Based on interview and document review, the facility failed to maintain a Quality Assurance and Performance Improvement (QAPI) Committee which included the required members at their meetings. Specifically, the facility's Infection Preventionist failed to attend three of three QAPI meetings reviewed.Findings include:Review of the facility's policy titled Quality Assurance on (sic) Performance Improvement (QAPI) Program, dated as revised January 2025, indicated but was not limited to:-The facility Administrator is responsible and accountable for developing, leading and closely monitoring our QAPI program.-QAPI activities will be governed and monitored by the Quality Assurance and Assessment (QAA) committee which will include: -The Medical Director, or designee -The Director of Nursing… …
F868 citations in Massachusetts
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
Massachusetts cites F868 more often than its own record predicts
1.17 times the share F868 takes of citations nationally.
Of every deficiency written in Massachusetts 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 Massachusetts surveyors wrote
F868 findings written in Massachusetts, 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 and interview, the facility failed to ensure that the required members were included in the Quality Assessment and Performance Improvement (QAPI) committee quarterly meetings. Specifically, the facility failed to provide evidence that the Medical Director attended two out of the four quarterly QAPI meetings as required. Findings include: Review of the facility document titled Facility QAPI Plan dated 1/16/2019, indicated the following: -Medical Director must attend at least quarterly, preferred monthly. -All attendees present sign in. …
The short window
Recent years
| Year | Share of Massachusetts citations | vs expected |
|---|---|---|
| 2023 | 0.38% | 1.48× |
| 2024 | 0.27% | 1.13× |
| 2025 | 0.27% | 1.17× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Massachusetts surveyors cite →
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