Failure to Analyze and Document QAPI Data and Actions
Summary
The facility failed to ensure that data submitted to the Quality Assurance and Performance Improvement (QAPI) committee was properly analyzed and documented. Although department heads regularly brought data on topics such as medication errors, falls, pressure ulcers, weight loss, pharmacy services, infection control, admissions and discharges, staff agency use, and adverse event monitoring to the QAPI meetings, only falls and pressure ulcers had benchmark goals identified. Even for these areas, there was no analysis of the data or documentation of actions the facility would take to achieve the goals, nor was there monitoring to determine if the goals were met or if continued QAPI oversight was needed. For all other areas, there were no documented benchmarks, data analysis, or action plans. Review of QAPI meeting minutes from multiple months confirmed the lack of documented benchmarks, analysis, and action plans across a range of quality indicators. An interview with the regional administrator confirmed that the facility had not identified goals, action plans, or analyzed data brought forth in the QAPI meetings. The facility's own QAPI policy required oversight, action plan development, and analysis, but these steps were not documented or implemented as required.
Penalty
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The facility failed to maintain an effective QAPI performance improvement plan (PIP) for systemic staffing concerns, despite its QAPI plan requiring a data‑driven process to identify and address gaps in care systems and ensure adequate staffing. Facility staffing data showed low weekend staffing, and resident council minutes over several months documented repeated complaints about weekend short staffing, delayed medication administration, missed snacks, and closure of the independent dining hall when staffing was insufficient. A resident reported that residents stopped complaining when the facility did not respond to their concerns. The Administrator stated a staffing PIP had been opened and then closed once residents stopped complaining, and acknowledged that independent dining was closed when there were not enough staff, while also indicating no specific staffing system gaps or metrics were identified before closing the PIP.
The facility’s QAPI/QAA program failed to identify multiple systemic problems, focusing only on falls, pressure ulcers, and transcription errors while missing significant issues in ADLs, care planning, and the environment. Surveyors found that several dependent residents were not receiving regular full-body baths, with observations of oily hair, scaly skin, body odor, and complaints about not getting showers or hair washed, corroborated by shower/tub documentation. Review of person-centered care plans for sampled residents showed they were not being routinely reviewed and revised as residents’ conditions changed. Environmental observations revealed resident rooms that were not safe, clean, comfortable, or homelike, including a room with ongoing heating problems where a resident reported being cold at night, and more than 15 rooms with damaged or deteriorated wall surfaces. These system failures had not been identified or brought to the QAPI team by facility staff.
The facility failed to use its QAPI process to identify, investigate, and analyze three respiratory‑related deaths and did not document corrective actions. Two residents on ventilators experienced critical tracheostomy events—an inappropriate trach change by respiratory staff and a broken trach flange causing dislodgement—leading to cardiac arrest and death. Two residents did not receive access to outside provider appointments for trach care, and verbal orders for trach changes were not followed. For one comatose resident in a vegetative state whose trach flange broke and who later died, the SSA and APS were not notified within the required timeframe. The ADM reported that only two of the deaths were reviewed in QAPI, was not informed of one death and its circumstances until the next morning, and stated that a contracted respiratory company, which had not reported equipment issues, was responsible for respiratory equipment.
The facility failed to operate an effective QAPI system that incorporated pharmacy and controlled substance issues into its quality review and performance improvement activities. Although the QAPI policy assigned the committee responsibility for ongoing systemwide quality improvement, the HIM Director reported that QAPI meetings focused on other topics and did not address controlled substances or known pharmacy issues identified over several months. The DON stated that medication concerns, including internal findings of extra narcotic sheets, were not brought to QAPI and that related checks were not documented. The Administrator acknowledged concern about wasted medications but stated the facility did not track them and that such issues were not presented to QAPI or the Medical Director. The Medical Director confirmed he had not been informed of prior pharmacy audit concerns and believed these discrepancies should have been addressed through QAPI.
The facility did not implement an effective QAPI program, as evidenced by a QAPI policy that lacked implementation and review dates, had not been approved by the QAPI team, and appeared to be a generic document from another company. The NHA confirmed the policy was not in use and could not explain the lack of approval. Although several PIPs addressing annual staff competencies, required CNA continuing education hours, and dietitian requirements had been presented to the QAPI committee, leadership was unaware that the facility would not achieve substantial compliance with these areas by the stated compliance date, affecting all residents.
The facility did not effectively use its QAPI program to identify and address ongoing issues in pressure ulcer prevention and treatment, despite holding monthly QA meetings that were supposed to review trends such as falls, pressure ulcers, antibiotic use, and weight loss. The Administrator confirmed that in multiple consecutive months no residents with ongoing pressure ulcer issues were identified or discussed, even though survey findings later showed noncompliance in pressure ulcer care that resulted in substandard quality of care, including Immediate Jeopardy for a resident and Actual Harm for another. This practice conflicted with the facility’s own QAPI policy, which required continuous review of resident care trends and targeted performance improvement, including pressure ulcer care.
Failure to Maintain Effective QAPI PIP for Systemic Staffing Concerns
Penalty
Summary
The deficiency involves the facility’s failure to implement and sustain a performance improvement plan (PIP) for a systemic staffing concern, despite its QAPI Facility Plan requiring a data‑driven, organized, facility‑wide program to identify and address gaps in systems and ensure adequate staffing. The facility’s own PBJ staffing data for the first quarter of 2026 documented concerns with low weekend staffing. Resident council minutes showed that residents repeatedly reported staffing problems over several months: in November 2025, residents reported the facility was often short staffed on weekends; in December 2025, they reported weekend staffing issues that delayed medication administration until 9:30–10:00 AM, with staffing concerns noted as in progress; and in January 2026, residents were told new staff had been trained and were working regularly, and residents stated short staffing had significantly improved, with the concern noted as resolved. A resident later reported that residents stopped complaining about staffing around December 2025 when the facility had failed to respond to their earlier concerns. Additional findings showed that residents continued to experience staffing‑related issues after the staffing PIP was closed. In March 2026, resident council minutes documented that residents were concerned about not receiving snacks when the facility was short staffed. During a group interview, residents voiced concerns about low weekend staffing and poor staff response time during the night shift, and independent diners reported they could not eat in the independent dining hall when there were not enough staff on weekends. The Administrator confirmed that independent dining had to be closed when staffing was insufficient so residents could dine in the dependent dining hall with available staff. The Administrator reported that a staffing PIP opened in October 2025 was closed in December 2025 when residents stopped complaining, and he did not identify any specific gaps in staffing systems or metrics used to evaluate staffing effectiveness before closing the concern, despite ongoing documented staffing‑related issues.
Failure of QAPI Program to Identify Systemic Issues in ADLs, Care Planning, and Environment
Penalty
Summary
The deficiency involves the facility’s failure to operate an effective QAPI/QAA program that identifies and addresses failed systems. During an interview, the Administrator stated that the QAPI committee relied on data from the 5-star report, Resident Council meetings, grievances, families, residents, and the IDT, and that current focus areas included falls, pressure ulcers, and transcription errors. However, during the survey, three additional system failures were identified by surveyors—Activities of Daily Living (ADLs) related to showers/tub baths, ongoing review and revision of person-centered care plans, and maintaining a safe, clean, comfortable, and homelike environment—that had not been recognized or presented to the QAPI team by facility staff. Surveyors found that several dependent residents were not receiving regular full-body baths, specifically showers or tub baths, and observations revealed residents with oily hair, scaly skin, and body odor, with some residents reporting not receiving showers or hair washing. Review of shower/tub bath documentation confirmed that residents were not receiving regular full-body bathing. Review of person-centered care plans for all sampled residents showed a pattern of plans not being reviewed and revised on an ongoing basis as residents’ conditions improved or deteriorated. Environmental observations identified resident rooms that were not safe, clean, comfortable, or homelike, including one room with ongoing heating issues where a resident reported being cold on several nights, and more than 15 rooms with walls needing painting or with torn wallpaper and exposed wallboards. These issues were not identified by the facility’s QAPI process, and when given an opportunity, the leadership team did not provide additional information to demonstrate that these system failures had been recognized or addressed through QAPI/QAA activities.
Failure to Integrate Respiratory-Related Deaths and Tracheostomy Incidents into QAPI and Required Reporting
Penalty
Summary
The deficiency involves the facility’s failure to use its QAPI and QAA processes to identify, report, investigate, analyze, and prevent adverse events related to three respiratory‑related resident deaths, and to document corrective actions. Surveyors found that the facility did not include all three deaths, particularly one resident’s death, in its QAPI review despite the events involving serious clinical issues with ventilators and tracheostomies. Two residents on ventilators experienced critical tracheostomy events: in one case, respiratory staff changed a tracheostomy when they were not supposed to, and in another, a tracheostomy flange broke, causing the tracheostomy to become dislodged. Both residents went into cardiac arrest and died. The facility also failed to ensure residents had access to outside provider appointments for tracheostomy care and did not follow verbal orders for tracheostomy changes. The report further notes that the facility did not ensure residents were free from neglect and did not meet reporting requirements for incidents involving serious bodily injury. For two residents, the facility did not provide access to outside tracheostomy care as ordered, and verbal orders for tracheostomy changes were not followed. One comatose resident in a vegetative state experienced a broken tracheostomy flange, resulting in a dislodged tracheostomy, cardiac arrest, and death. For this same resident, the State Survey Agency and Adult Protective Services were not notified when the tracheostomy flange broke and the resident died, despite the requirement to report such events within two hours. During interview, the Administrator stated that deaths were reviewed in QAPI with a focus on staff adherence to procedure and reported that residents associated with the immediate jeopardy events had been addressed in QAPI, but one resident’s death had not been reviewed. The Administrator also stated he was not informed of one resident’s death and the broken flange until the following morning and indicated that the contracted respiratory company was responsible for respiratory equipment and had not reported any equipment issues.
Failure to Integrate Pharmacy and Controlled Substance Issues into QAPI
Penalty
Summary
The facility failed to develop, implement, and maintain an effective, comprehensive QAPI system that addressed adverse events and pharmacy-related issues, including controlled substances and wasted medications. The facility’s QAPI policy stated that the QAPI committee was responsible for implementing and maintaining an ongoing systemwide process of quality improvement. However, the Director of Health Information Management (HIM) reported that although the QAPI committee met monthly and had recently held an emergency meeting related to a resident fall, she did not recall controlled substances being discussed in QAPI and was not aware of pharmacy issues identified in October and November 2025 and January 2026. She stated the current performance improvement plan focused on Medicare certification and inventory sheets, not on the pharmacy concerns cited by surveyors. The DON stated that medication concerns were never brought to QAPI meetings and that an internal audit involving extra narcotic sheets had been a concern, but those checks were not documented. She indicated that topics typically brought to QAPI included mealtime delivery, falls, and pressure ulcers, and that medication issues would only be sent to QAPI if not addressed by nursing. The Administrator acknowledged that wasted medication was a concern but stated the facility did not track wasted medications and that wasted medication issues, which she believed should have been brought to QAPI and to the Medical Director, were not addressed there. She described medication errors as wrong medications given or controlled substances pulled and not documented in the eMAR. The Medical Director reported he had not been informed of pharmacy audit concerns from October and November 2025 and stated he would want to know about discrepancies affecting his residents and believed such issues should be brought to QAPI to determine root causes and corrective actions.
Failure to Implement an Effective QAPI Program
Penalty
Summary
The facility failed to develop and maintain an effective Quality Assurance and Performance Improvement (QAPI) program that identified and prioritized quality deficiencies, analyzed their underlying causes, and implemented effective corrective actions. Surveyors reviewed the facility’s QAPI policy and found that the document titled “Quality Assurance and Performance Improvement (QAPI)” had no entries for Date Implemented, Date Reviewed/Revised, or Reviewed/Revised by. The document also bore a 2025 copyright and a heading from another company, indicating it was not a facility-specific, implemented policy. During interview, the Nursing Home Administrator (NHA) confirmed that this QAPI policy had not been implemented by the facility and could not explain why it had not been approved. The NHA reported that the facility had several Performance Improvement Plans (PIPs) that had been approved by the QAPI team, including plans related to annual competencies, annual 12 hours of continuing education for CNAs, and dietitian requirements. These PIPs were reported and approved by the QAPI committee shortly before the facility’s alleged date of compliance following a prior abbreviated survey. However, the NHA stated that neither she nor the QAPI committee knew that the facility would not be in substantial compliance with the annual competencies, CNA education hours, and dietitian requirements by the alleged compliance date. The deficient QAPI process had the potential to affect the safety and quality of life of all 63 residents in the facility.
Failure to Use QAPI to Identify and Address Pressure Ulcer Care Issues
Penalty
Summary
The facility failed to implement and maintain a comprehensive Quality Assurance Performance Improvement (QAPI) program and plan to address care issues and concerns, particularly related to pressure ulcer care. Review of Quality Assurance (QA) committee attendance records for the previous eight months showed that QA meetings were held monthly and included discussion of falls, pressure ulcers (healing, not healing, present on admission, and in-house acquired), antibiotic use, and weight loss. However, the annual survey identified noncompliance in pressure ulcer care, including prevention and treatment, which resulted in substandard quality of care. This noncompliance led to an Immediate Jeopardy situation for one resident beginning on 08/27/25 and Actual Harm for another resident beginning on 01/12/26. During interviews, the Administrator stated that QAPI meetings were held monthly and confirmed attendance at the December 2025 and January 2026 meetings, during which no residents were identified as having ongoing issues or care needs related to pressure ulcers. The Administrator further reported that, upon review, there had been no identification of ongoing issues and care for pressure ulcers in the six months of QAPI meetings prior to his tenure (May 2025 through November 2025). This was inconsistent with the facility’s written QAPI policy, dated November 2025, which described QA as a continuous process in which the QA Committee is responsible for reviewing resident care and service trends, identifying quality issues, and developing plans of action, including review of pressure ulcer care trends based on data collection.
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