Based on observation, interview, and record review conducted during a Partial Extended survey (Complaint #NY 249) completed on 2/23/18, the facility failed to ensure that the Quality Assessment and Assurance (QAA) committee effectively developed and implemented appropriate plans of action to correct identified quality deficiencies with the potential to cause serious harm to residents. Specifically, the facility QAA failed to implement a plan to prevent residents from elopement when the facility identified their door alarm system was not compatible with a newly installed VOIP (Voice Over Internet Protocol) telephone system. One (Resident #1) of six cognitively impaired residents identified at risk to wander and/or elope was able to exit the building through an exterior door. …
F867 citations in New York
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
New York cites F867 less often than its own record predicts
0.67 times the national share — cited less often here than elsewhere.
Of every deficiency written in New York 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 New York surveyors wrote
F867 findings written in New York, 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 conducted during an Onsite Post Survey Revisit #1 completed on 06/25/2026, the facility did not ensure that the Quality Assurance Performance Improvement Program (QAPI) Committee developed and implemented appropriate plans of action to correct identified quality deficiencies and regularly reviewed, analyzed, and acted on available data to make improvements. Specifically, the facility did not maintain effective systems to maintain compliance, and there were repeated deficiencies observed from the Standard survey completed on 04/30/2026, in the areas of Right to be Free from Physical Restraints, Care Plan Timing and Revision, Food Procurement, Store/Prepare/Serve-Sanitary, Emergency Lighting, and Fire Alarm System - Testing and Maintenance. …
The short window
Recent years
| Year | Share of New York citations | vs expected |
|---|---|---|
| 2023 | 0.10% | 0.18× |
| 2024 | 0.25% | 0.55× |
| 2025 | 0.22% | 0.67× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else New York 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