Based on interviews and record review, the facility failed to maintain a Quality Assessment and Assurance Committee consisting at a minimum of the Director of Nursing Services, the Medical Director or his/her designee, at least three (3) other members of the facility's staff, one (1) of who must be an individual in a leadership role, and the Infection Preventionist. Specifically, the facility could not provide documented evidence that the Infection Preventionist attended the Quality Assurance and Performance Improvement meetings on a regular basis (quarterly).The findings include:The facility's Quality Assurance and Performance Improvement Program policy revised April 2014, included the primary purpose of the Quality Assurance and Performance Improvement Program was to establish… …
F868 citations in New York
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
New York cites F868 more often than its own record predicts
2.06 times the share F868 takes of citations nationally.
Of every deficiency written in New York 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 New York surveyors wrote
F868 findings written in New York, 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 record review and interviews during the Recertification Survey initiated on 12/22/2025 and completed on 12/24/2025, the facility did not ensure it maintained a quality assessment and assurance committee that included the Infection Preventionist (IP) as a member of the committee. Specifically, the Infection Preventionist did not participate and report on the Infection Prevention and Control Program (IPCP) and on incidents (for example health care associated infections) regularly to the Quality Assurance & Performance Improvement committee meetings that were held from 03/31/2025 through 09/11/2025.The finding is:The facility's policy titled Quality Management/Performance Improvement dated 09/2025 documented that all staff participates in the performance improvement process. …
The short window
Recent years
| Year | Share of New York citations | vs expected |
|---|---|---|
| 2023 | 0.10% | 0.41× |
| 2024 | 0.04% | 0.14× |
| 2025 | 0.48% | 2.06× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else New York surveyors cite →
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