Based on record review and staff and Nurse Practitioner interviews, the facility Quality Assurance and Performance Improvement (QAPI) committee failed to meet at least quarterly to fulfill the responsibilities of the committee to identify and correct deficient practices in the facility effectively for 2 quarters and failed to have the Medical Director attend the meeting for 1 quarter. This deficient practice was observed for 3 of 3 quarters reviewed and had the potential to impact all facility residents. …
F868 citations in North Carolina
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
North Carolina cites F868 less often than its own record predicts
0.21 times the national share — cited less often here than elsewhere.
Of every deficiency written in North Carolina 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 North Carolina surveyors wrote
F868 findings written in North Carolina, 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 record review and staff interviews, the facility failed to have the Infection Preventionist in attendance for 1 of 6 quality assessment and assurance (QAA) committee meetings. This could affect 110 of 110 residents. The findings include: A review of the facility Monthly Meeting Agenda & Calendar QAA sign in sheets from January through July 2024 revealed the Infection Preventionist (IP) was not present for the meeting held on 6/28/24. On 8/1/24 at 2:02 PM, the IP verified that she was not present for the 6/28/24 meeting due to illness. During an interview on 8/1/24 at 1:10 PM, the Administrator revealed that the IP might not have been in the facility or forgot to sign the Monthly Meeting Agenda & Calendar sign in sheet. …
The short window
Recent years
| Year | Share of North Carolina citations | vs expected |
|---|---|---|
| 2023 | 0.05% | 0.19× |
| 2024 | 0.04% | 0.16× |
| 2025 | 0.05% | 0.21× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else North Carolina surveyors cite →
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