Failure to Follow Physician Orders and QAPI Process in Hypoglycemia Event
Summary
The facility failed to utilize its Quality Assessment and Performance Improvement (QAPI) process to investigate, identify, and implement an effective performance improvement plan regarding the management of a resident's change in condition and adherence to physician orders. Specifically, a resident with Type 2 Diabetes Mellitus and a history of blood sugar monitoring experienced multiple episodes of hypoglycemia. On one occasion, an LPN administered glucose gel without a physician's order and did not notify the provider when the resident's blood sugar was 72. Subsequently, the resident became less responsive, and further blood sugar checks revealed dangerously low values. Despite a physician's order to administer Glucagon intramuscularly and send the resident to the emergency room if there was no positive response, the facility staff did not follow these instructions. When the resident's blood sugar dropped below 60 for a second time and the resident was unresponsive, the provider was not notified, Glucagon was not administered as ordered, and the resident was not sent to the emergency room. The resident's condition continued to deteriorate, with a blood sugar value of 32, and only then was emergency medical services contacted. The resident was transported to a hospital and did not survive. Interviews and record reviews revealed that the facility's QAPI process did not identify this event as a reportable incident or an area in need of improvement. The DON and nurse managers reviewed the case but failed to recognize deficiencies in care, documentation, and adherence to professional standards. The facility's policies and procedures for change in condition, physician notification, and following physician orders were not implemented, leading to a determination of Immediate Jeopardy.
Removal Plan
- The DON/designee completed a comprehensive audit of active residents in the facility with orders for blood sugar monitoring to ensure insulin administration was documented to identify concerns related to insulin administration in accordance with physician orders including administration of hypoglycemia interventions with documentation of repeat blood sugars.
- The DON/designee completed a review of residents who return to the hospital to ensure timeliness of RTH as it related to hypoglycemia was carried out.
- The DON/designee completed a comprehensive audit of active residents in the facility with change in condition to validate physician was notified and if blood sugar was completed as ordered.
- An Ad Hoc QA meeting was held for investigation of the concern and determination of the root cause analysis.
- Staff A, LPN, received 1:1 education on hypoglycemia/hyperglycemia protocol, and change in condition.
- The facility initiated a systemic change to include the notification to the DON/ADON when hypoglycemic interventions are initiated.
- Licensed nurses received education on blood sugar monitoring, documentation of results, follow up with physician, guideline for diabetes management, policy and procedure on change in condition, and notification of DON/ADON when hypoglycemic interventions initiated.
- VPCS reeducated the Clinical Management Team including the Administrator and Director of Nursing on the components of job descriptions and 5 elements of QAPI, root cause analysis, QAPI at a glance, and QAPI self-assessment tool.
- The Administrator/designees and Director of Nursing Services designee will ensure that the safety and well-being as it related to blood glucose monitoring and treatment is maintained by the continued participation, evaluation, and intervention through Dashboard, Risk reports, RTH Resident records and hour report review during clinical standup and stand down meeting, and maintaining QA/PI process.
- An Ad Hoc QAPI meeting was convened to review the components of ongoing PIP and review the findings of F867 QAPI/QAA.
Penalty
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The facility failed to use its QAPI program to guide changes in its restorative care services and nurse aide workload. Residents reported that the restorative program had been discontinued and that restorative duties were shifted to nurse aides, and they confirmed they were not receiving restorative care. Resident Council minutes documented prior concerns about the loss of the restorative program. The NHA acknowledged ongoing state enforcement for lack of nurse aide care and confirmed that multiple information sources, including residents, the Resident Council, the local Ombudsman, interviews, and staffing data, showed insufficient CNA staffing to meet basic care needs. The NHA further confirmed that the QAPI plan was not utilized to evaluate the impact of discontinuing the restorative program and adding duties to already short-staffed CNAs, and that the QAPI committee failed to ensure effective delivery of care and services.
The facility failed to maintain proper kitchen sanitation and food labeling for all residents receiving meals, with surveyors observing multiple open and undated food items, including frozen products, dry goods, and bread, as well as seasoning stored without a lid. Similar issues had been cited previously under F812 for sanitation, open food items, and lack of labeling and dating. The ED reported that she and an assistant conducted undocumented kitchen observations and that a committee had been working on food temperatures, labeling, dating, and cleanliness, but no related policy was provided at survey exit.
The facility failed to implement an effective, data‑driven QAPI program when QAPI meetings were used mainly for informational departmental updates rather than systematic problem‑solving, root cause analysis, and follow‑up on identified concerns. Staff reported that PIPs existed in multiple departments, but meeting records showed that issues such as infection control, housekeeping/environmental problems, care plans, pain management, and skin/wound care were repeatedly identified without documented root cause analysis, measurable goals, timelines, or monitoring of interventions. Review of PIP and QAPI documentation showed a lack of defined action plans and evaluation of effectiveness, despite a written QAPI policy requiring regular analysis of quality deficiencies and structured performance improvement activities.
The facility’s QAPI process failed to prevent ongoing deficiencies in nutritional management and monitoring. Despite a policy and prior identification of problems with timely recognition of weight changes, implementation of nutritional interventions, and notification of physicians and responsible parties, similar issues recurred. A resident experienced progressive weight loss without a verifying re‑weight for a significant change, and there were delays between RD recommendations and corresponding physician orders. Documentation did not show timely implementation of recommended supplements or timely notification of the attending physician and responsible party, and the DON acknowledged these failures, demonstrating that quality assurance monitoring did not identify or correct the ongoing deficient practice.
A deficiency occurred when the facility’s QAA/QAPI program and Supervised Care process were not implemented as required by facility policy to address repeated care concerns and adverse events involving a CNA. One resident with dementia and other comorbidities developed a nasal bruise after an incident during personal care, and another resident with Parkinson’s disease and dementia was mishandled by the same CNA, as shown on video, resulting in a fall and the resident being left on the floor unattended. Despite a policy requiring clear documentation, staff notification, active supervision, and auditing under Supervised Care, the CNA’s Supervised Care form contained only vague "care concerns," had signature irregularities, and there was no evidence of actual supervision or audits. The DON identified increased bruising, injuries, and falls on the CNA’s shift and discrepancies between the CNA’s reports and other information, yet these issues were not effectively brought through the QAA/QAPI process, and the Administrator reported that the investigation and concerns were not discussed in the QAPI meeting while present, demonstrating a failure to use established quality systems to monitor, investigate, and correct identified deficiencies in care and resident safety.
The facility failed to adequately track, trend, and analyze resident-to-resident abuse incidents within its QAA/QAPI process. QAA meeting minutes showed missing and inconsistent data on reportable incidents and unit trends, and the DON’s clinical review did not specifically address resident-to-resident abuse. The only documented action plan was a general, non-measurable strategy focused on staff education and keeping residents at arm’s length, with no evidence of resolved plans or measurable progress. Interviews with the DON and Administrator confirmed that altercations were tracked mainly as reportable events by location, without deeper analysis of triggers or patterns, despite policies requiring QAPI review and performance improvement initiatives for abuse-related events.
Failure to Use QAPI to Maintain Restorative Care and Adequate Nurse Aide Services
Penalty
Summary
The deficiency involves the facility’s failure to use its Quality Assurance Performance Improvement (QAPI) program to ensure effective delivery of care and services, specifically related to the restorative program and nurse aide staffing. The facility’s written Performance Improvement Program Plan states that it is the policy of the facility to continually improve the delivery of health care services by designing, measuring, assessing, improving, and redesigning processes of resident care, and that new or modified processes should meet criteria such as being clinically sound, meeting the needs of staff and individuals served, and incorporating results of performance improvement activities. Despite this written plan, the facility did not apply its QAPI processes when making changes to the restorative program and reallocating duties to nurse aides. During a confidential resident group interview, residents reported that the restorative program had been discontinued and that restorative duties had been placed on nurse aides. The residents in the group confirmed that they were not receiving restorative care. Review of Resident Council minutes from a prior meeting showed that residents had already expressed concerns that the restorative program had been discontinued, indicating that this issue had been raised through resident feedback mechanisms before the survey. In an interview, the Nursing Home Administrator (NHA) confirmed that the facility was in the state enforcement process for a lack of nurse aide care, with issues dating back several months, and that residents, the Resident Council, the local Ombudsman, resident interviews, and facility staffing data all indicated that nurse aide staffing was insufficient to meet basic resident care needs. When asked, the NHA confirmed that the facility had not used its QAPI process and plan to ensure effective delivery of the restorative program and acknowledged that, had the QAPI plan been utilized, it would have shown that assigning additional restorative duties to already short-staffed nurse aides was not a feasible replacement for the discontinued restorative program. The NHA further confirmed that the QAPI committee failed to ensure that the delivery of care and services was effectively provided to residents.
Plan Of Correction
A Quality Assurance and Performance Improvement (QAPI) will be held by the Administrator/Designee on May 11, 2026 Resident recently discharged from Therapy will be assessed by both the Therapy department and Nursing for the need for any restorative programming. A POC task for documentation will be created to ensure the program is completed by the CNA. When Staff in is insufficient to provide these services the Therapy Department staff will assist. The DON/Designee will Monitored the when the need for the therapy staff to assist occurs A Quality Assurance and Performance Improvement (QAPI) will be held by the administrator/Designee at least quarterly or more often if needed. Minutes of the QAPI committee will be presented to the Governing Body of the Greenery Center for Rehab and Nursing. The Management Team will be educated on the timing and requirement of the QAPI committee by the Administrator. The Governing Body of the Greenery Center for Rehab and Nursing will monitor for compliance of this regulation. The DON/Designee will audit the Restorative care documentation on the CNA task weekly times four and monthly times two. The DON/ Designee will monitor the need for therapy to assist ongoing
Repeat Failure to Maintain Kitchen Sanitation and Food Labeling
Penalty
Summary
The facility failed to effectively implement interventions to maintain kitchen sanitation for all 103 residents who consumed food prepared in the kitchen. During a kitchen observation, surveyors found multiple food items improperly stored and not dated, including a bag of frozen chips and cinnamon rolls in the freezer open to air with no open dates, beef base without an open date, and elbow macaroni in a clear bin without a date. Additional undated bread products included white bread, whole wheat bread, hamburger buns, and sub buns, and dill weed seasoning was observed without a lid and open to air. These sanitation and food labeling issues were similar to those cited under F812 in a prior recertification survey, which had identified problems with maintaining sanitation, open food items, labeling of food, and dating of opened food. In an interview, the Executive Director reported that she and the Assistant Executive Director conducted various observations of the main kitchen and neighborhood kitchenettes but had no documentation of these observations. The Executive Director stated that the committee had been working on food temperatures, labeling, dating, and cleanliness since the previous April and noted there had been turnover among dietary aides, which she believed had corrected the problem until the most recent annual survey results. No policy related to these issues was provided at the time of survey exit.
Failure to Implement Effective, Data‑Driven QAPI Program
Penalty
Summary
The facility failed to develop and implement an effective, comprehensive, data‑driven QAPI program. Interviews revealed that department managers used a shared PowerPoint to present departmental updates and Performance Improvement Projects (PIPs) at quarterly QAPI meetings, and that each department had multiple PIPs in the past year. However, one staff member reported that QAPI meetings were primarily informational, focused on reviewing departmental activities rather than problem‑solving or process improvement, and did not consistently include follow‑up on previously identified concerns. Another staff member stated that the QAPI committee "definitely needs to be more than it has been" and that meetings should occur more frequently to address ongoing system failures and monitor progress of PIPs. Review of quarterly QAPI meeting documentation for 2025 showed that multiple quality concerns were identified, including infection control practices, housekeeping/environmental issues, care plans, pain management, and skin and wound issues, but the records lacked evidence of root cause analysis, clearly defined action plans, or monitoring for effectiveness and sustained improvement. Review of PIP documentation for 2025 showed that multiple projects were initiated without measurable goals, timelines for completion, or evidence of ongoing evaluation of interventions, and several issues were repeatedly identified across multiple meetings without documented resolution or progress. These practices did not align with the facility’s written QAPI policy, which required at least monthly meetings to identify performance improvement opportunities, establish goals and performance indicators, systematically analyze underlying causes, prioritize and develop action plans, implement process improvement strategies, and evaluate effectiveness and sustained results.
Failure of QAPI Process to Address Ongoing Nutritional Management Deficiencies
Penalty
Summary
The deficiency involves the facility’s failure to ensure its Quality Assurance Performance Improvement (QAPI) committee developed and implemented effective corrective action plans to prevent ongoing problems in the food and nutrition services department. The facility had a written QAPI policy stating it would maintain an effective, comprehensive, data‑driven program focused on care outcomes and quality of life, using evidence‑based indicators and goals predictive of desired resident outcomes. Despite this, during a survey ending in late January 2026, surveyors identified deficient practice related to timely identification of changes in nutritional parameters, implementation of appropriate nutritional interventions, and notification of the attending physician and responsible party when significant weight loss occurred. Following that survey, the facility created a plan of correction that included reviewing current residents for significant weight loss, completing nutritional assessments, implementing interventions, adjusting care plans, and notifying physicians and responsible parties as needed. The plan also called for education of the RD and licensed nursing staff on identifying significant weight loss and appropriate notifications, as well as ongoing audits of residents with significant weight loss. However, by the time of the subsequent survey ending in late March 2026, the same types of deficiencies were still present, demonstrating that the QAPI process had not effectively corrected or prevented recurrence of the identified issues. For one resident, weight records showed a decline from 124 pounds in early January 2026 to 114.5 pounds by late March 2026, including a 3 percent loss in one week and a 7.5 percent loss since early January. The record did not show that a re‑weight was obtained to verify this significant change. The remote RD documented weight alerts and recommended additional nutritional interventions, including increasing nutritional shakes with meals and adding a frozen nutritional treat with dinner, as well as weekly weights. There were delays of several days between the RD’s recommendations and the corresponding physician orders, and the clinical record did not show timely implementation of the recommended interventions. The record also lacked documentation that the attending physician and the resident’s responsible party were notified of the significant weight loss on the date it was identified, and the DON confirmed the failures in timely notification and implementation, indicating that the facility’s quality assurance monitoring did not detect or correct the ongoing deficient practice for this resident’s nutritional status.
Failure of QAA/QAPI and Supervised Care Processes to Address Staff Care Concerns and Adverse Events
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its Quality Assessment and Assurance (QAA)/Quality Assurance Performance Improvement (QAPI) program functioned as described in its own policies to identify, analyze, and correct quality problems, including adverse events and staff performance concerns. The facility’s QAPI policy required consistent data collection, monitoring, and analysis of care and services, including adverse event tracking and implementation of action plans to prevent recurrence. Despite this, the facility did not ensure that the QAA committee developed and implemented appropriate plans of action to correct identified quality deficiencies, and did not implement written policies and procedures for feedback, data collection systems, and monitoring related to performance improvement plans, staff correction, and resident safety. One resident, identified as having unspecified dementia with behavioral disturbances, hypothyroidism, and major depressive disorder, was found on an incident report to have a blue/gray bruise on the nose. The report attributed contributing factors to poor safety awareness, dementia, ill-fitting glasses, an unpadded wall, and the resident resting their head on the table when fatigued. The report also documented that a CNA described the resident as difficult during care, stated the resident swung their hands during personal care, and hit their head on the wall while rolling over, though the CNA reported not seeing an injury at that time. This event triggered the use of the facility’s “Supervised Care” process for the CNA, but the documentation and implementation of that process did not follow the facility’s own Supervised Work and Supervised Care policy, which required clear documentation of reasons, staff notification, and ongoing supervision and auditing until the staff member was deemed safe to perform their job. Another resident, with Parkinson’s disease with dyskinesia and unspecified dementia without behavioral disturbance, was involved in an incident where the CNA reported that the resident stood from their wheelchair, grabbed a handrail, and had to be lowered to the floor to prevent a fall. However, video footage reviewed during the facility’s abuse investigation showed the CNA entering the resident’s room without knocking, physically pulling the resident into a wheelchair despite apparent resistance, nearly causing a fall, and later pulling the wheelchair backward while the resident stood, resulting in the resident falling to the floor. The CNA then walked away, leaving the resident on the floor for approximately two minutes before returning with a mechanical lift and then leaving again as an LPN began attending to the resident. This sequence of events, combined with prior concerns about bruising, injuries, and falls on the CNA’s shift, demonstrated that the facility’s systems for monitoring adverse events, reconciling staff accounts with objective evidence, and escalating concerns through QAA/QAPI were not effectively implemented. The facility’s Supervised Care policy required that any employee who failed to follow resident care, medication, or treatment policies, or whose care was under review, be placed on Supervised Care with documented job responsibilities, supervisory sign-off each shift, and Department Head review with notification to the Administrator if problems were identified. In this case, the Supervised Care form for the CNA listed only vague “care concerns,” lacked detailed reasons such as bruising or rough care, and had signature discrepancies, including a misspelled version of the CNA’s name that did not match other documents. There was no documented evidence that any actual auditing of the CNA’s care occurred, and the CNA stated they were never informed they were on Supervised Care and were not supervised while working. The DON later stated they did not believe the CNA was truly placed on Supervised Care and that the form may have been retroactively documented or not appropriately implemented. Additionally, the Administrator reported that the last QAPI meeting did not address this investigation while they were present, and the DON acknowledged that video footage was only reviewed reactively after an increase in bruising and incident reports, rather than as part of a systematic monitoring process. These facts show that the facility did not operationalize its QAA/QAPI policies to ensure consistent monitoring, investigation, and corrective action for identified quality and safety concerns involving staff performance and resident adverse events. Interviews further underscored the breakdown in the facility’s quality systems. The DON reported noticing a notable increase in incident reports of bruising, injuries, and falls on the unit and during the CNA’s shift, with discrepancies between the CNA’s accounts and other staff reports or observed injuries, yet there was no evidence that these concerns were effectively brought through the QAA process or resulted in a properly implemented Supervised Care plan. The Assistant DON described Supervised Care in this case as primarily an educational tool without one-to-one supervision, while the DON described Supervised Care as meaning the staff member should not be alone and should receive hands-on instruction and audits. The CNA denied being placed on Supervised Care and alleged the Supervised Care form signature was forged. The Administrator stated they were not aware of the care concerns surrounding the CNA until suspicions of multiple cases of abuse arose and acknowledged that the incident and related concerns were not discussed in the QAPI meeting while they were present. Collectively, these actions and inactions demonstrate that the facility did not follow its own policies for Supervised Care, did not consistently monitor and track adverse events and staff performance issues, and did not ensure that the QAA/QAPI committee developed and implemented appropriate plans of action to correct identified quality deficiencies.
Failure to Analyze and Trend Resident-to-Resident Abuse Incidents in QAA/QAPI
Penalty
Summary
The deficiency involves the facility’s failure to track, trend, and analyze resident-to-resident abuse incidents and to implement a measurable, data-driven prevention plan through its Quality Assessment and Assurance (QAA) process. Review of QAA meeting minutes for a December meeting covering November showed that the number of reportable incidents for November was left blank, despite trends indicating multiple incidents across specific units. The Director of Nursing’s clinical systems review did not specifically address resident-to-resident abuse, and the documented action plan remained a general approach focused on education about behaviors, memory care, and keeping residents at arm’s length, without measurable elements. The section for resolved action plans was left blank, and there was no documentation of measurable progress on preventing resident-to-resident abuse. Further review of QAA minutes for a February meeting covering December and January showed inconsistencies between the total number of reportable incidents and the number of incidents listed by unit, and again reflected the same non-specific action plan without measurable outcomes. Interviews with the DON and the Administrator confirmed that resident-to-resident altercations were only tracked as reportable events and primarily by location, with no deeper trend analysis such as triggers, patterns, or other causative factors. The Administrator acknowledged that trend tracking for resident-to-resident abuse did not go far enough, and the DON stated that the facility did not know what triggered residents, relying on psych services after altercations. These practices did not align with facility policies requiring QAPI review and analysis of all abuse-related occurrences and integration of confirmed abuse findings into performance improvement initiatives.
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