Repeat Deficiencies in QAPI, Medication Management, and Food Sanitation
Penalty
Summary
The facility failed to correct previously identified deficiencies in four of fourteen areas of concern, as evidenced by repeat citations in multiple survey cycles. Specific deficiencies included failures in the QAPI program and plan, comprehensive assessments and their timing, appropriate use and documentation of psychotropic medications (including PRN use and gradual dose reduction), and food storage, preparation, and service sanitation. Surveyors observed inaccurate coding on the MDS for hospice level of care, antipsychotic and anticoagulant medication use, and urinary tract infection diagnosis. There were also failures to document non-medical interventions before administering PRN antipsychotic medications and to attempt gradual dose reductions as required. Additionally, staff were observed not following proper food safety protocols, such as failing to perform hand hygiene between touching contaminated surfaces and resident food items, and improper glove use during food service. Despite the facility's QAPI plan outlining a data-driven, proactive approach to quality improvement, these deficiencies persisted across several survey periods. The administrator acknowledged the repeat citations and described the facility's ongoing efforts to address these issues, but the report documents that the same types of deficiencies continued to be identified by surveyors.