Failure to Implement and Document QAPI Activities
Penalty
Summary
The facility failed to prioritize quality improvement, develop and implement action plans, conduct at least one Performance Improvement Project (PIP) annually, and regularly review, analyze, and act on collected data. During the survey, the facility was unable to provide documentation of any PIPs for the years 2024 and 2025. Administrative staff confirmed that no PIPs had been started or documented in the previous year, and noted that the facility had experienced turnover with seven administrators in the past two years. The facility's QAPI policy required the development and maintenance of a comprehensive, data-driven QAPI program, including systematic identification, reporting, investigation, analysis, and prevention of adverse events. The policy also specified the composition of the QAPI committee and the frequency of meetings. Despite these requirements, the facility did not provide evidence of QAPI committee activities or action plans addressing quality deficiencies, placing all 30 residents at risk for a lack of quality improvement activities.