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 maintain a QAPI committee with participation of the required members established in 483.75 (g)(1):Findings include:Review of trimestral QAPI committee meeting 2025 and 2026 on 05/21/26 at 11:55 am, the following was identified: QAPI committee meeting performed on 09/25/25 did not evidence the participation of the Director of Nursing.QAPI committee meeting of 06/27/25 attendance list did not demonstrate participation of the Administrator.Review of QAPI rules and regulation last updated on January 2026 with QAPI officer (employee #2) on 05/21/26 at 11:50 am evidence that Administrator, Director of… …
F868 citations in Puerto Rico
Quality assurance committee · Administration Deficiencies
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2024
Puerto Rico cites F868 more often than its own record predicts
7.22 times the share F868 takes of citations nationally.
Of every deficiency written in Puerto Rico in 2024, this is the portion that was F868.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Puerto Rico surveyors wrote
F868 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.
Based on review of Quality Assessment Performance Improvement- QAPI and interview with facility director of institutional program (employee #2) on 03/27/2026, it was determined that the facility failed to maintain a QAPI committee with the participation of the Medical Director or his/her designee; and Infection Control Officer in each QAPI committee meeting.Findings include:1.During review of monthly QAPI committee meeting of year 2025 and the months of January and February of year 2026 on 03/27/2026 at 11:00 AM, the following was identified:A. QAPI monthly committee meeting performed on July 18, 2025, June 20, 2025 and April 28, 2025 did not evidence the participation of the Medical Director or his/her designee.B. …
The short window
Recent years
| Year | Share of Puerto Rico citations | vs expected |
|---|---|---|
| 2023 | 2.78% | 10.85× |
| 2024 | 1.76% | 7.22× |
Shares of citations, not counts: earlier years hold fewer inspections.
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