Based on interview and record review, the facility did not include as part of its QAPI (Quality Assurance and Performance Improvement) program mandatory training that outlines and informs staff of the elements and goals of the facility's QAPI program for 5 of 5 randomly sampled Certified Nursing Assistants (CNA). This had the potential to affect all residents who reside in the facility.CNA J, CNA K, CNA L, CNA M, and CNA N did not receive and have documented mandatory yearly QAPI in-service training. Evidenced by:The Facility Assessment, last reviewed 1/2026, states in part:. Staff Training/Education and Competencies/Recruitment/Retention: 3.4 Staff will be provided with training and education to assure competent care is provided to residents in the facility. …
F944 citations in Wisconsin
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
Wisconsin cites F944 more often than its own record predicts
4.79 times the share F944 takes of citations nationally.
Of every deficiency written in Wisconsin 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 Wisconsin surveyors wrote
F944 findings written in Wisconsin, 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 staff interview and record review, the facility did not ensure staff received required Quality Assurance Performance Improvement (QAPI) training. This practice had the potential to affect all 49 residents residing in the facility. The facility did not provide staff with required annual training on the facility's QAPI program. Findings include: The facility's Quality Assurance Performance Improvement (QAPI) Plan/Program, dated 9/27/19, indicates: AAHealthcare pursues the highest quality of care and services for our residents and customers through a data-driven, proactive approach to improving the quality of life, care, and services at our facility while emphasizing autonomy and resident choice. …
The short window
Recent years
| Year | Share of Wisconsin citations | vs expected |
|---|---|---|
| 2023 | 0.17% | 2.71× |
| 2024 | 0.17% | 1.88× |
| 2025 | 0.44% | 4.79× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Wisconsin surveyors cite →
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