Based on record review, policy review, and interview, the facility failed to ensure its Quality Assessment and Assurance (QAA) Committee met at least quarterly for two (2) of four (4) quarters reviewed.Findings include:Review of facility policy titled Quality Assurance and Performance Improvement (QAPI) - Role of the QAPI Coordinator undated revealed, Duties and responsibilities to the QAPI Program includes.2. Meeting with the QAPI Committee monthly to review assessment tools, data reports, and QAPI activities carried out by departments, services, or committees.Review of facility's Quality Assurance and Performance Improvement (QAPI) Meeting Signature Pages revealed a meeting was held on 1/20/2026 and 6/19/2026.During an interview on 7/30/2026 at 2:00 PM, the Administrator confirmed the… …
F868 citations in Mississippi
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
Mississippi cites F868 less often than its own record predicts
0.83 times the national share — cited less often here than elsewhere.
Of every deficiency written in Mississippi 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 Mississippi surveyors wrote
F868 findings written in Mississippi, 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 facility policy review, record review, and staff interview, the facility failed to conduct the required Quarterly Quality Assessment and Assurance (QAA) meetings for two (2) of the four (4) quarters in (YEAR) that were reviewed, the 3rd and 4th Quarters. Findings include: Review of an untitled typed document on the facility's letterhead, provided, signed, and dated 05/30/19, by the facility's Administrator,revealed the Quality Assurance and Performance Improvement (QAPI) plan reviews, and the Quality Assessment and Assurance (QAA) are one in the same at the facility. The facility document also stated the facility follows the QAPI process for Quality Assessment(s) and Assurance(s). …
The short window
Recent years
| Year | Share of Mississippi citations | vs expected |
|---|---|---|
| 2024 | 0.10% | 0.41× |
| 2025 | 0.19% | 0.83× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Mississippi surveyors cite →
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