F867 in Colorado. Pick another state for the same tag.
Against expectation — 2025
Colorado cites F867 more often than its own record predicts
Versus expected share3.07×
3.07 times the share F867 takes of citations nationally.
Share of Colorado citations1.01%
Of every deficiency written in Colorado in 2025, this is the portion that was F867.
Colorado1.01%
National0.33%
Share of all citations that were F867.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Colorado surveyors wrote
F867 findings written in Colorado, 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.
G · Actual harm, isolatedJanuary 11, 2024
Based on record review and interviews, the facility failed to have an effective system to identify deviations in performance and adverse events, and to develop and implement appropriate quality assurance and performance improvement (QA/QAPI) plans of action to correct quality deficiencies.
Specifically, the QAPI program committee failed to identify and address concerns related to suicidal ideations and the prevention of incidents of self-harm that rose to the level of immediate jeopardy. Cross-reference F740.
Findings include:
I. Facility policy and procedure
The Quality Assessment and Assurance Committee policy and procedure, revised January 2018, was provided by the nursing home administrator (NHA) on 1/8/24 at 2:00 p.m. …
F · No harm, potential for more than minimal, widespreadMarch 12, 2026
Based on record review and interviews, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented in order to facilitate improvement in the lives of nursing home residents through continuous attention to quality of care, quality of life, and resident safety.Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to quality of life and quality of care.Findings include:I. …
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