Based on record review and interview the facility's Quality Assurance Performance Improvement (QAPI) Committee failed to establish and implement policies and procedures for feedback, data collections system, monitoring, and adverse event monitoring. This deficient practice could likely result in the facility not having opportunities for improvement, obtaining feedback from staff, the residents and the resident's representative to identify problems or concerns. The findings are: A. Record review of the Quality Assurance Performance Improvement (QAPI) Committee binder revealed, the facility do not have any policies and procedures in place. B. On 05/22/24 at 2:43 PM during an interview the Administrator confirmed did not have policy and procedures for QAPI. …
F867 citations in New Mexico
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 — 2024
New Mexico cites F867 less often than its own record predicts
0.23 times the national share — cited less often here than elsewhere.
Of every deficiency written in New Mexico in 2024, 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 New Mexico surveyors wrote
F867 findings written in New Mexico, 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 New Mexico surveyors cite →
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