 17, 2023 | Good Shepherd Health and Rehabilitation | Phelps, KY | J | Complaint |
| September 22, 2023 | Diversicare of Oak Ridge | Oak Ridge, TN | J | Complaint |
| August 16, 2023 | Sandy Health and Rehab | Sandy, UT | H | Standard |
| August 2, 2023 | Antioch Tn Opco, LLC | Antioch, TN | J | Standard |
| May 23, 2023 | Gresham Post Acute Care and Rehabilitation | Gresham, OR | I | Standard |
| May 9, 2023 | Courtyard Health and Rehabilitation | McComb, MS | K | Standard |
| April 13, 2022 | Spring Creek Healthcare Center | Salt Lake City, UT | H | Standard |
| April 3, 2021 | Seneca Place | Louisville, KY | L | Standard |
| January 30, 2020 | Life Care Center of Pueblo | Pueblo, CO | G | Standard |
| October 11, 2019 | Crowley County Nursing Center | Ordway, CO | G | Standard |
Most recent F865 citations
F865 citations by state
Counts depend on how many homes a state has and how often its inspectors visit, so a larger number is not by itself a worse record.
By inspection year: 2018 1, 2019 9, 2020 4, 2021 22, 2022 40, 2023 124, 2024 223, 2025 258, 2026 163.
Common questions
- What is F865 in a nursing home inspection?
- F865 is the federal requirement to "have a plan that describes the process for conducting qapi and qaa activities". CMS files it under administration. A home cited under F865 did not meet that requirement at the inspection.
- How often is F865 cited?
- The CMS files as of September 1, 2026 list 844 F865 citations at 749 nursing homes, 230 of them in the 12 months to that date. 2.6% were rated as actual harm or immediate jeopardy.
- Is a F865 citation serious?
- It depends on the letter. Most F865 citations (94.5%) were rated as potential for more than minimal harm, D to F. 13 were immediate jeopardy, the most serious level.
The interpretive guidance inspectors use for each F-tag is CMS's State Operations Manual, Appendix PP. NursingHomeClear reports the citations as CMS records them and is not affiliated with CMS. All F-tags · Methodology