Based on interview and document review, the facility failed to ensure the medical director (MD-A) attended QAPI meetings for 4 of 4 quarters. Findings include: Review of the QAPI meeting minutes submitted for the months of June, August, Sept and [DATE], and Jan and April 2026, identified the facilities quarters were Quarter 1: July-Sept, Quarter 2: Oct-Dec, Quarter 3: Jan-March, and Quarter 4: April-June. Of the months submitted, in:June 2025: MD-A is listed on the attendance sheet, but he had not signed off as having attended the meeting.The remaining months of August, September and October 2025, and January and April 2026, MD-A's name was not on sign in sheet and there was no evidence to support he attended at least quarterly as required. …
F868 citations in Minnesota
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
Minnesota cites F868 more often than its own record predicts
1.51 times the share F868 takes of citations nationally.
Of every deficiency written in Minnesota 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 Minnesota surveyors wrote
F868 findings written in Minnesota, 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 document review and interview, the facility failed to demonstrate routine attendance and participation in the QA/QAPI process for 1 of 1 medical director (MD) required to be in attendance quarterly at Quality Assurance Performance Improvement (QAPI) meetings. Findings include: Review of the 9/10/21, Quality Assurance and Performance Improvement (QAPI) Plan Sacred Heart Care Center, Inc. identified the QAPI committee members required to be present consisted of the administrator, the Director of Nursing (DON), the Consultant Pharmacist, the Medical Director, the Infection Preventionist (IP), Director of Social Services, Environmental Services Director, Dietary Manager, Activity Director, Financial Managers, Clinical managers, Quality Assurance Coordinator, and other staff when… …
The short window
Recent years
| Year | Share of Minnesota citations | vs expected |
|---|---|---|
| 2023 | 0.26% | 1.01× |
| 2024 | 0.16% | 0.65× |
| 2025 | 0.35% | 1.51× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Minnesota surveyors cite →
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