Based on interview and record review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) program committee met at least quarterly with the required members present. This had the potential to affect all residents by limiting the facility's ability to identify and address quality of care and safety concerns. The facility's census was 67. Review of the facility's policy titled, Quality Assessment and Assurance (QAA), reviewed 01/26/26, showed:- This facility is committed to ensuring high-quality care and continuous improvement in resident outcomes through a structured QAA program. …
F868 citations in Missouri
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
Missouri cites F868 more often than its own record predicts
2.29 times the share F868 takes of citations nationally.
Of every deficiency written in Missouri 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 Missouri surveyors wrote
F868 findings written in Missouri, 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 maintain quarterly Quality Assessment and Assurance/Quality Assurance and Improvement Program (QAA/QAPI - a written plan containing the process that will guide the facility's efforts in assuring care and services are maintained at acceptable levels of performance and continually improved) committee meetings with the required members. The facility census was 55. Review of the facility's policy titled, Quality Assurance and Performance Improvement Program, dated April 2014, showed: - The facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that builds on the Quality Assessment and Assurance Program to actively pursue quality of care and quality of life goals; - Establishing a QAPI… …
The short window
Recent years
| Year | Share of Missouri citations | vs expected |
|---|---|---|
| 2023 | 0.61% | 2.37× |
| 2024 | 0.43% | 1.77× |
| 2025 | 0.53% | 2.29× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Missouri surveyors cite →
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