Based on staff interviews, facility documentation, and policy review, the facility failed to track, trend, and analyze the cause of resident-to-resident abuse and implement a measurable preventative action plan. The deficient practice could result in continued resident-to-resident abuse.Findings include:Review of a quality assessment and assurance committee (QAA) meeting dated December 11. 2025, revealed that the meeting review period was for November 2025. Review of the meeting minutes revealed that the number of reportable incidents for November was blank. Further review of the meeting minutes revealed there were 1 pending report for November, however, trends listed for November 2025 revealed 1 incident in Kiva and 3 incidents in Vista East. …
F867 citations in Arizona
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 — 2024
Arizona cites F867 less often than its own record predicts
0.68 times the national share — cited less often here than elsewhere.
Of every deficiency written in Arizona in 2024, 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 Arizona surveyors wrote
F867 findings written in Arizona, 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.
The short window
Recent years
| Year | Share of Arizona citations | vs expected |
|---|---|---|
| 2023 | 0.52% | 0.89× |
| 2024 | 0.31% | 0.68× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Arizona 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