Based on interview 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 other members of the facility's staff, at least one of who must be the Administrator, owner, or board member or other individual in a leadership role, and the infection preventionist for 4 of 4 quarterly meetings (09/12/25, 12/11/25, 03/12/26, and 06/11/26) reviewed for Quality Assessment Assurance committee. The facility did not ensure the Administrator attended Quality Assurance and Performance Improvement meetings on 09/12/25, 12/11/25, 03/12/26, and 06/11/26. …
F868 citations in Texas
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
Texas cites F868 less often than its own record predicts
0.14 times the national share — cited less often here than elsewhere.
Of every deficiency written in Texas 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 Texas surveyors wrote
F868 findings written in Texas, 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 a quality assessment and assurance committee consisting at a minimum the required committee members for three (October 2025, November 2025 and December 2025 of four meetings reviewed for QAPI.1. The facility did not ensure the Infection Preventionist attended the December 2025 meeting.2. The facility did not ensure meeting occurred monthly as per their policy and did not conduct meetings for January 2026 and February 2026.These failures could place residents at risk for quality deficiencies being unidentified, infections, no appropriate plans of action developed and implemented, and no appropriate guidance developed.Findings include:Record Review of the facility's QAPI Committee sign in sheets indicated the Infection… …
The short window
Recent years
| Year | Share of Texas citations | vs expected |
|---|---|---|
| 2023 | 0.22% | 0.87× |
| 2024 | 0.06% | 0.24× |
| 2025 | 0.03% | 0.14× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Texas surveyors cite →
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