Based on interview and record review, the facility failed to ensure the Quality Assessment and Assurance (QAA) committee met at least quarterly and evaluated activities under the Quality Assurance Performance Improvement (QAPI) program, including identifying issues related to QAA activities and implementing performance improvement projects (PIP) as required. In addition, the facility's QAA committee failed to include the administrator, owner, board member or designee.This failure had the potential to result in failure to identify and correct systemic problems, such as supply shortages, leading to unresolved issues that negatively impact the quality of care and services provided to residents.Findings:On 08/22/25 at 03:01 PM, an interview and concurrent review of the facility's QAA and QAPI… …
F868 citations in Guam
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
Guam cites F868 more often than its own record predicts
23.99 times the share F868 takes of citations nationally.
Of every deficiency written in Guam 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 Guam surveyors wrote
F868 findings written in Guam, 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 Guam surveyors cite →
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