Based on observation, interview, record review, review of the facility's policy and procedures, review of Statements of Deficiencies (SOD) issued to the facility on [DATE] and [DATE], and review of Allegations of Compliance (A[NAME]) submitted by the facility on [DATE] and [DATE], it was determined the facility failed to ensure the Quality Assurance Committee identified quality deficiencies and implemented actions to correct quality deficiencies. Immediate Jeopardy was identified and SODs were issued on [DATE] and [DATE] related to the following: failure to administer medications based on residents' Medication Administration Records (MARs)/Physician orders; failure to ensure sufficient staffing to meet residents' needs; failure to supervise residents to prevent accidents; and failure to… …
F868 citations in Kentucky
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
Kentucky cites F868 less often than its own record predicts
0.61 times the national share — cited less often here than elsewhere.
Of every deficiency written in Kentucky 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 Kentucky surveyors wrote
F868 findings written in Kentucky, 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, record review, and review of the facility's policy, the facility failed to meet at least quarterly and have the required attendees present. The findings include: Review of the facility's policy titled, QAPI [Quality Assurance Performance Improvement] Plan Standard of Practice, revised 04/2025, revealed the facility was to conduct ongoing quality reviews and monitor action plans monthly to evaluate effectiveness and identify the need for revision. Further review revealed that the QAPI committee, at a minimum, consisted of the Medical Director or designee, Director of Nursing (DON), Infection Preventionist (IP), and at least three additional staff members, including the Administrator.Review of the facility's QAPI meeting minutes, dated 05/15/2025, revealed the Medical… …
What else Kentucky surveyors cite →
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