Deficiency Index

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.

F867 in Virginia. Pick another state for the same tag.

Against expectation — 2025

Virginia cites F867 less often than its own record predicts

Versus expected share0.47×

0.47 times the national share — cited less often here than elsewhere.

Share of Virginia citations0.15%

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.

G · Actual harm, isolatedMarch 29, 2024

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. …

Old Southwest Health and Rehabilitation

F · No harm, potential for more than minimal, widespreadApril 28, 2026

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… …

Thalia Gardens Rehabilitation and Nursing

The short window

Recent years

YearShare of Virginia citationsvs expected
20230.20%0.34×
20240.16%0.36×
20250.15%0.47×

Shares of citations, not counts: earlier years hold fewer inspections.

What else Virginia surveyors cite →

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