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F867: Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action

F867 is one of the federal requirements every Medicare and Medicaid certified nursing home must meet. CMS describes it as: Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. It sits in CMS's administration category.

1,744citations in the CMS files
1,416homes cited at least once
259in the 12 months to September 2026
6.4%rated actual harm or immediate jeopardy

CMS Health Deficiencies file, data as of September 1, 2026. The files hold each home's last three standard inspections and three years of complaint visits.

How seriously inspectors rate it

Every citation gets a letter for how much harm inspectors found and how many residents it touched (how to read the letters). 22.4% of F867 citations came from a complaint visit rather than a routine inspection.

  • Immediate jeopardy (J, K, L)79 (4.5%)
  • Actual harm (G, H, I)32 (1.8%)
  • Potential for more than minimal harm (D, E, F)1,609 (92.3%)
  • Potential for minimal harm (A, B, C)24 (1.4%)

By letter: B 9, C 15, D 579, E 516, F 514, G 18, H 14, J 31, K 22, L 26.

What inspectors wrote

Three recent F867 citations from different states, quoted from the inspectors' statements of deficiencies (CMS form 2567). Names are removed by CMS.

Inspectors wrote, August 7, 2026, scope and severity DBased on review of facility documentation, results of previous survey, and results of the current survey, it was determined that the facility Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed deficiencies.

Providence Health & Rehab Center, Beaver Falls, PA

Inspectors wrote, August 5, 2026, scope and severity DBased on interview and document review, the facility failed to provide evidence of 1 of 1 required Performance Improvement Project (PIP), which focused on high-risk or problem-prone areas with identified interventions and analysis to track performance to ensure improvement after implementing actions.

Good Samaritan Society - Pipestone, Pipestone, MN

Inspectors wrote, July 17, 2026, scope and severity EBased on staff interviews and review of facility documentation it was determined the facility failed to ensure that a Performance Improvement Project (PIP) was identified and implemented through the facility's Quality Assessment and Assurance (QAA) committee and/or Quality Assurance Performance and Improvement (QAPI) program annually. This was found evident for 1 year of QAA/QAPI notes reviewed.

Autumn Lake Healthcare at Homewood, Baltimore, MD

Most recent F867 citations at the harm or jeopardy level

Newest first, the latest 40 in the current files. Each home's page shows the citation in full context, with its correction status.

InspectionHomeTownLetterVisit
June 16, 2026Emerald Nursing & Rehabilitation MercyOmaha, NE HComplaint
April 18, 2026Vista Manor Healthcare and Rehabilitation CenterTitusville, FL JComplaint
April 1, 2026Westside Oaks Rehabilitation & Nursing CenterJacksonville, FL LComplaint
January 18, 2026Enterprise Health & Rehabilitation CenterEnterprise, AL JComplaint
December 10, 2025Bartram CrossingJacksonville, FL LComplaint
September 2, 2025Falkville Rehabilitation and Healthcare CenterFalkville, AL JStandard
August 20, 2025Mission at Alpine Rehabilitation CenterPleasant Grove, UT HStandard
July 31, 2025Rosewood at Tybee Island of Journey LLC, theTybee Island, GA LComplaint
July 7, 2025Blue Point Healthcare CenterBaltimore, MD JComplaint
July 2, 2025Westside Oaks Rehabilitation & Nursing CenterJacksonville, FL JComplaint
June 5, 2025Magnolia RidgeGardendale, AL JComplaint
May 29, 2025Pruitthealth - PalmyraAlbany, GA KComplaint
May 2, 2025Grove Healthcare and Rehabilitation Center and RehHernando, FL JComplaint
April 18, 2025Adviniacare at NaplesNaples, FL KComplaint
April 17, 2025Highland Pines Rehabilitation CenterClearwater, FL KComplaint
April 15, 2025Greenway Health and Rehabilitation Center, LLCGrand Bay, AL LComplaint
April 8, 2025Blue Lake Post AcuteDeland, FL JComplaint
April 3, 2025Orchard Health and RehabilitationPulaski, GA JComplaint
March 5, 2025Ridgeway Manor Healthcare CenterRidgeway, SC JComplaint
January 10, 2025Page Rehabilitation and Healthcare CenterFort Myers, FL JComplaint
December 6, 2024Sunset Lake Healthcare and Rehabilitation CenterVenice, FL LComplaint
November 30, 2024Walker Rehabilitation Center, IncCarbon Hill, AL LComplaint
November 22, 2024Bourbon Heights Nursing HomeParis, KY LComplaint
November 19, 2024Cedar Crest at North FloridaGainesville, FL JComplaint
November 18, 2024Church Hill Post-Acute and Rehabilitation CenterChurch Hill, TN LStandard
November 15, 2024Park Meadows Healthcare & Rehabilitation CenterGainesville, FL JStandard
November 13, 2024Bella Terra St. George (black Rock Health and RehabSt. George, UT HComplaint
November 7, 2024Eaton Creek Post AcuteNashville, TN LComplaint
October 16, 2024Meadowview Healthcare and RehabHuntsville, AR LStandard
September 26, 2024Tri State Health and Rehabilitation CenterHarrogate, TN KComplaint
September 1, 2024Merry Wood LodgeElmore, AL LComplaint
August 29, 2024Eagle Lake Nursing and Rehab Care CenterSaint Petersburg, FL GComplaint
August 22, 2024Rocky Top Care CenterRocky Top, TN LComplaint
August 21, 2024Regency Health Care and Rehabilitation CenterHuntsville, AL JComplaint
August 15, 2024Oak Hollow of Georgetown Rehabilitation Center LLCGeorgetown, SC JStandard
August 14, 2024Mountain View Health ServicesOgden, UT HComplaint
June 13, 2024W Frank Wells Nursing HomeMacclenny, FL LComplaint
June 3, 2024Cumberland Health and RehabBridgeport, AL LComplaint
May 15, 2024Tennessee Veterans HomeMurfreesboro, TN LComplaint
May 13, 2024Highlands Rehabilitation and Wellness CenterBirmingham, AL LComplaint

Most recent F867 citations

InspectionHomeTownLetter
August 7, 2026Providence Health & Rehab CenterBeaver Falls, PA D
August 5, 2026Good Samaritan Society - PipestonePipestone, MN D
July 30, 2026Saint Anne HomeGreensburg, PA D
July 23, 2026Mountain Laurel Healthcare and Rehabilitation CtrClearfield, PA D
July 22, 2026Southside Care CenterMinneapolis, MN F
July 21, 2026Avir at PecosPecos, TX D
July 17, 2026Autumn Lake Healthcare at HomewoodBaltimore, MD E
July 16, 2026Avir at GranburyGranbury, TX D
July 16, 2026Lakeshore Rehabilitation Center LLCWaseca, MN F
July 16, 2026Brownsburg Health Care CenterBrownsburg, IN E
July 15, 2026Midtown Oaks Health & Rehab CenterAltoona, PA D
July 15, 2026Embassy of ScrantonScranton, PA E
July 10, 2026Cherry Ridge of CascadiaEmmett, ID F
July 10, 2026Susanna Wesley Health CenterHialeah, FL D
July 9, 2026California Nursing & Rehabilitation CenterPalm Springs, CA D
July 8, 2026Live Oak Nursing and Rehabilitation CenterGeorge West, TX E
July 8, 2026Oak Hill Rehabilitation & Healthcare CenterGreensburg, PA D
July 8, 2026Arcadia Care WatsekaWatseka, IL F
June 30, 2026Gainesville Health and RehabilitationGainesville, FL F
June 25, 2026Edenbrook on Second AveKingston, PA D
June 25, 2026The Gardens at Foley LLCFoley, MN E
June 22, 2026Avantara ArrowheadRapid City, SD F
June 18, 2026Avenue at LyndhurstLyndhurst, OH F
June 18, 2026Victoria Nursing & Rehabilitation Center, Inc.Miami, FL D
June 17, 2026Oneida Nursing and Rehab CenterOneida, TN F

F867 citations by state

Counts depend on how many homes a state has and how often its inspectors visit, so a larger number is not by itself a worse record.

StateCitations
North Carolina295
Florida246
California190
Pennsylvania158
Minnesota70
Maryland62
Colorado58
Missouri45
Tennessee41
Massachusetts38
Michigan36
Utah36
Indiana32
Illinois30
Mississippi26
Ohio26
Kansas25
New York24
Virginia23
Georgia21
Texas20
Maine19
Alabama18
New Jersey17
Louisiana15
Kentucky14
Iowa12
Oregon12
Washington11
Connecticut10
Nevada10
South Carolina9
Wisconsin9
West Virginia9
Arkansas8
Arizona8
Montana8
Nebraska8
Hawaii7
District of Columbia6
Oklahoma6
Delaware5
Rhode Island5
Idaho4
Puerto Rico3
South Dakota3
Alaska1
Guam1
North Dakota1
New Hampshire1
New Mexico1
Wyoming1

By inspection year: 2018 9, 2019 41, 2020 10, 2021 63, 2022 136, 2023 400, 2024 544, 2025 356, 2026 185.

Common questions

What is F867 in a nursing home inspection?
F867 is the federal requirement to "set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action". CMS files it under administration. A home cited under F867 did not meet that requirement at the inspection.
How often is F867 cited?
The CMS files as of September 1, 2026 list 1,744 F867 citations at 1,416 nursing homes, 259 of them in the 12 months to that date. 6.4% were rated as actual harm or immediate jeopardy.
Is a F867 citation serious?
It depends on the letter. Most F867 citations (92.3%) were rated as potential for more than minimal harm, D to F. 79 were immediate jeopardy, the most serious level.

The interpretive guidance inspectors use for each F-tag is CMS's State Operations Manual, Appendix PP. NursingHomeClear reports the citations as CMS records them and is not affiliated with CMS. All F-tags · Methodology

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