Based on review of facility documentation, results of previous survey, and results of the current survey, it was determined that the facility Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed deficiencies.Findings include: The facility deficiencies and plans of correction for a State Survey and Certification (Department of Health) survey ending May 22, 2025, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. …
F867 citations in Pennsylvania
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
Pennsylvania cites F867 more often than its own record predicts
1.98 times the share F867 takes of citations nationally.
Of every deficiency written in Pennsylvania 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 Pennsylvania surveyors wrote
F867 findings written in Pennsylvania, 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.
The short window
Recent years
| Year | Share of Pennsylvania citations | vs expected |
|---|---|---|
| 2023 | 0.70% | 1.19× |
| 2024 | 0.95% | 2.11× |
| 2025 | 0.65% | 1.98× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Pennsylvania 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