Based on record review and interview, the facility failed to ensure the required staff were present at the monthly Quality Assessment and Assurance (QAA) and Quality Assurance and Performance Improvement (QAPI) meetings related to the Infection Preventionist and Medical Director, or designee, and Director of Nursing not being present. This had the potential to affect all residents in the facility.Finding includes:During an interview on 2/17/26 at 11:31 A.M., the Administrator indicated the QAA/QAPI committee met monthly. Monthly attendance records of meetings were requested. …
F868 citations in Indiana
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
Indiana cites F868 less often than its own record predicts
0.12 times the national share — cited less often here than elsewhere.
Of every deficiency written in Indiana 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 Indiana surveyors wrote
F868 findings written in Indiana, 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 Indiana citations | vs expected |
|---|---|---|
| 2024 | 0.03% | 0.11× |
| 2025 | 0.03% | 0.12× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Indiana surveyors cite →
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction