Failure to Implement Effective QAPI Process Resulting in Repeat Deficiencies
Penalty
Summary
The facility failed to maintain an effective Quality Assurance Performance Improvement (QAPI) process to address previously identified quality deficiencies, resulting in repeated citations across multiple surveys and complaint investigations. Review of the Department of Inspections, Appeals and Licensing (DIAL) website and CMS-2567 reports revealed that the facility had recurring deficiencies in areas such as abuse prevention, resident assessment, care planning, quality of care, and infection control. These deficiencies were cited during annual surveys and complaint investigations over several years, indicating a pattern of unresolved issues. The facility also had a 1-star staffing rating for the reported quarter, attributed to high staff turnover, particularly in nursing leadership positions including the DON, ADON, and MDS nurse. Interviews with the Administrator confirmed awareness of the repeat deficiencies and acknowledged that the entire nursing department had turned over earlier in the year, with delays in filling key positions. The QAPI committee reportedly met quarterly and identified areas for improvement, but the persistent recurrence of deficiencies suggests that the QAPI process was not effective in ensuring sustained compliance. The facility's QAPI plan described a systematic approach to quality improvement, including root cause analysis and monitoring, but the ongoing repeat citations demonstrate that these processes were not successfully implemented or maintained.