Based on interview and record review, the facility failed to ensure the Medical Director or a designated representative attended the Quality Assessment and Assurance (QAA) / Quality Assessment Performance Improvement (QAPI) committee meetings at least quarterly. This deficient practice had the potential to affect all 57 residents residing in the facility. Findings include:A review of the facility's QAPI/QAA committee meeting attendance records on 7/22/26 revealed that the facility Medical Director or an approved clinical designee had not signed or been documented as in attendance at any QAPI committee meeting since 3/10/26, creating a gap in mandatory quarterly attendance.During an interview on 7/23/26 at 11:12 AM, the Nursing Home Administrator (NHA) and Registered Nurse (RN) P confirmed… …
F868 citations in Michigan
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
Michigan cites F868 more often than its own record predicts
1.26 times the share F868 takes of citations nationally.
Of every deficiency written in Michigan 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 Michigan surveyors wrote
F868 findings written in Michigan, 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 and record review, the facility failed to ensure required members of the Quality Assurance and Performance Improvement (QAPI) committee met at least quarterly, resulting in the potential for decreased quality of care for all 87 residents living in the facility. Findings include: Review of the QAPI committee meeting attendance logs with the Director of Nursing (DON) on 10/30/24 at 1:46 PM revealed meetings were held on 1/10/24, 3/13/24, 5/8/24, 7/10/24, and 9/11/24. …
The short window
Recent years
| Year | Share of Michigan citations | vs expected |
|---|---|---|
| 2023 | 0.15% | 0.58× |
| 2024 | 0.47% | 1.93× |
| 2025 | 0.29% | 1.26× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Michigan 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