Repeated Deficiencies in Assessment Accuracy, Food Sanitation, and QAPI Processes
Penalty
Summary
The facility failed to implement effective plans of action to correct previously identified quality deficiencies, as evidenced by repeated citations in the areas of assessment accuracy, food storage and sanitation, and quality assurance processes. During a prior recertification survey, the facility was cited for improper food storage due to incorrect temperatures in a reach-in cooler, failure to ensure the cooler was functioning properly, and inaccurate coding of the Minimum Data Set (MDS). Additionally, the Quality Assurance and Performance Improvement (QAPI) committee was cited for failing to identify and prevent potential problems and for not effectively implementing QAPI/QAA activities. In the most recent survey, similar deficiencies were observed, including the absence of a thermometer in a unit pantry freezer, failure to ensure proper dishwashing temperatures, and continued inaccuracies in MDS coding. The QAPI/QAA committee continued to fail in identifying and preventing these recurring issues, despite holding regular monthly meetings with key facility leadership and department heads. The facility's own QAPI policy requires the development and implementation of corrective action plans for identified deficiencies, but the repeated nature of these citations indicates that effective corrective actions were not taken.