Based on observation, interview and record review, the facility Quality Assurance and Performance Improvement committee (QAPI) failed to develop and implement appropriate plans of action to correct and identify quality deficiencies for 1 of 1 facility. The facility QAPI failed to identify and implement an action plan to address multiple, resident to resident altercations, that occurred on 6/5/23, 6/14/23, 6/20/23, 8/21/23 and 9/18/23. The facility QAPI failed to identify and implement an action plan to address an elopement that occurred on 6/6/23. These failures resulted in an Immediate Jeopardy (IJ) situation identified on 10/25/23 at 3:49 PM. …
F867 citations in Texas
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
Texas cites F867 less often than its own record predicts
0.19 times the national share — cited less often here than elsewhere.
Of every deficiency written in Texas 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 Texas surveyors wrote
F867 findings written in Texas, 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 observation, interviews and records review, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to take actions aimed at performance improvement and after implementing those actions, measure its success, and track performance to ensure that improvements were realized and sustained.-The facility failed to monitor and track performance of the black debris presence in the 300-hall shower room.The failure could place residents within the facility at risk for potential illness.An observation was made on 07/21/2026 at 3:05 PM in the 300-hall shower room of the inner bottom corners of the shower with white paste that was open with black debris underneath.Record review of the Nursing Facility's Quality Assessment and Performance Improvement Plan 2026,… …
Based on interviews, record reviews the facility failed to ensure that the quality assessment and assurance committee developed and implemented appropriate plans of actions to correct deficiency of having a full time Social Worker on staff for Residents social needs for all resident. The facility failed to ensure the QAPI committee, which included the Administrator, DON, Medical Director, had followed the facility's plan of correction dated 04/12/2023. This failure could place all residents at risk for unmet social services and psychosocial needs. …
The short window
Recent years
| Year | Share of Texas citations | vs expected |
|---|---|---|
| 2023 | 0.07% | 0.11× |
| 2024 | 0.05% | 0.11× |
| 2025 | 0.06% | 0.19× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Texas surveyors cite →
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