Ineffective QAPI Process With Repeat Deficiencies: The facility failed to maintain an effective QAPI process to address repeated deficiencies cited on prior recertification and complaint surveys, including repeat F760 and F880 citations. The Administrator reported daily QA meetings and monthly QAPI committee meetings, with infection control identified as a focus area and staff education, PPE competency checks, and audits already in place, but the repeat citations showed the facility had not achieved substantial compliance.
The facility failed to show good faith efforts to correct repeat quality deficiencies during the survey process. The CMS 2567 showed a prior F725 for insufficient nursing staff, and the ADON reported ongoing call light audits and on-the-spot education when staff were observed sitting at the nurse’s station while active call lights were present. The QAPI policy required the committee to analyze data, identify and resolve quality problems, use root cause analysis, and help implement systems to correct issues.
Failed QAPI Program and Repeated Deficiencies: The facility failed to maintain an effective QAPI program and had repeated deficient practices across multiple areas, including resident rights, reporting and investigating allegations, care planning, ADL care, quality of care, pressure ulcer prevention, staffing, pharmacy services, unnecessary drugs, nutrition, records confidentiality, and infection prevention and control. The Administrator stated QAPI meetings had occurred without his involvement and noted the facility had PIPs in place and planned additional plans due to repeat deficiencies.
Repeat deficiencies were identified in F812, F880, F725, and F684 after review of the State Agency Website, Federal Provider History Report, QAPI, staff interview, and policy review. The facility had prior citations in each category across multiple surveys, and the Administrator acknowledged the repeated issues and attributed them to staff turnover.
Ineffective QAPI Program With Re-cited Deficiencies: The facility failed to ensure an effective QAPI program to address previously cited deficiencies, and five deficiencies were re-cited on the recertification survey, including F641, F684, F689, F812, and F880. The Administrator stated the facility had worked on the prior deficiencies in QAPI, but they remained ongoing and had been tracked for years. The QAPI policy assigned the Administrator and QAPI Committee responsibility for identifying priorities, using resident and staff input, and analyzing QAPI performance.
The facility failed to complete QAA activities to gather feedback, use data, and conduct structured analysis of problems affecting quality of care, quality of life, and resident safety. Review of QAPI meeting documentation, policy, and staff interview showed no documentation of QA activities focused on restorative services and staffing, despite the QAPI/QAA plan stating that survey findings and other data would be used for systematic action and analysis. Prior CMS and current survey findings identified related concerns.
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 processes were not effective in addressing repeated deficiencies cited under F658, F725, and F880. CASPER reports showed F658 had been cited in multiple prior years, and F725 and F880 had been cited in 2025, yet the same deficient practices were identified again on the current survey. The QAPI plan described monitoring through CASPER reports, audits, grievances, and survey results, and the Administrator said issues were brought to the QA Committee from audits and grievance forms, with the Committee choosing topics based on need, urgency, and requirements.
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.
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