QAPI program failed to address repeated deficiencies. Review of the facility’s visit history showed repeated F689, Free of Accident Hazards/Supervision/Devices, and F880, Infection Prevention and Control, across multiple annual surveys and complaint investigations. The QAPI plan stated it would review sources of information for gaps or patterns in care systems, and the Administrator acknowledged the repeated deficiencies and said the facility would review and discuss plans to improve.
QAPI process failed to address PASRR deficiencies after a prior F644 citation. A resident’s record showed a PASRR completed by a hospital that listed suspected anxiety disorder and use of antidepressant and antianxiety meds, but the resident was later admitted with PTSD and then started on Abilify without an updated PASRR evaluation in the record. The DON confirmed no updated PASRR had been completed since the hospital screening, while the Administrator stated tagged-area audits were to be tracked through QAPI.
The facility failed to maintain a comprehensive, effective QAPI program, as evidenced by repeated deficiencies over multiple surveys in areas including failure to report, protection of resident-identifiable information, infection prevention and control, environmental cleanliness and comfort, and ADL care for dependent residents. Although a written QAPI policy described broad data monitoring and committee review processes, survey history showed that these processes were not effectively implemented to prevent recurrence of the same problems, and leadership acknowledged only recent efforts to change QAPI activities.
The facility failed to show good faith efforts to correct repeat quality issues tied to insufficient nursing staff and ongoing call light concerns. CMS survey results showed repeated deficiency F725, and leadership reported that call light audits were still in progress while staff education on timely call light response continued, with call lights still remaining a concern.
The facility failed to maintain a comprehensive and effective QAPI program with a plan for QAPI and QAA activities. DIAL visit history showed repeat deficiencies from the prior annual survey and the current survey, including F582, F584, F677, F684, and F880. The facility's QAPI policy stated the program is intended to continually assess performance across all service areas and support person-centered care.
The facility was cited for failing to implement an effective QAPI/QAA process to correct ongoing insufficient nursing staff deficiencies. State survey records showed multiple prior surveys over about two years with repeated staffing-related citations, culminating in a fifth Insufficient Nursing Staff deficiency. Although the facility’s QAPI plan identified staff retention as an improvement focus and described a process for identifying issues, leadership reported that no Performance Improvement Plan (PIP) addressing staffing was in place at the time of the survey.
The facility failed to maintain an effective QAPI process to identify and correct a previously cited infection control deficiency. A prior survey had found that staff did not use Enhanced Barrier Precautions during care for at-risk residents, and a later complaint and incident survey again cited the same issue under F880. The Administrator reported that she monitors and audits QAPI effectiveness and confirmed the ongoing concern about the repeated infection control deficiency, with 47 residents in the facility at the time.
The facility was cited for repeatedly failing over several survey cycles to correct known staffing deficiencies despite an active QAPI focus on assuring appropriate staffing. Public state survey records showed multiple surveys over a multi-year period with cited staffing violations while the facility maintained a census of 82 residents. QAPI notes identified staffing as an ongoing action item, and the Administrator acknowledged that leadership had been aware of staffing needs prior to his tenure and that the issue represented a repeat failure, though earlier QAPI documentation was unavailable.
The facility was repeatedly cited for deficiencies related to its QAPI program, including failures to report and investigate incidents, as documented in multiple complaint investigations. Despite having a QAPI/QAA plan in place, the same types of deficiencies recurred over an extended period, indicating that the facility's processes for identifying and correcting quality issues were not effective.
The facility experienced ongoing deficiencies in pressure sore management, professional standards of care, nursing staffing, and infection control, as evidenced by repeated citations over multiple surveys. Despite having a QAPI plan and implementing various tracking and auditing measures, the same issues continued to recur, indicating that the facility's quality assurance processes were not effective in preventing or correcting these problems.
Self-audit
Pick a level of detail and, optionally, what to focus on — then generate a survey-ready checklist distilled from the most recent citations.
Beta · AI-generated — for reference only, not professional advice. Verify against current CMS guidance before relying on it. Assisto accepts no responsibility for how this checklist is used.
Citations used to create this checklist
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Get More From Your Search Results
Create an account to access advanced search filters, save your searches, and get unlimited access to detailed Plan of Corrections.
Create an Account