Based on interviews, record review, and facility policy review, the facility failed to develop and implement appropriate plans of action to correct identified quality deficiencies. In September of 20, the facility was cited for failure to implement and monitor an effective screening process for staff to prevent a novel Coronavirus Disease (COVID-19) outbreak. The facility implemented a screening policy that indicated nurses, or any department head, could screen employees upon entrance to the facility. In March of 21, the facility revised the policy and established that any staff could witness another employee screening prior to working. …
F867 citations in Iowa
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
Iowa cites F867 less often than its own record predicts
0.51 times the national share — cited less often here than elsewhere.
Of every deficiency written in Iowa 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 Iowa surveyors wrote
F867 findings written in Iowa, 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 facility assessment, clinical record review and staff interview the facility failed to properly establish and implement written policies and procedures for the Quality Assurance and Performance Improvement (QAPI) plan and properly monitor and measure its success and track performance to ensure that improvements are realized and sustained for the QAPI plan. The facility reported a census of 28 residents.Findings include:Clinical record review completed on 1/29/26 at 12:20 PM revealed no QAPI policy in place with a description of how the facility would identify, report, track, investigate and analyze adverse events or problem-prone concerns, a description as to how the facility obtains and uses any feedback from resident representatives to identify high-risk or problem prone issues,… …
Based on facility record review and staff interviews, the facility failed to have an effective quality assurance (QA) program in place to assist in the provision of quality care for residents. The facility identified a census of 52 residents. Findings include: Review of facility records revealed repeated deficient practices identified during the facility's annual survey completed 4/10/14, 7/2/15, 6/20/16, 7/1/17 and current survey investigation. During interview on 8/2/18 at 11:55 AM, the acting Director of Nursing (DON) acknowledged the facility has had repeat deficiencies. She explained she had more to do with the clinical side. The DON stated since the interim Administrator is out of town, she only knew that he had met with the individual department heads.
The short window
Recent years
| Year | Share of Iowa citations | vs expected |
|---|---|---|
| 2023 | 0.12% | 0.20× |
| 2024 | 0.18% | 0.40× |
| 2025 | 0.17% | 0.51× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Iowa 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