F868 in Utah. Pick another state for the same tag.
Against expectation — 2025
Utah cites F868 less often than its own record predicts
Versus expected share0.96×
0.96 times the national share — cited less often here than elsewhere.
Share of Utah citations0.22%
Of every deficiency written in Utah in 2025, this is the portion that was F868.
Utah0.22%
National0.23%
Share of all citations that were F868.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Utah surveyors wrote
F868 findings written in Utah, 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.
H · Actual harm, patternOctober 31, 2022
Based on interview, record review, and interview, the facility did not maintain a quality assessment and assurance committee consisting of the Director of Nursing, Medical Director, and and least three other members of the facility's staff. In addition the committee did not meet quarterly.
Findings include:
On 10/11/22 the sign in sheets for the last 12 months of the Quality Assurance (QA) meetings were requested verbally to the Administrator (ADM).
On 10/12/22 at 9:50 AM, the sign in sheets for the last 12 months of the QA meetings were requested from the ADM via email.
On 10/24/22 at 6:08 PM, an interview was conducted with the facility ADM. …
F · No harm, potential for more than minimal, widespreadJune 28, 2025
Based on interview, document review, and facility policy review, the facility failed to ensure quarterly quality assurance performance improvement (QAPI) meetings were conducted and the facility maintained a list of staff who were present/participated in the quarterly QAPI meetings. These deficient practices had the potential to affect all residents who resided in the facility.A facility policy titled, QAPI Program, with a copyright date of 2024, indicated, [Facility name] QAPI team shall meet at least quarterly to review all Quality Assurance Performance Improvement items.During an interview on 06/28/2025 at 11:50 AM, the Administrator the facility was recently purchased from another company, so the current administrative team had only had one QAPI meeting, which was in 03/2025. …
C · No harm, potential for minimal, widespreadJune 17, 2021
Based on interview and record review it was determined the facility did not maintain a quality assessment and assurance (QAA) committee consisting at a minimum of the director of nursing services, the Medical Director or his/her designee and at least three other members of the facility's staff. Specifically, the Medical Director (MD) did not attend quarterly QAA meetings.
Findings include:
On 6/17/21 at 12:03 PM, the QAA notes from June 2020 to June 2021 were reviewed. Attendance and note sheets indicated the MD did not attend QAA meetings, at least quarterly. Those in attendance included;
1. the Administrator
2. the Director of Nursing (DON)
3. the Minimum Data Set (MDS) coordinator, who acts as the Infection Preventionist
4. …
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