Based on review of 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 (Registered Nurse (RN) Employee E22).Findings include: Review of RN Employee E22's personnel file indicated a date of hire on 7/1/23. Review of RN Employee E22's personnel file did not include annual in-service training on QAPI from 1/1/25 through 12/31/25. During an interview on 8/5/26, at 2:17 p.m. Assistant Director of Nursing Employee E10 confirmed that the facility failed to provide training on QAPI for one of five staff members (RN Employee E22). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.20(a) Staff development.
F944 citations in Pennsylvania
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 — 2025
Pennsylvania cites F944 more often than its own record predicts
3.97 times the share F944 takes of citations nationally.
Of every deficiency written in Pennsylvania in 2025, 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 Pennsylvania surveyors wrote
F944 findings written in Pennsylvania, 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 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. …
The short window
Recent years
| Year | Share of Pennsylvania citations | vs expected |
|---|---|---|
| 2023 | 0.16% | 2.57× |
| 2024 | 0.26% | 2.81× |
| 2025 | 0.36% | 3.97× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Pennsylvania surveyors cite →
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