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. …
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.
Against expectation — 2024
Puerto Rico cites F867 less often than its own record predicts
0.78 times the national share — cited less often here than elsewhere.
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.
What else Puerto Rico surveyors cite →
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