of F867 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
Citations in 2025356
Every F867 citation surveyors wrote nationally that year.
Facilities cited345
Distinct nursing homes with at least one F867 finding.
The harm level
How severely F867 is cited
6.4% of citations found actual harm or worse (level G and above).
Citations by CMS scope and severity. Rows are harm level, columns are how widespread the finding was.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
J351.8%
K251.3%
L261.4%
Actual harm
G221.2%
H140.7%
I—
No harm, potential for more than minimal
D61932.7%
E55529.3%
F57130.2%
No harm, potential for minimal
A—
B100.5%
C150.8%
Every recorded F867 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F867 citation says
One finding from each severity level, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
J · Immediate jeopardy, isolatedAugust 1, 2026
Based on interview and record review, the facility failed to develop and implement a performance improvement plan following the identification an incident occurred to 1 of 4 reviewed residents, Resident #1, when the facility staff failed to provide adequate supervision and failed to take necessary actions to meet the resident's needs. On 7/24/2026 at 11:45 AM, Resident #1 was seen with her walker heading toward the outside courtyard. At 1:55 PM, Resident #1 was found unresponsive on the bench in the courtyard. Resident #1 was brought to her room. Staff applied packed ice and cool blankets. At 2:55 PM, Emergency Medical Service (EMS) was contacted. …
Licensure Reference Number 175 NAC 12-006.07(C) Based on observation, interview, and record review, the facility failed to ensure the Quality Assurance and Performance (QAPI, . It is a data-driven, proactive program required by the Centers for Medicare and Medicaid Services for healthcare facilities like nursing homes to continuously track and elevate patient care safety and quality) program identified and addressed concerns related to deficient practice identified on the survey and ensure correction for repeat deficient practice from previous surveys were maintained. This had the potential to affect all residents that resided in the facility. The facility census was 79. …
D · No harm, potential for more than minimal, isolatedSeptember 10, 2026
Based on interview and document review, the facility failed to have evidence of measurable goals and documentation of an analysis and evaluation of the data, submitted to the QAPI committee to ensure Performance Improvement Projects (PIPS) areas identified had oversight and a documented action plan. This had the potential to affect all 38 residents living in the facility. Findings include: Review of QAPI meeting minutes provided from October 2025 through July 2026, identified department heads were bringing data forth to QAPI on various topics such as; infection control with an upward trend of skin infections, data analysis of employee illnesses, resident booster vaccinations, identified requirement of consents needed for psychotropic medication use, prevalence of pressure sore in high-risk… …
C · No harm, potential for minimal, widespreadSeptember 4, 2025
Based on interview and record review the facility failed to prioritize its improvement activities; measure the success of actions, track performance; regularly review, analyze, and act on data collected regarding the facilities performance improvement plan. This had the potential to effect all residents.The facility census was 39. Review of the facilities Quality Assurance Performance Improvement Program (QAPI) policy, dated 10/31/2024, showed:- Design of the QAPI program will:-gather quality concerns and issues from a variety of data sources;-establish methods to identify quality issues then to correct or show targeted improvement through scheduled monitoring;-develop and implement corrective action and performance improvement programs, and monitor and evaluate the effectiveness of the… …
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Cited in the same inspection, not caused by one another.
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