Based on facility policy review and interview, the facility failed to provide evidence of meaningful participation by the Medical Director and facility staff in the Quality Assurance and Performance Improvement (QAPI) program. The findings include: Review of the undated facility policy titled, .Preamble for 2019 QAPI Plan for [Named Facility], revealed .Our organization encourages the input of all staff in all departments to address areas and ways in which we can improve the care we provide.Our organization makes decisions based on data, which includes the input and experience of caregivers, residents, health care professionals, and families.We achieve our goals in providing quality care for each Resident as an individual by determining appropriate care with an interdisciplinary team. …
F868 citations in Tennessee
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 — 2023
Tennessee cites F868 less often than its own record predicts
0.64 times the national share — cited less often here than elsewhere.
Of every deficiency written in Tennessee in 2023, 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 Tennessee surveyors wrote
F868 findings written in Tennessee, 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.
What else Tennessee surveyors cite →
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