Based on record review and interview, the facility failed to develop and implement a comprehensive, written Quality Assurance and Performance Improvement (QAPI) plan, failed to include documentation demonstrating the evaluation of the effectiveness of corrective actions or performance improvement activities, and failed to document a process/protocol for conducting systematic Root Cause Analyses (RCA). These failures have the potential to affect all 50 residents residing in the facility.On July 8, 2026, at 1:00 PM, review of the facility's QAPI Plan-Aperion Care Burbank dated Reviewed 1-5-26 QAPI Plan lacks explicit sections for evaluation of the effectiveness of corrective actions or performance improvement activities and systematic root cause analysis. …
F865 citations in Illinois
QAPI program · Administration Deficiencies
Have a plan that describes the process for conducting QAPI and QAA activities.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Illinois cites F865 less often than its own record predicts
0.13 times the national share — cited less often here than elsewhere.
Of every deficiency written in Illinois in 2025, this is the portion that was F865.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Illinois surveyors wrote
F865 findings written in Illinois, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on interview, and record review the facility failed to follow Quality Assurance / Performance Improvement Program (QAPI) policy and procedure by not establishing any QAPI programs to address care and services for the year 2022. These failures can affect all 133 residents in receiving well planned care and services in facility. Findings include: On 04/13/2023 at 01:41 PM. V1 (Administrator) said, I only have project or program for March 16, 2023, because for the year 2022 there were no projects done. I think they just met in groups but did not utilize QAPI for making any project to identified problems. I understand that what is needed is that facility using QAPI as a tool to help care and services in facility. …
The short window
Recent years
| Year | Share of Illinois citations | vs expected |
|---|---|---|
| 2023 | 0.11% | 0.65× |
| 2024 | 0.08% | 0.44× |
| 2025 | 0.03% | 0.13× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Illinois surveyors cite →
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