Based on interview and document review, the facility failed to ensure the Chief of Staff/Medical Director (MD) attended the Quality Assurance and Performance Improvement (QAPI) committee meetings between 06/05/2025 and 04/14/2026. This deficient practice had the potential to limit the ability of the MD to be informed of and inform the QAPI committee of identified concerns within the facility. Findings include:The facility provided QAPI Committee sign-in sheets for the following dates:-03/19/2025.-06/05/2025.-08/13/2025. The QAPI Committee sign-in sheet lacked documented evidence the MD attended and participated as a committee member.-09/17/2025. The QAPI Committee sign-in sheet lacked documented evidence the MD attended and participated as a committee member.-11/19/2025. …
F868 citations in Nevada
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
Nevada cites F868 more often than its own record predicts
2.12 times the share F868 takes of citations nationally.
Of every deficiency written in Nevada 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 Nevada surveyors wrote
F868 findings written in Nevada, 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.
The short window
Recent years
| Year | Share of Nevada citations | vs expected |
|---|---|---|
| 2023 | 0.19% | 0.72× |
| 2024 | 0.38% | 1.57× |
| 2025 | 0.49% | 2.12× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Nevada 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