Failure to Implement QAPI Action Plan for Environmental Repairs
Penalty
Summary
The facility failed to develop and implement an action plan to address and repair environmental deficiencies, impacting the safety and quality of life for all residents. Observations included fall mats with edges sticking up and significant rips, as well as nail holes in the wall next to a window. These environmental hazards were not addressed through the facility's Quality Assurance and Performance Improvement (QAPI) process, despite being identified. Additionally, a resident reported having to use a bathroom down the hall for several months due to non-functioning toilets. Interviews with facility leadership confirmed that the QAPI Committee was aware of the issue with the toilets but had not developed a Performance Improvement Plan (PIP) to address it. The Corporate Executive acknowledged that repairs had been attempted but had not been discussed with the QAPI Committee, indicating a lack of coordinated action through the established quality assurance processes.