Repeat Deficiencies Due to Inadequate QAPI Monitoring and Oversight
Penalty
Summary
The facility failed to implement its Quality Assurance and Performance Improvement (QAPI) policies to ensure thorough monitoring and tracking of previously identified areas of concern. Specifically, the facility did not adequately audit or oversee issues related to infection control and medication administration, which had previously resulted in deficiencies at F880 and F554. Despite having a QAPI program in place that outlined the need for organized data collection and evaluation of state survey deficiencies, the facility did not sustain improvements or prevent repeat citations in these areas. During the survey, it was found that the QAPI committee did not sufficiently implement, monitor, or review the identified problem areas, leading to repeat deficiencies. The administrator acknowledged that while medication-related audits were performed, no recent trends were identified, and the committee's oversight was insufficient to prevent recurrence of the same issues. No specific resident details or medical histories were provided in the report.