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F0865
F

Failure to Develop and Present Comprehensive QAPI Plan

Batavia, Illinois Survey Completed on 06-05-2025

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 failed to develop and present a comprehensive QAPI (Quality Assurance Performance Improvement) plan as required. During the survey, the administrator provided a QAPI Policy document dated January 2024, stating it was the facility's QAPI plan. However, upon review, the document did not detail how the QAPI committee would identify and correct quality deficiencies, nor did it reflect specific aspects unique to the facility's population and programs. The policy also lacked information on tracking and measuring performance, establishing goals and thresholds, analyzing root causes of quality concerns, and monitoring or evaluating the effectiveness of corrective actions. This deficiency applied to all 37 residents in the facility at the time of the survey.

See complete original report
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