Failure to Maintain Safe, Sanitary, and Functional Environment Due to Ineffective QAPI Program
Penalty
Summary
The facility failed to maintain a functioning Quality Assurance Performance Improvement (QAPI) program, resulting in repeated deficiencies related to the timely repair and maintenance of essential equipment and the provision of a safe, sanitary, and comfortable environment for residents. Multiple observations revealed that several resident rooms had malfunctioning overhead lights, with one resident reporting a flickering light and another stating their light did not work at all. In another instance, a resident received a replacement bed that was also not functioning properly. Additionally, the activities room and pantry areas were found to have significant environmental issues, including water damage, bio growth (mold), loose baseboards, and exposed pipes. The pantry refrigerator and freezer were not maintaining safe temperatures, resulting in thawed food items and lukewarm milk, and the area under the pantry sink was contaminated with dark bio growth. Ceiling tiles were missing or damaged in several locations, and loose flooring was observed throughout the facility, creating potential tripping hazards. Several residents reported issues with their air conditioning (A/C) units, with one resident stating their A/C did not work and another moving their bed to receive better airflow. Observations confirmed that some A/C units were non-functional, had filters with heavy black bio growth, and that room temperatures were uncomfortably high. Staff interviews revealed that the issue with at least one A/C unit had been ongoing for several months, but the facility administration was unaware of the problem until the survey. The maintenance assistant confirmed the long-standing nature of the A/C issue, and the facility did not have a policy in place for A/C maintenance and repairs. During facility tours, the Nursing Home Administrator (NHA), Director of Nursing (DON), and other staff acknowledged the environmental and equipment deficiencies only after they were pointed out by surveyors. The QAPI committee and program were found to be ineffective in identifying, tracking, and correcting these deficiencies, as evidenced by the recurrence of issues previously cited and the lack of awareness among leadership regarding ongoing problems. The facility's policies on general cleaning and maintenance were not being followed, resulting in unsanitary and unsafe conditions in both resident and common areas.