Failure to Hold and Document Required Quarterly QAA Meetings
Penalty
Summary
The facility failed to hold quarterly Quality Assessment and Assurance (QAA) meetings with the required committee members present, as evidenced by the absence of documentation for the 4th quarter of 2024 and the 1st quarter of 2025. Record review showed that QAA meetings were conducted in the second and third quarters of 2024, but there was no evidence of meetings for the subsequent two quarters. During interviews, the Administrator and Director of Nursing confirmed that they could not provide documentation of QAA meetings with the required participants for the specified periods. No information regarding residents or their medical conditions was included in the report, and the deficiency centers solely on the facility's failure to document and conduct required QAA meetings with appropriate membership.