Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure that their quality program implemented a corrective action plan following an initial medication error which resulted in a resident (Resident #9) requiring transfer and treatment at an acute care hospital. After the failure of the facility's quality program to adequately address the initial medication error, Resident #9 was subsequently provided the same incorrect medication which resulted in the resident again requiring transfer and treatment at an acute care hospital. …
F867 citations in Virginia
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
Virginia cites F867 less often than its own record predicts
0.47 times the national share — cited less often here than elsewhere.
Of every deficiency written in Virginia 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 Virginia surveyors wrote
F867 findings written in Virginia, 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 staff interview and facility documentation review, the facility staff failed to ensure implementation of a comprehensive QAPI (Quality Assurance Performance Improvement) Program/Plan included performance improvement projects potentially for three of four quarters affecting all residents in the facility The Findings included:Substandard quality of care was identified at the facility during the survey resulting in an extended survey from 04/24/2026-04/28/2026.During the end of day debriefing on 04/24/2026, the Facility Administrator, the Regional [NAME] President of Operations, Assistant Administrator, Regional Nurse Consultants and Director of Nursing were informed of the findings of the substandard quality of care that were identified by the survey team resulting in an extended… …
The short window
Recent years
| Year | Share of Virginia citations | vs expected |
|---|---|---|
| 2023 | 0.20% | 0.34× |
| 2024 | 0.16% | 0.36× |
| 2025 | 0.15% | 0.47× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Virginia surveyors cite →
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