Based on interview and record review the facility failed to include the Administrator or designee in the Quality Assessment and Assurance Process. Total sample size 39. Findings:Review of the facility's policy titled Quality Assurance Performance Improvement (QAPI) Program-Governance and Leadership, with a revision date of 03/2020 revealed in part. Policy Interpretation and Implementation:(6) The following individuals serve on the committee:Administrator, or designee who is in a leadership role.Director of Nursing Services;Medical Director;Infection PreventionistInterview and record review on 08/05/2026 at 1:45 p.m. with S8 Admin/RN revealed the facility's Administrator or designee had not been included on the Quality Assessment and Assurance Process Sign-in-sheets for 04/2026. …
F868 citations in Louisiana
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
Louisiana cites F868 more often than its own record predicts
2.85 times the share F868 takes of citations nationally.
Of every deficiency written in Louisiana 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 Louisiana surveyors wrote
F868 findings written in Louisiana, 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 Louisiana citations | vs expected |
|---|---|---|
| 2023 | 0.73% | 2.86× |
| 2024 | 0.51% | 2.08× |
| 2025 | 0.66% | 2.85× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Louisiana surveyors cite →
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