F867 in North Carolina. Pick another state for the same tag.
Against expectation — 2025
North Carolina cites F867 less often than its own record predicts
Versus expected share0.44×
0.44 times the national share — cited less often here than elsewhere.
Share of North Carolina citations0.14%
Of every deficiency written in North Carolina in 2025, this is the portion that was F867.
North Carolina0.14%
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 North Carolina surveyors wrote
F867 findings written in North Carolina, 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.
J · Immediate jeopardy, isolatedFebruary 4, 2022
Based on observation, record review, and staff interviews, the facility Quality Assurance and Performance Improvements (QAPI) committee failed to self-identify and [MEDICATION(S)] to ensure one (1) of four (4) unvaccinated residents did not remain in the same room on a COVID-19 unit, with a COVID-19 positive resident (Resident #4). The QAPI committee was unaware Resident #4 had been on the COVID hall (A) since the resident's admission on 01/07/22. In addition, the QAPI committee failed to ensure the facility sustained compliance related to infection control practices previously identified on the past two surveys. …
Based on observations, record review, and interviews with the physician and staff, the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions that the committee put into place in order to sustain compliance. This included a recited deficiency in the area of Supervision to Prevent Accidents (F689) as evidenced by repeat citations resulting in harm or immediate jeopardy for a high likelihood of harm to residents. During the 6/11/21 recertification and complaint investigation survey, deficient practice at F689 was identified as immediate jeopardy for a high likelihood of harm when a resident was found smoking in their room with oxygen in use on three occasions. …
F · No harm, potential for more than minimal, widespreadAugust 1, 2025
Based on observations, interviews, record review, and review of the facility's policy titled Quality Assessment and Assurance Committee, the facility Quality Assurance and Performance Improvement (QAPI) committee failed to 1. ensure the QAPI committee policy addressed data collection and analysis, data and adverse event monitoring, and feedback; 2. track and analyze data and conduct at least one process improvement plan (PIP) this year; and 3. maintain implemented procedures and monitor interventions that the committee put into place following the recertification survey of 08/22/24 and the complaint surveys on 10/18/24 and 04/10/25. This was for deficiencies re-cited during the recertification and complaint survey conducted 07/28/25-08/01/25. …
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