Based on interview and record review the facility failed to ensure as part of its QAPI program mandatory training that outlined and informed staff of the elements and goals of the facility's QAPI program and informed staff of the elements and goals of the facility's QAPI program for 8 of 14 employees (LVN C, LVN D, DOR, CNA E, CNA F, CNA G, CNA H and CNA K) reviewed for training. The facility failed to ensure quality assurance and performance improvement training was provided to LVN C, LVN D, DOR, CNA E, CNA F, CNA G, CNA H and CNA K. This failure could place residents at risk for not being aware of facility programs, implementation, and monitoring.Findings include: Record review of the personnel file for LVN C indicated she was hired at the facility on 11/12/2025. …
F944
Administration Deficiencies
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Every F944 citation surveyors wrote nationally that year.
Distinct nursing homes with at least one F944 finding.
The harm level
How severely F944 is cited
0.0% of citations found actual harm or worse (level G and above).
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J— | K— | L— |
| Actual harm | G— | H— | I— |
| No harm, potential for more than minimal | D7622.7% | E10230.4% | F10431.0% |
| No harm, potential for minimal | A— | B298.7% | C247.2% |
In the surveyor’s words
What an F944 citation says
One finding from each severity level, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on review of facility policy, facility in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on Quality Assurance and Performance Improvement (QAPI) for one of five staff members (Physical Therapist (PT) Employee E12). Findings include: Review of facility policy Facility Assessment last reviewed 8/4/26, with a previous review date of 1/14/26, indicated compliance with the annual trainings includes post tests to determine competency and designated Managers/ Supervisors monitor attendance. The mandatory training program included QAPI. Review of PT Employee E12's personnel record indicated a hire date of 4/23/18. …
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