Based on interview, record review, and facility policy review, the facility failed to implement a Quality Assurance and Performance Improvement (QAPI) program when they did not adequately identify, analyze, and address issues impacting resident care through proper data collection, monitoring, and improvement initiatives related to pharmaceutical services. This had the potential to affect 85 of 85 residents who resided at the facility. The facility's failure to adequately identify, analyze, and address issues impacting resident care through proper data collection, monitoring, and improvement initiatives related to pharmaceutical services had the potential to cause serious harm to residents. …
F867 citations in South Carolina
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
South Carolina cites F867 more often than its own record predicts
2.43 times the share F867 takes of citations nationally.
Of every deficiency written in South Carolina 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 South Carolina surveyors wrote
F867 findings written in South 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.
Based on record review, observation, and interview, the facility failed to implement an effective Performance Improvement Plan to address facility water temperatures. This had the potential to affect all 78 residents. Findings include: Review of facility document titled 'QAPI' (not dated) revealed, Maintenance-We provide a maintenance program that maintains building safety, conducts repairs as needed, and performs safety inspections in accordance with State and Federal expectations to ensure all aspects of safety are enforced, ensuring the safety and well- being for each resident, visitor, and staff who enters the building. …
The short window
Recent years
| Year | Share of South Carolina citations | vs expected |
|---|---|---|
| 2024 | 0.32% | 0.72× |
| 2025 | 0.80% | 2.43× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else South Carolina 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