Deficiency Index

F867 citations in Puerto Rico

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 Puerto Rico. Pick another state for the same tag.

Against expectation — 2024

Puerto Rico cites F867 less often than its own record predicts

Versus expected share0.78×

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

Share of Puerto Rico citations0.35%

Of every deficiency written in Puerto Rico 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 Puerto Rico surveyors wrote

F867 findings written in Puerto Rico, 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.

F · No harm, potential for more than minimal, widespreadMay 21, 2026

Based on review of Quality Assessment Performance Improvement-QAPI and interview with facility QAPI officer (employee #2) on 05/21/26 at 11:55 am, it was determined that the facility failed to assure QAPI program feedback and data system monitoring performed by the Director of Nursing and Administrator are included in every committee meeting.Findings include:During review of trimestral QAPI committee meeting 2025 and 2026 on 05/21/26 at 11:55 am, the following was identified:1.QAPI committee meeting performed on 09/25/25 did not evidence the participation of the Director of Nursing. …

Alternative Healthcare Solutions LLC

What else Puerto Rico surveyors cite →

Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction