Deficient QAPI Program and Environmental Maintenance Failures
Summary
The facility failed to maintain a functioning Quality Assurance and Performance Improvement (QAPI) program, as evidenced by ongoing deficiencies in the timely repair and maintenance of essential equipment and the failure to provide a safe, sanitary, and comfortable environment for residents. Multiple observations revealed that several resident rooms had malfunctioning overhead lights, with one resident reporting a flickering light and another stating their light did not work at all. In another instance, a resident received a replacement bed that was also not functioning properly, specifically the head adjustment feature. Staff confirmed these issues during interviews and observations. Environmental concerns were also documented throughout the facility. The activities room had a ceiling tile with visible mold and water damage, loose baseboards, and bio growth both inside and outside the room. Water accumulation was observed in a garbage can placed under the damaged ceiling. The pantry room in the east hallway had a refrigerator and freezer with temperatures outside the normal range, resulting in thawed and lukewarm food items. The inside of the pantry cabinet showed significant mold growth, and a ceiling tile was partially hanging down. Additionally, a wall fan vent had an opening to the outside, allowing debris and leaves to enter. Flooring in several areas was loose and could be lifted easily, posing a tripping hazard, and a bathroom had a missing ceiling tile with exposed pipes. Air conditioning issues were persistent, with one unit (A/C #11) reported as non-functional since the previous October. Residents reported discomfort due to non-working A/C units, with one resident's room measured at 80 degrees Fahrenheit and the A/C filter covered in black bio growth. Staff interviews confirmed that the maintenance issue had been ongoing and that the facility lacked a policy for A/C maintenance and repairs. The administrative team was unaware of some of these issues until they were pointed out during the survey. These findings demonstrate a lack of effective systems for identifying, tracking, and correcting quality deficiencies, as required by the facility's QAPI program.
Plan Of Correction
This Plan of Correction constitutes this facility's written allegation of compliance for deficiencies cited. However, submission of this Plan of Correction is not an admission that the deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by state and federal law. F867 What corrective actions(s) will be accomplished for those residents found to have been affected by the deficient practice: 1. Quality Assurance Performance Improvement Plan meeting was held 6/13/2025 and 6/18/2025 to review F908. 2. By 7/12/2025, Roof top Air Conditioning Unit (#11) repaired by 7/12. 3. By 7/12/2025, Residents #5, #6, #7, #11, #12, and #13 interviews completed and rooms audited. 4. By 7/12/2025, Residents #5, #6, and #11 overbed light repaired. 5. By 7/12/2025, Resident #7 bed replaced, with head of bed working properly. 6. By 7/12/2025, the ceiling tile in the activities room on the south hallway replaced. 7. By 7/12/2025, the loose baseboard along the perimeter of the activities room replaced. 8. By 7/12/2025, the green bio-growth substance outside of the sliding glass door to the left of the activities room exiting the courtyard was cleaned. 9. By 7/12/2025, the ceiling outside of the activities room adjacent to the ceiling file was repaired and repainted. 10. By 7/12/2025, the refrigerator in the nourishment room on east hallway was removed, discarded, and replaced. The cupboard under the sink of the east pantry room was cleaned. The ceiling tile above the door was replaced. The exhaust fan in the wall with the collection of debris was cleaned. 11. By 7/12/2025, the air conditioning was replaced in Resident #12 and #13 shared room, and the missing ceiling tile in the bathroom was replaced. 12. By 7/12/2025, the flooring in room 215 was replaced. 13. By 7/12/2025, the loose flooring was replaced in the east 200 hallway. 14. By 7/12/2025, common areas, to include food storage pantry areas, were audited to ensure equipment is safe, sanitary, comfortable, and operational. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: By 7/12/2025, resident interviews, resident rooms, and common areas will be audited to ensure equipment is safe, sanitary, comfortable, and operational. The audit includes roof top AC units, resident room HVAC, refrigerators and cupboards in pantry rooms, ceiling tiles, flooring, beds for proper function, resident room overbed lights, and fans in the pantry rooms. Maintenance equipment and/or environmental items identified on the audit will be repaired or replaced as/or designee educated staff on the Quality Assurance Performance Improvement process. Additional corrective actions include: - Resident #7 bed replaced, with head of bed working properly. - The ceiling tile in the activities room on the south hallway replaced. - The loose baseboard along the perimeter of the activities room replaced. - The green bio-growth substance outside of the sliding glass door to the left of the activities room exiting the courtyard was cleaned. - The ceiling outside of the activities room adjacent to the ceiling file was repaired and repainted. - The refrigerator in the nourishment room on east hallway was removed, discarded, and replaced. The cupboard under the sink of the east pantry room was cleaned. The ceiling tile above the door was replaced. The exhaust fan in the wall with the collection of debris was cleaned. - The air conditioning was replaced in Resident #12 and #13 shared room, and the missing ceiling tile in the bathroom was replaced. - The flooring in room 215 was replaced. - The loose flooring was replaced in the east 200 hallway. - Common areas, including food storage pantry areas, were audited to ensure equipment is safe, sanitary, comfortable, and operational. How you will ensure the practice does not recur: 1. By 7/12/2025, the Administrator and/or designee will educate staff on the Quality Assurance Performance Improvement (QAPI) process. 2. By 7/12/2025, the Administrator and/or designee will educate staff on reporting of safe, sanitary, comfortable, and operational equipment concerns via TELS. 3. Newly hired staff will be educated on QAPI and reporting equipment, maintenance, and environmental concerns via TELS. How the corrective action will be monitored to ensure the practice will not recur: The Administrator and/or designee will conduct an interview of 5 residents and audit 5 resident rooms on each unit to ensure equipment is safe, sanitary, comfortable, and operational. This audit will be completed weekly for 4 weeks, then monthly for 3 months. The maintenance director and/or designee will audit the roof top AC units weekly for 4 weeks and then monthly for 3 months. The findings of the audits will be reported to the Quality Assurance Performance Improvement committee monthly until the committee determines substantial compliance is maintained.
Penalty
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The facility failed to include adverse event monitoring of alleged physical and sexual abuse in its QAPI activities. Surveyors reviewed 2 FRIs involving injuries of unknown origin and 4 FRIs involving alleged abuse, and the DON stated these incidents had not been reviewed or tracked through the QAPI process, despite facility policy requiring abuse, neglect, and misappropriation investigations to be reviewed by QAPI.
QAPI failed to identify all causal factors related to two elopements and smoking noncompliance involving two residents. The committee did not determine all contributing factors or what actions were needed to prevent further resident safety concerns. The facility’s policy required systematic analysis and root cause review, but the investigation showed the events involved a resident accessing clippers and cutting a screen, a window that was not properly secured, and smoking concerns tied to the absence of a locked container for smoking materials.
QAPI Committee Failed to Address Repeated Deficiencies: The facility’s QAPI committee did not successfully implement prior plans of correction tied to repeated survey deficiencies. Current findings showed ongoing problems with MDS accuracy, care plan creation and revision, quality care, safety hazards, incontinence and catheter care, IV catheter maintenance, narcotic accountability, and infection control, despite prior audit-based plans being reported to the QAPI committee.
Surveyors found that the facility’s QAPI/QAA program was ineffective in correcting repeated deficiencies related to improper medication storage (F0761). Despite having a written QAPI policy, holding monthly QAA Committee meetings attended by the administrator, DON, medical director, and other department heads, and reporting that direct care staff were invited to participate, the same medication storage deficiency previously cited during an earlier survey recurred. With 94 residents in care, the facility’s QAPI activities did not produce an effective plan of action to resolve and prevent the ongoing medication storage problem.
The QAA Committee failed to identify and address multiple deficient practices, including missing Medicare/Medicaid coverage liability notices, lack of a stop date for an as-needed antianxiety med, missing bed hold notification, failure to report a change in condition after an unresponsive episode, inadequate fall investigations, failure to address weight loss, missing dialysis assessments and care planning, kitchen sanitation issues, an incomplete facility assessment, and failure to provide EBP for a resident with a Foley catheter. Admin staff stated monthly QAA meetings were held with the MD, but the facility had not self-identified or corrected the deficiencies through PI monitoring.
The facility’s QAPI process was found ineffective because multiple QAPI action plans lacked a specific point person, clear completion dates, and documented monthly progress. Review of QAPI minutes showed repeated issues involving falls, dietary services, infection control, wound care, discharge documentation, pharmacy services, MDS assessments, and other areas, with no evidence that prior action items were revisited or that full PIPs were completed. The Administrator, DON, and RDI acknowledged there was no evidence of auditing, education, or other documented monitoring tied to the identified concerns, and the Administrator stated there was not yet a mechanism for residents and staff to report issues to QAPI.
Failure to Include Abuse and Injury Incidents in QAPI Review
Penalty
Summary
The facility failed to include adverse event monitoring of alleged physical and sexual abuse in its Quality Assurance and Performance Improvement (QAPI) activities. Based on record review and interviews, this was identified for 2 of 2 facility reported incidents involving injuries of unknown origin and 4 of 4 facility reported incidents involving allegations of abuse. The incidents reviewed included FRI #2670676 and #2686939 for injuries of unknown origin, and FRI #2707002, #2787931, #2987931, and #3012852 for alleged abuse. According to the facility policy, all investigations involving abuse, neglect, and misappropriation are to be reviewed by the QAPI committee. During the survey, the Nursing Home Administrator stated that resident safety is prioritized when determining areas of focus for QAPI. When asked whether any of the alleged abuse incidents or injuries of unknown origin had been reviewed or tracked through the facility's QAPI process, she stated that they had not.
QAPI Committee Failed to Fully Analyze Elopement and Smoking Noncompliance Events
Penalty
Summary
The facility’s QAPI committee failed to identify all causal factors related to two elopements involving RI #106 and RI #121 and smoking noncompliance involving RI #33 and RI #109. The report states that these deficient practices were identified through investigations of facility-reported incident/complaint/report numbers 447450, 2983895, and 2621001, and that the committee did not determine all of the factors contributing to the events or what corrective actions were needed to prevent further resident safety concerns. A review of the facility’s QAPI policy showed that the committee was expected to use systematic analysis, including root cause analysis or PDSA, to identify improvement opportunities and understand how to improve them. During interview, the Regional Administrator stated that the facility had recognized issues related to elopement and smoking noncompliance, and described the events as involving a resident accessing clippers and cutting a screen, with a window not properly secured, and smoking concerns related to the absence of a locked container for smoking materials. The report also notes that the facility had identified pressure injury concerns, but the cited deficiency focused on the QAPI committee’s failure to fully analyze the elopements and smoking noncompliance events and to determine all causal factors.
QAPI Committee Failed to Address Repeated Deficiencies
Penalty
Summary
The facility’s QAPI committee failed to correct repeated quality deficiencies and did not ensure that plans to improve the delivery of care and services effectively addressed recurring problems identified in prior and current surveys. The report states that the facility’s plans of correction for the annual survey ending July 2, 2025, included quality assurance systems and audits to maintain compliance, but the current survey ending May 18, 2026, found repeated deficiencies involving accurate MDS assessments, care plan creation and revision, quality care, safety and accident hazards, bowel/bladder incontinence and indwelling urinary catheters, IV catheter maintenance, narcotic accountability, and infection control. The report specifically notes that for each of these previously cited areas, the facility had stated in its prior plans of correction that audits would be completed and results reported to the QAPI committee for review. Despite those stated plans, the current survey found that the QAPI committee failed to successfully implement the plans to ensure MDS assessments were completed accurately, care plans were created and revised timely, quality care was provided, safety hazards were prevented, incontinence and catheter care were treated appropriately, IV catheters were maintained appropriately, narcotics were accounted for appropriately, and infection control was properly maintained.
Ineffective QAPI Program Fails to Correct Repeated Medication Storage Deficiencies
Penalty
Summary
The deficiency involves the facility’s failure to demonstrate an effective Quality Assurance and Performance Improvement (QAPI/QAA) program to correct repeated deficiencies related to medication storage (F0761). Surveyors identified that the facility had previously been cited for failing to properly store medications during a recertification and re-licensure survey with an exit date of October 31, 2024. Despite this prior citation, the same deficient practice of improper medication storage was again identified, indicating that the facility did not effectively correct or prevent recurrence of the problem area. Record review showed that the facility held monthly QAA Committee meetings, as evidenced by sign-in sheets dated 02/10/2026, 03/10/2026, and 04/14/2026. Attendees included the Administrator, DON, Medical Director, and other department heads. The facility’s written QAPI policy, implemented on 9/1/2022 and revised on 1/1/2026, stated that it was the facility’s policy to maintain an effective, comprehensive, data-driven QAPI program focusing on outcomes of care and quality of life, and that the QA Committee was to develop and implement appropriate plans of action to correct identified quality deficiencies. During an interview, the Administrator reported that the QAA Committee membership included the Medical Director, nursing home administrator, other department heads, and invited direct care staff, and that they met monthly and as needed to assess ways to make improvements. However, the survey findings indicated that, despite these meetings and the written QAPI policy, the facility’s QAPI/QAA activities did not result in an effective plan of action to correct the repeated deficiency in medication storage. At the time of the survey, there were 94 residents residing in the facility, and the Administrator was informed of concerns related to the repeated deficiencies and the facility’s QAPI activities.
Plan Of Correction
The facility continues to ensure that the quality assurance and improvement program is used to identify and track areas for improvement throughout the facility. IMMEDIATE CORRECTIVE ACTION Ad hoc QA meeting performed on 5/15/26 to address QAPI/QAA concerns and plan of action for current alleged deficiencies including alleged noncompliance with QAPI/QAA Improvement Activities. IDENTIFICATION OF OTHER RESIDENTS HAVING POTENTIAL TO BE AFFECTED All active residents in the facility can potentially be affected by the alleged deficient practice. Administrator/Risk Manager reviewed and audited previous 6 months of QA meetings on 5/18/26 to ensure areas of concern were addressed. SYSTEMATIC CHANGES On 5/19/26, ongoing in-services was conducted by Regional Consultant with facility Quality Assurance Committee about Quality Assurance and Performance improvement Policy with emphasis on implementation, monitoring, and evaluation of performance improvement projects. The Quality Assessment and Assurance Committee will meet monthly and conduct random audit of 1 current performance improvement project monthly to validate reported substantial compliance. MONITORING The Interdisciplinary Team as well as Regional Consultant will attend monthly QAPI meeting to ensure QAA Committee compliance with QAPI process. Regional Consultant will assist with random audit process for 3 months. Any and all findings will be reported during monthly quality assurance meeting until substantial compliance is achieved.
QAA Committee Failed to Identify Multiple Deficient Practices
Penalty
Summary
The facility failed to ensure its Quality Assessment and Assurance (QAA) Committee adequately identified deficient areas of practice and developed and implemented plans of action to correct them. Survey findings included multiple deficiencies that were not self-identified or corrected through performance improvement monitoring, including failure to provide Medicare/Medicaid Coverage Liability Notice forms 10055 and 10123 regarding non-coverage of skilled services, failure to ensure a stop date for a resident’s as-needed antianxiety medication, and failure to provide bed hold notification to a resident or representative when the resident was admitted to the hospital. Additional findings included failure to report a resident’s change of condition after an unresponsive episode and failure to follow up on charting after the incident, failure to investigate falls and determine root causes for several residents, failure to provide nutritional care or notify the physician of a resident’s weight loss, and failure to provide pre- and post-dialysis assessments, a dialysis contract, and a care plan for a resident receiving dialysis. The facility also failed to wear hairnets, clean the kitchen, and discard unlabeled food, failed to complete the facility assessment for the 35 residents in the building, and failed to provide Enhanced Barrier Protection for a resident with a Foley catheter. Administrative staff stated the QAA meetings were held monthly and included the medical director, and confirmed the deficiencies had not been self-identified and corrected through QAA monitoring.
Ineffective QAPI Oversight and Incomplete Performance Improvement Plans
Penalty
Summary
The facility failed to ensure an effective QAPI committee was in place to identify and address concerns in a timely and effective manner. Review of QAPI minutes and PIP documentation showed multiple action plans for issues including physical environment/pest control, care plan revisions, falls, leave of absence, dietary services, therapy/equipment, smoking policy, pharmacy services, infection control, wound care, discharge documentation, MDS 3.0 assessments, nursing point of care documentation, abuse reporting and prevention, laundry services, and PASRR. In the reviewed minutes, the plans generally identified the department responsible for the corrective action, but most did not identify a specific point person, and the monthly progress sections were blank or lacked dates and other information showing when completion was expected. The record also showed no additional information to verify that the correction plans were completed, revised when needed, or changed when they were ineffective. In several sets of QAPI minutes, previously identified action items were not revisited or followed up on, including pharmacy services, nutrition, infection control, wound care for pressure and non-pressure wounds, discharge documentation, dietary services, physical environment, and MDS assessments. During the annual survey, deficiencies were identified in many of the same areas listed in the QAPI action plans, including physical environment, care plan revisions, falls, inappropriate discharge, dietary services, pharmacy services, nutrition, infection control, wound care, discharge documentation, and MDS assessments. During interview, the Administrator, DON, and RDI stated that QAPI was intended to identify and resolve issues. The Administrator acknowledged that none of the QAPI meeting minutes had a full PIP developed and that there was no evidence of auditing, education, or other corrective measures completed to address the facility-identified concerns or ongoing monitoring to prevent recurrence. The Administrator also stated he was unaware the PIPs were not completed from QAPI meetings prior to his employment in December 2025 and confirmed there was not yet a mechanism for residents and staff to report issues to the facility's QAPI program.
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