Based on interview and record review, the facility failed to maintain a Quality Assessment and Assurance Program (QAA) that identified deficiencies, and implemented appropriate preventative or corrective actions. The facility's QAA program failed to timely recognize already compromised care and services that resulted in the severity of harm, immediate Jeopardy (IJ), as well as a potential for a pattern of resident harm. Findings included: Free from Abuse and Neglect (Please refer to F600) The facility failed to recognize and/or address ongoing staffing issues, did not have clinical systems in place to identify or manage risk factors of conditions, implement proactive measures to avoid complications of infections, which demonstrated a pattern of allowing neglect and the inaction and serious… …
F867 citations in Washington
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
Washington cites F867 less often than its own record predicts
0.32 times the national share — cited less often here than elsewhere.
Of every deficiency written in Washington 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 Washington surveyors wrote
F867 findings written in Washington, 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 interview and record review, the facility failed to maintain a Quality Assurance Performance Improvement (QAPI) program that, 1) included the thorough collection of data/feedback and systematic investigations and/or analysis regarding adverse events (an unexpected, undesirable and usually unanticipated event that causes death or serious injury to a resident) within the facility and, 2) showed actions taken towards development of activities regarding, recent adverse events within the facility, problem prone areas, and contributing factors that could impact quality of care, quality of life, and/or resident safety for 1 of 1 QAPI program, reviewed for quality assessment and assurance. …
Based on interview and record review, the facility failed to maintain an effective system to obtain and use information from staff, residents, and resident representatives to identify problems areas within the facility through a Quality Assurance and Performance Improvement (QAPI) program. This failure placed residents at risk of receiving lower quality services, lacking ability to improve facility performance, and a diminished quality of life. Findings included . During an interview on 10/27/2023 at 3:15 PM, Staff A, Administrator, stated that the facility maintained a QAPI program which met monthly and included department heads and a Nursing Assistant Certified when available. …
The short window
Recent years
| Year | Share of Washington citations | vs expected |
|---|---|---|
| 2023 | 0.05% | 0.09× |
| 2024 | 0.12% | 0.27× |
| 2025 | 0.10% | 0.32× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Washington surveyors cite →
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