F867 in New Jersey. Pick another state for the same tag.
Against expectation — 2025
New Jersey cites F867 less often than its own record predicts
Versus expected share0.14×
0.14 times the national share — cited less often here than elsewhere.
Share of New Jersey citations0.05%
Of every deficiency written in New Jersey in 2025, this is the portion that was F867.
New Jersey0.05%
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 New Jersey surveyors wrote
F867 findings written in New Jersey, 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.
L · Immediate jeopardy, widespreadNovember 17, 2018
Based on review of the facility capacity statement, quality assessment data, and interview, the facility failed to ensure the Quality Assessment and Performance Improvement (QAPI) committee developed improvement activities based on systemic analysis of data, failed to develop an action plan based on the data, and failed to have a process in place to measure the success and sustained improvement of high risk problems. Specifically, the facility failed to develop a QAPI action plan to evaluate corrective actions to assure that efforts by the facility were effective to contain the high-risk problem of respiratory infections in the pediatric ventilator unit where 90 residents resided. …
F · No harm, potential for more than minimal, widespreadMarch 26, 2026
Based on interview and document review, it was determined that the facility Quality Assessment and Performance Improvement (QAPI) committee failed to utilize the facility Performance Improvement Plan (PIP) to follow the facility process to measure and utilize data acquired and develop quantitative and measurable goals, this deficient practice was evidenced by the following:On 3/24/2026 at 11:00 AM, the surveyor reviewed facility provided Performance Improvement Plans (PIPs) for activities regarding resident participation, missed reimbursement related to failure to capture respiratory treatments, CNA staffing, MDS modifications, and baseline care plans. All PIPs reviewed did not include quantitative and measurable goals. …
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