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.
A medication error deficiency was cited again at the current survey after the same concern had already been identified in prior complaint surveys. The facility’s QAPI policy described a process for tracking performance, identifying quality deficiencies, and analyzing causes, and the DON stated medication errors had been discussed in QAPI meetings, but also acknowledged repeat concerns with medication errors remained.
QAPI process failed to prevent repeated F760 citations for significant medication errors. Prior surveys found one resident received 6 medications not prescribed and was hospitalized overnight for observation, and later two residents had significant med errors, including one receiving 5 non-prescribed meds and another continuing to receive a discontinued med. The Administrator stated the facility completed prior POCs and audits, and the DON worked the floor, but no cause for concern was found.
QAPI Program Failed to Address Repeat F689 Deficiency: The facility failed to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program to address and prevent recurrence of a repeat F689 deficiency involving free of accident hazards and adequate supervision/assistive devices. The Administrator said QAPI meetings were held monthly and the Medical Director attended quarterly, and the DON said the facility reviewed resident falls and prior mechanical lift incidents and provided CNA education on checking sling loops during full-body mechanical lift transfers.
Failure to implement effective QAPI activities was identified after review of CASPER, the facility QAPI plan, and staff interviews showed repeat citations in infection control and pharmacy services. The facility had repeated F761 and F880 deficiencies, and the Administrator stated staff education, peri care audits, and one-on-one education were being provided for infection control issues. The QAPI plan stated it was comprehensive and ongoing and based performance improvement projects on CMS data, resident and family surveys, councils, annual surveys, and colleague feedback.
Repeated QAPI deficiencies remained unresolved across 5 of 9 areas of concern identified in prior surveys, including abuse reporting, comprehensive care planning, professional standards of care, accident hazards/supervision/devices, and the QAPI program/plan disclosure/good faith attempt. The QAPI report described resident-centered care goals and system-focused monitoring, and the Administrator acknowledged the repeat concerns were not fully resolved and that more work remained in QAPI.
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