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F0867
F

Lack of Evidence for Required Performance Improvement Project

Belview, Minnesota Survey Completed on 04-24-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide evidence of a Performance Improvement Project (PIP) that addressed high risk or problem-prone areas, as required by their Quality Assurance and Performance Improvement (QAPI) policy. Review of QAPI meeting minutes over a five-month period showed that no PIP projects were documented. During an interview, the regional administrator confirmed that although a PIP project had been identified, no goal was set, no action plan was developed, the project was not discussed in QAPI meetings, and staff had not been trained. The facility's QAPI policy requires the committee to oversee improvement areas, develop action plans, and maintain documentation of ongoing QAPI activities, including at least one distinct PIP project annually. This deficiency had the potential to affect all 18 residents in the facility.

See complete original report
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