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F0868
F

QAA Committee Lacked Required Member Participation

Henderson, Nebraska Survey Completed on 10-23-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility administrator failed to ensure that the Quality Assessment and Assurance (QAA) committee included all required members and that these members attended the quarterly meetings as mandated. Record review showed that the facility's Medical Director did not participate in any of the quarterly QAA meetings for the past four quarters. Additionally, on one occasion, both the Director of Nursing (DON) and the Administrator were absent from a quarterly QAA meeting. These findings were confirmed through interviews with the Assistant Administrator and the Administrator, who acknowledged the lack of documentation and attendance by the required committee members. The facility census at the time of the survey was 37 residents. There is no mention of specific residents or their medical conditions being directly affected in the report.

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