Based on record review and staff interview the facility failed to assure they had provided training for all their staff on the facility's QAPI (Quality Assurance Performance Improvement) program. The findings included: During a review of facility records on 12/8/23, there was no documentation that the facility had incorporated training for all their staff on the facility's QAPI. The Administrator was interviewed on 12/8/23 at 5:30 PM and reported the following. She began her employment as facility Administrator in June 2023. She had been working on the facility's quality improvement program since she began as the Administrator and tried to include her line staff in the quality improvement program, but she had not educated or included 100% of her staff. …
F944 citations in North Carolina
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.
Against expectation — 2023
North Carolina cites F944 more often than its own record predicts
1.56 times the share F944 takes of citations nationally.
Of every deficiency written in North Carolina in 2023, this is the portion that was F944.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What North Carolina surveyors wrote
F944 findings written in North Carolina, 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.
What else North Carolina surveyors cite →
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