Based on interview and record review, the facility failed to ensure the Quality Assessment and Assurance/Quality Assurance Performance Improvement (QAA/QAPI - a written plan containing the process that will guide the facility's efforts in assuring care and services are maintained at acceptable levels of performance and continually improved) committee developed and implemented an appropriate plan of action to correct identified quality deficiencies. This had the potential to affect all residents in the facility. The sample was 47. …
F867 citations in Missouri
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
Missouri cites F867 more often than its own record predicts
1.05 times the share F867 takes of citations nationally.
Of every deficiency written in Missouri 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 Missouri surveyors wrote
F867 findings written in Missouri, 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 interview and record review the facility failed to prioritize its improvement activities; measure the success of actions, track performance; regularly review, analyze, and act on data collected regarding the facilities performance improvement plan. This had the potential to effect all residents.The facility census was 39. Review of the facilities Quality Assurance Performance Improvement Program (QAPI) policy, dated 10/31/2024, showed:- Design of the QAPI program will:-gather quality concerns and issues from a variety of data sources;-establish methods to identify quality issues then to correct or show targeted improvement through scheduled monitoring;-develop and implement corrective action and performance improvement programs, and monitor and evaluate the effectiveness of the… …
The short window
Recent years
| Year | Share of Missouri citations | vs expected |
|---|---|---|
| 2023 | 0.29% | 0.49× |
| 2024 | 0.23% | 0.50× |
| 2025 | 0.35% | 1.05× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Missouri surveyors cite →
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