Based on record review, interview, the facility's policy titled Abuse, Neglect, and Exploitation, and the facility plan titled Quality Assurance and Performance Improvement (QAPI) Plan the facility failed to implement an effective QAPI program related to a resident-to-resident sexual abuse incident.Specifically, the facility's Quality Assurance Committee failed to review the incident to verify that a thorough investigation was conducted, failed to the incident as abuse, and failed to analyze contributing risk factors including residents wandering without supervision on a unit with a resident who had a documented history of sexually inappropriate behavior toward staff. …
F867 citations in Alabama
QAPI improvement activities · Administration Deficiencies
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Alabama cites F867 more often than its own record predicts
6.06 times the share F867 takes of citations nationally.
Of every deficiency written in Alabama in 2025, this is the portion that was F867.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Alabama surveyors wrote
F867 findings written in Alabama, 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 interviews, record review, and a review of the facility policy titled, Quality Assurance/ Performance Improvement, the Quality Assurance Performance Improvement (QAPI) committee failed to identify all causal factors related to two elopements for Resident Identifiers (RI) #106 and RI #121 and for smoking non compliance for RI #33 and RI #109. The facility also failed to determine what corrective actions needed to be taken to prevent any further resident safety concerns. …
The short window
Recent years
| Year | Share of Alabama citations | vs expected |
|---|---|---|
| 2023 | 1.04% | 1.77× |
| 2024 | 2.19% | 4.87× |
| 2025 | 1.99% | 6.06× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Alabama 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