Based on record review and interview, the facility did not maintain a quality assessment and assurance committee consisting of the required members to identify issues through the committee. This deficient practice has the potential to affect all 49 residents currently in the facility.The IPC (Infection Prevention and Control nurse) did not attend Quality Assurance Performance Improvement (QAPI) meetings on 2 out of 4 quarterly meetings.This is evidenced by:The facility's policy Quality Assurance/Assessment and Performance Improvement Plan, undated, includes: The Quality Assessment and Assurance (QAA) Committee consist of the Director of Nursing Services, the Medical Director, the Administrator, at least two other members of the facility staff, and the infection control and prevention… …
F868 citations in Wisconsin
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
Wisconsin cites F868 less often than its own record predicts
0.79 times the national share — cited less often here than elsewhere.
Of every deficiency written in Wisconsin 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 Wisconsin surveyors wrote
F868 findings written in Wisconsin, 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 staff interview and record review, the facility did not ensure the minimum required members of the facility's Quality Assessment and Assurance (QAA) committee met at least quarterly. This practice had the potential to affect all 31 residents residing in the facility. The facility did not have documentation that the minimum required members of the QAA committee met for quality assessment and assurance purposes on a quarterly basis. Findings include: On 5/29/25 at 8:56 AM, Surveyor reviewed the facility's QAA committee meeting sign-in sheets for the last four quarters and noted the QAA committee met on 7/19/24, 10/18/24, 1/17/25, and 4/18/25. Surveyor noted the minimum required committee members were not in attendance for two of the QAA meetings (7/19/24 and 4/18/25). …
The short window
Recent years
| Year | Share of Wisconsin citations | vs expected |
|---|---|---|
| 2023 | 0.17% | 0.65× |
| 2024 | 0.24% | 1.00× |
| 2025 | 0.18% | 0.79× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Wisconsin surveyors cite →
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