Based on policy review and staff interview, it was determined the facility failed to meet the minimum member requirement of a quality assurance and performance improvement (QAPI) committee. This failure placed all residents at risk of not receiving quality care. Findings include: On 7/11/24 at 3:42 PM, the QAPI monthly meeting minutes for the prior six months were reviewed and noted the Medical Director had not attended the QAPI meetings. On 7/11/24 at 3:45 PM, the DON stated the Medical Director had not attended the QAPI committee meetings and she was not aware he needed to be at the meetings.
F868 citations in Idaho
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
Idaho cites F868 more often than its own record predicts
1.69 times the share F868 takes of citations nationally.
Of every deficiency written in Idaho 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 Idaho surveyors wrote
F868 findings written in Idaho, 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.
The short window
Recent years
| Year | Share of Idaho citations | vs expected |
|---|---|---|
| 2023 | 0.48% | 1.86× |
| 2024 | 0.41% | 1.69× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Idaho surveyors cite →
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