On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator, Regional Director of Clinical Operations, and Director of Operations were informed of the Immediate Jeopardy (IJ) on [DATE], at 3:48 pm. The noncompliance related to the IJ was identified to have existed on [DATE]. …
F867 citations in Georgia
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
Georgia cites F867 less often than its own record predicts
0.70 times the national share — cited less often here than elsewhere.
Of every deficiency written in Georgia 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 Georgia surveyors wrote
F867 findings written in Georgia, 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 record review, staff interviews, and review of the facility policy titled, Quality Assurance and Performance Improvement (QAPI), the facility failed to maintain a Quality Assessment and Assurance (QAA) program that effectively identified, developed, and implemented corrective action plans to effectively addressed concerns related to ensuring a safe, clean, comfortable, homelike environment and completion of Level I PASRR Screenings. The deficient practice had the potential to affect the quality of life and quality of care for residents. …
The short window
Recent years
| Year | Share of Georgia citations | vs expected |
|---|---|---|
| 2023 | 0.51% | 0.87× |
| 2024 | 0.40% | 0.90× |
| 2025 | 0.23% | 0.70× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Georgia 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