of F868 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
Citations in 2025251
Every F868 citation surveyors wrote nationally that year.
Facilities cited251
Distinct nursing homes with at least one F868 finding.
The harm level
How severely F868 is cited
0.2% of citations found actual harm or worse (level G and above).
Citations by CMS scope and severity. Rows are harm level, columns are how widespread the finding was.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
J—
K—
L—
Actual harm
G—
H20.2%
I—
No harm, potential for more than minimal
D31128.8%
E23621.9%
F43840.6%
No harm, potential for minimal
A—
B232.1%
C696.4%
Every recorded F868 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F868 citation says
One finding from each severity level, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
J · Immediate jeopardy, isolatedMarch 10, 2021
Based on interviews, record review and policy review, the facility's Quality Assessment and Assurance (QAA) committee failed to meet on at least a quarterly basis to conduct QAA activities to identify potential or actual concerns that have caused or have the potential to cause serious harm to residents. The facility census was 117.
On 3/1/2021 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents.
The facility's Administrator and Director of Nursing were informed of the Immediate Jeopardy for F580, F600, and F835 on 3/1/2021 at 11:40 a.m. …
Based on interview, record review, and interview, the facility did not maintain a quality assessment and assurance committee consisting of the Director of Nursing, Medical Director, and and least three other members of the facility's staff. In addition the committee did not meet quarterly.
Findings include:
On 10/11/22 the sign in sheets for the last 12 months of the Quality Assurance (QA) meetings were requested verbally to the Administrator (ADM).
On 10/12/22 at 9:50 AM, the sign in sheets for the last 12 months of the QA meetings were requested from the ADM via email.
On 10/24/22 at 6:08 PM, an interview was conducted with the facility ADM. …
D · No harm, potential for more than minimal, isolatedAugust 28, 2026
Based on review of facility policy, facility records, and staff interview, it was determined that the facility failed to ensure required attendance of the Infection Preventionist to Quality Assurance and Performance Improvement (QAPI) Committee meetings for one of four quarters reviewed (Quarter one).Findings include: Review of facility policy entitled, Quality Assurance and Performance Improvement Program dated 7/7/26, revealed The following individuals serve on the committee.Infection Preventionist.The committee meets at least quarterly (or more often as necessary). Committee members are reminded of meeting day, time and location via e-mail at least two business days prior to the meeting. …
B · No harm, potential for minimal, patternSeptember 2, 2026
Based on record review, facility policy, and interview, the facility failed to ensure required members of the Quality Assessment and Assurance Committee (QAA) participated in Quarterly QAA meetings for 3 of 4 quarterly meetings reviewed. Findings: Review of the facility policy titled Center Quality Assurance Performance Improvement Process revised 3/24/25 indicated the QAA committee meets at least quarterly. The policy indicated the committee is composed of the Administrator, Director of Nursing (DON), Medical Director and the Infection Preventionist (IP). Review of the QAA Committee attendance documentation dated 10/1/25 indicated the DON was not in attendance. …
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Cited in the same inspection, not caused by one another.
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