Based on observations, interviews and record review, the facility failed to ensure that Quality Assurance Performance Improvement (QAPI) meetings were conducted quarterly, and that the necessary staff members attended those meetings for 3 of 6 months reviewed during QAPI review. The findings included: A review of the facility ' s policy titled Quality Assurance Performance Improvement Program, dated 11/30/2014, showed that the Quality Assessment and Assurance Committee (QAA) meetings are at least quarterly but may be held more frequently as appropriate. The QAA committee members include, but are not limited to, the Executive Director, Medical Director, Director of Nursing, and Infection Preventionist. A review of records revealed the last QAPI meeting was held on December 18, 2024. …
F868 citations in Florida
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 — 2025
Florida cites F868 less often than its own record predicts
0.14 times the national share — cited less often here than elsewhere.
Of every deficiency written in Florida in 2025, 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 Florida surveyors wrote
F868 findings written in Florida, 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 observation, interview, review of Quality Assessment and Assurance (QA&A) meeting sign-in sheets, and QA&A Committee Membership, the QA&A committee failed to ensure documented evidence of the participation of 2 of 3 mandated members of the committee, were in attendance at their monthly meetings (the Medical Director and Administrator or other individual in a leadership role). The findings included: Review of the QAA Committee membership documentation revealed the QAA committee meets monthly. During an interview on 08/24/23 at 1:49 PM, the Assistant Nursing Home Administrator (NHA), who was accompanied by the NHA, was asked to locate and provide the last three QAA Committee Meeting Sign-in Sheets. …
The short window
Recent years
| Year | Share of Florida citations | vs expected |
|---|---|---|
| 2023 | 0.08% | 0.30× |
| 2024 | 0.06% | 0.23× |
| 2025 | 0.03% | 0.14× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Florida surveyors cite →
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