Based on interview and review of the facility's Quality Assurance and Performance Improvement (QAPI) Program, the facility failed to present evidence that the required members attended 3 of 5 quarterly committee meetings provided from April 2025 through April 2026. Finding: On 5/28/26, a surveyor reviewed the facility's QAPI program and attendance sheets for the previous year. The attendance sheets lacked evidence that the facility's Medical Director attended quarterly committee meetings held on 10/15/25, 1/14/26, and 4/9/26. On 5/28/26 at 1:45 p.m., in an interview with a surveyor, the Administrator and Director of Nursing confirmed the finding and stated that future meetings have been rescheduled to allow for the Medical Director's attendance. …
F868 citations in Maine
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
Maine cites F868 more often than its own record predicts
2.25 times the share F868 takes of citations nationally.
Of every deficiency written in Maine 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 Maine surveyors wrote
F868 findings written in Maine, 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 record review, facility policy, and interview, the facility failed to ensure required members of the Quality Assessment and Assurance Committee (QAA) participated in Quarterly QAA meetings for 3 of 4 quarterly meetings reviewed. Findings: Review of the facility policy titled Center Quality Assurance Performance Improvement Process revised 3/24/25 indicated the QAA committee meets at least quarterly. The policy indicated the committee is composed of the Administrator, Director of Nursing (DON), Medical Director and the Infection Preventionist (IP). Review of the QAA Committee attendance documentation dated 10/1/25 indicated the DON was not in attendance. …
The short window
Recent years
| Year | Share of Maine citations | vs expected |
|---|---|---|
| 2023 | 0.32% | 1.23× |
| 2024 | 1.18% | 4.85× |
| 2025 | 0.52% | 2.25× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Maine surveyors cite →
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