The facility's Quality Assurance Performance Improvement Program (QAPI) failed to maintain a program that developed and implemented effective improvement plans to correct identified areas of concern. After identifying Immediate Jeopardy at F600, F689, F835, F837, and F919, the facility's QAPI plan was requested. The Administrator was unable to locate the facility QAPI plan. It was determined the facility's noncompliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.75 - Quality Assurance and Performance Improvement at a scope and severity of L. The Administrator was notified of the IJ on 10/11/2024 at 11:51 AM. …
F867 citations in Arkansas
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
Arkansas cites F867 less often than its own record predicts
0.26 times the national share — cited less often here than elsewhere.
Of every deficiency written in Arkansas 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 Arkansas surveyors wrote
F867 findings written in Arkansas, 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 observation, record review and interview, the facility failed to ensure the Quality Assessment and Assurance (QAA) Committee conducted ongoing monitoring of a corrective action plan after identifying quality deficiencies related to call light response times, to ensure the in-servicing of staff was sufficient to correct the problems and failed to identify and intervene to correct issues with adequate staffing levels, which resulted in failure to ensure a resident was promptly provided with toileting assistance and, after experiencing an incontinent episode, was promptly provided with incontinent care and a bed linen change for 1 (Resident #11) of 39 (Residents #118, 119, 117, 109, 17, 70, 61, 24, 80, 65, 57, 51, 30, 9, 108, 43, 42, 84, 67, 11, 28, 217, 83, 95, 116, 5, 14, 3, 104,… …
Based on record review and interview, the facility failed to ensure an effective feedback system was in place for the Quality Assurance and Performance Improvement Plan (QAPI). The findings are: A review of the Quarterly QAPI Minutes revealed that admissions, staffing issues, facility issues (such as the Certified Nursing Assistants (CNAs) needing smaller linen carts), ongoing staff education, shower scheduling, improving transport, and staff scheduling had been discussed. The was no mention of falls, behaviors, Minimum Data Sets (MDS), care plans or other resident concerns identified during the survey had been discussed. A review of the Quality Assurance and Performance Improvement Plan (QAPI) Program stated, .1. …
The short window
Recent years
| Year | Share of Arkansas citations | vs expected |
|---|---|---|
| 2023 | 0.46% | 0.79× |
| 2024 | 0.12% | 0.26× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Arkansas 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