Failure to Sustain QAPI Oversight for Kitchen and Waste Deficiencies
Penalty
Summary
The facility failed to maintain an ongoing process within its Quality Assurance and Performance Improvement (QAPI) program to address and prevent the recurrence of previously identified deficiencies. Specifically, during an annual survey, surveyors found non-compliance related to labeling and dating food items in the kitchen and the maintenance of facility waste in the dumpster. Although these issues were identified and the facility committed to correcting them, a review of the current QAPI program revealed that performance improvement plans did not include ongoing monitoring or actions related to these specific deficiencies. The Administrator confirmed that after six months of review, the concerns were considered closed and the QAPI team shifted focus to other areas, without ensuring sustained improvement in the previously cited areas.