Failure to Correct Repeated Deficiencies in QAPI Areas
Penalty
Summary
The facility failed to correct previously identified deficiencies in three areas: dignity, infection control, and food procurement/store/prepare/serve/sanitation. Despite having a QAPI plan in place that outlined systematic approaches for identifying and correcting quality deficiencies, the facility did not ensure that these processes were effectively implemented. The QAPI plan emphasized staff participation, accountability, and data-driven decision-making, but repeated deficiencies were still observed in the cited areas. The Administrator acknowledged that while a correction plan was developed for dignity concerns, the previous DON did not follow through with required audits as directed, and this lack of follow-through contributed to the ongoing issues. The repeated deficiencies in infection control and kitchen processes were also recognized during the survey, indicating that the facility's QAPI activities were not successful in addressing and resolving these concerns.