Based on interview and record review the facility failed to ensure the required Quality Assessment and Assurance (QAA) committee members attended the facility's QAA meetings. This failure has the potential to affect all 58 residents in the facility.The findings include:The facility's Long-Term Care Facility Application for Medicare and Medicaid form dated 7/13/26 showed a resident census of 58. The facility's QAA meeting member sign-in sheets dated July 2025-June 2026 were reviewed. The sheets dated 7/23/25, 8/29/25, 9/30/25,11/24/25, and 2/24/26 showed the facility's Medical Director did not attend the meetings, in house or via phone. The sheets dated 9/30/25, 11/24/25, 2/24/26, and 5/26/26 showed the facility's Infection Preventionist did not attend the meetings. …
F868 citations in Illinois
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
Illinois cites F868 less often than its own record predicts
0.78 times the national share — cited less often here than elsewhere.
Of every deficiency written in Illinois 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 Illinois surveyors wrote
F868 findings written in Illinois, 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 interview and record review, the facility failed to ensure that the medical director participated in the facility's QAA/QAPI programming. This failure has the potential to affect all 158 residents that reside within the facility. Facility census documents an active census of 158 residents. Facility QAA committee meeting sign-in sheets (4/30/2025, 7/17/2025) do not document any signature from the facility's medical director affirming the medical director's attendance. On 7/30/2025 at 10:04 AM, QAA meeting minutes were reviewed with V1 (Administrator) and V1 affirmed that the facility's medical director was not at the QAA meetings. V1 affirmed that the medical director is required to be at the QAA meetings. …
The short window
Recent years
| Year | Share of Illinois citations | vs expected |
|---|---|---|
| 2023 | 0.31% | 1.20× |
| 2024 | 0.42% | 1.72× |
| 2025 | 0.18% | 0.78× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Illinois surveyors cite →
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