Based on interview and record review, the facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program by not conducting quarterly meetings for three consecutive quarters, and when a meeting was held in July 2025, the team failed to address an ongoing supply concern. In addition, there was no system in place for obtaining feedback and input for direct care staff and residents, including how such input would be used to identify and address problems. …
F867 citations in Guam
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
Guam cites F867 more often than its own record predicts
16.91 times the share F867 takes of citations nationally.
Of every deficiency written in Guam 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 Guam surveyors wrote
F867 findings written in Guam, 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.
What else Guam surveyors cite →
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