The facility failed to develop and implement a PIP for staffing concerns after those issues were identified in QAPI. The DON stated staffing had been discussed, but no current staffing PIP existed, and later said a PIP was not started because the owner said there was no staffing issue. The Administrator reported short staffing for about a month, with call outs and no shows worsening after delayed paychecks, and staff said staffing concerns were discussed in QAPI along with efforts to find solutions and hire CNAs and nurses.
QAA committee failed to show an effective plan of action was implemented to correct repeated deficiencies involving F695 respiratory/tracheostomy care and suctioning and F761 label/store drugs & biologicals. Survey history showed the facility previously failed to administer oxygen as ordered for one resident and failed to properly store medications for four residents. The QAPI committee met monthly with the Administrator, DON, Medical Director, and other department heads, and the Administrator stated QAPI is used to identify and implement interventions to improve resident care and safety, but the record did not show an effective corrective plan for the repeated problem areas.
A facility's QAPI program failed to identify repeated non-compliance with IV catheter care, despite prior CMS enforcement for F694 Parenteral/IV Fluids and the same deficiency recurring on the current recertification survey. The ADM could not provide evidence of a PIP or current audits for parenteral/IV fluids and could not explain the repeat IV concerns, while the facility's QAPI plan was intended to be a data-driven, facility-wide program with goals including no previously cited tags in the past 3 years.
The facility failed to ensure its QAPI process fully monitored and revised a PIP addressing narcotic accountability and diversion prevention after repeated narcotic-related incidents. A resident had a narcotic count discrepancy, and later another resident had a Dilaudid documentation issue where the MAR did not match the narcotic record and the dose was inconsistent with the order. Surveyors also found missing signatures on key exchange logs, incomplete narcotic count documentation, and delayed narcotic removal documentation by an LPN.
Repeated F761 deficiency was cited after surveyors observed an expired emergency kit and a thermometer reading 52 degrees Fahrenheit in medication rooms. The facility had previously been cited for improper medication storage, and the DON/QA stated the QAPI committee meets monthly and reviewed pharmacy reports, while a PIP was started on medication storage, expiration dates, and the emergency narcotic kit.
Surveyors found that the facility’s QAPI/QAA program was ineffective in correcting repeated deficiencies related to improper medication storage (F0761). Despite having a written QAPI policy, holding monthly QAA Committee meetings attended by the administrator, DON, medical director, and other department heads, and reporting that direct care staff were invited to participate, the same medication storage deficiency previously cited during an earlier survey recurred. With 94 residents in care, the facility’s QAPI activities did not produce an effective plan of action to resolve and prevent the ongoing medication storage problem.
QAPI Failure Related to Resident Smoking Material Supervision: A resident with dementia, schizophrenia, severe cognitive impairment, and continuous O2 was observed with cigarettes and a lighter in a plastic bag while on the smoking patio. Records showed the resident was supposed to have smoking materials stored by staff, and the Medical Director stated residents were not allowed to keep cigarettes or lighters. The FA stated smoking concerns had been identified earlier, but they were never brought to QAPI and no PIP was in place.
QAPI/QAA activities failed to show an effective plan of action to correct repeated deficiencies for F689 and F867. Survey history showed the facility had been cited previously for these tags, and QAA committee records showed monthly meetings with the Administrator, DON, Medical Director, and other department heads. The facility's QAPI policy stated the committee was to review quality indicators, incident reports, cited deficiencies, and grievances and develop plans of action to correct identified quality deficiencies.
Repeated F880 infection prevention and control deficiency was identified when staff failed to store respiratory equipment in a plastic bag after use for a resident. The facility had previously been cited for the same deficiency, and the Administrator reported that monthly QAPI meetings reviewed multiple data sources, including survey results, infection control data, complaints, and utilization trends.
QAPI failed to identify and address a breakdown in diabetes care for a resident with type II DM after the hospital stopped oral meds and started insulin, but the admitting nurse did not enter the order and the resident went without diabetic monitoring or treatment. The resident was later found with severe hypoxia and an unreadable BG, was sent to the hospital, and was admitted to the ICU with BG 945 mg/dl, sepsis, and HHS. The DON, NHA, and MD confirmed there was no formal PIP or QAPI review until the issue was raised during survey.
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