Based on interview and record review the facility failed to maintain a Quality Assurance and Process Improvement (QAPI) program that: 1) consistently identified areas for performance improvement; 2) developed and implemented appropriate Performance Improvement Plans (PIPs) for identified deficiencies; 3) evaluated results; and 4) monitored and measured outcomes. This failed practice, to achieve or maintain corrective action, resulted in 1) physical harm to residents who developed stage II, III, and IV pressure ulcers and 2) a potential for psychosocial harm to residents affected by isolation and inadequate care to meet physical, social, and emotional needs, due to staffing shortages, during room-based care (RBC) (residents cannot leave room and the resident receives care, treatment, and… …
F867 citations in Alaska
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.
No F867 citations were recorded in Alaska 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 Alaska surveyors wrote
F867 findings written in Alaska, 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 interview and record review, the facility failed to monitor the effectiveness of its performance improvement activities to ensure that improvements were sustained. Specifically, the facility had no evidence of tracking, trending or monitoring the decolonization (a medical intervention aimed at eliminating antimicrobial-resistant microorganisms) program. This failed practice placed all residents (based on a census of 18) at risk of receiving an ineffective decolonization intervention and at potential risk for adverse effects .Findings:.Residents' Medical Record ReviewRecord review on 3/2-6/26 of the quarterly Minimum Data Set (MDS - a federally required nursing assessment), revealed 15 residents had antibiotics checked as is taking with indication noted in the following… …
What else Alaska surveyors cite →
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