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
Resources
Below are regulatory guidelines relevant to this citation:
QAPI monitoring was deficient when the facility failed to ensure performance improvement activities were properly implemented and tracked for incomplete skin assessments and food labeling issues in the snack room. The CEO stated there were three PIPs, but benchmark measurements were not consistently documented, one PIP remained active after completion because the facility did not want to fall off track, and the current measurement method did not adequately track whether improvement had occurred since implementation.
The facility failed to develop and implement a PIP for staffing concerns after those issues were identified in QAPI. The DON stated staffing had been discussed, but no current staffing PIP existed, and later said a PIP was not started because the owner said there was no staffing issue. The Administrator reported short staffing for about a month, with call outs and no shows worsening after delayed paychecks, and staff said staffing concerns were discussed in QAPI along with efforts to find solutions and hire CNAs and nurses.
QAPI failed to address resident concerns about long call light wait times, which were linked to cares not being performed and toileting tasks not being completed in a timely manner. QAPI notes showed repeated discussion of call light delays over several months, including a 9-minute response goal, follow-up by nurse managers, daily report review, and adding management staff around mealtimes, but there was no discussion about increasing facility staffing related to the concern.
Failure to Maintain Clean and Homelike Environment: Surveyors found that resident rooms, shower rooms, and common areas were not kept clean and homelike, with black buildup in grout, damaged grout, chipped floor tiles, and dusty ceiling vents. On revisit, the same environmental deficiency recurred, showing the facility did not sustain compliance with the cleanliness requirement.
QAPI Program Failed to Analyze Repeated Incontinence Care Neglect: Multiple FRIs substantiated repeated failures to provide incontinence care, including not honoring a resident’s bedpan preference and instructing the resident to urinate in an incontinence brief. Although the facility used audits, staff education, and disciplinary action, the audit tool lacked meaningful documentation, and QAPI minutes did not include data analysis, RCA, or a PIP/action plan for the recurring incontinence care issues.
Ineffective QAPI oversight and tracking of PIPs: The facility’s QAPI minutes showed multiple ongoing PIPs for concerns such as staffing, hand hygiene, incontinence care, care conferences, tray accuracy, narcotic counts, HR, and showers, but many lacked measurable goals, dates, or a designated point person. Prior action items were not shown to be revisited or followed through in later meetings, and the Administrator, DON, and Corporate RN acknowledged that not all concerns were turned into PIPs. Several of the same issues later appeared as survey deficiencies.
QAPI Monitoring Deficiencies for Skin Assessments and Food Sanitation
Penalty
Summary
The facility failed to ensure good faith efforts were made to implement and monitor performance improvement activities related to skin assessments and food sanitation. Based on the facility's QAPI Committee policy, QAPI Plan, and staff interview, the committee was expected to identify performance improvement opportunities through tracking and trending of data and to monitor progress toward goals by comparing results to benchmarks and historical performance. During interview, the CEO stated the facility had three performance improvement plans. He reported that PIP #1 addressed incomplete skin assessments and was initiated on 3/30/26 and completed the following week on 4/6/26, but it remained active because the facility did not want to fall off track. He also stated PIP #1 did not include documented benchmark measurements, although percentages were used. For PIP #2, which addressed food labeling issues in the snack room and was initiated on 5/2/26, he stated benchmark measurement was documented as improved, but percentages were not used. He stated PIP #3 was complete and no longer in place, but did not provide additional information about it. He further stated the current method used to measure performance improvement plans did not adequately track whether improvement had occurred since the date of implementation.
Failure to Develop a Staffing PIP
Penalty
Summary
The facility failed to develop and implement a performance improvement plan related to staffing concerns after those concerns were identified in QAPI. The QAPI agenda dated 6/10/2026 listed staffing concerns among the ongoing items for review, along with current PIPs and new issues/new opportunities, but the record showed no current PIP for staffing. During interviews, the DON stated that staffing had been discussed in QAPI but there was no current PIP for staffing, and later stated that low staffing levels were brought to QAPI but a PIP was not started because the owner said there were no issues with staffing. The Administrator stated that the Medical Director/owner attended QAPI meetings and was aware of the staffing issues, and that staffing had been short for about a month, with call outs and no shows worsening after delayed paychecks. The Administrator also stated there were two weekends in that month that were short. Staff reported that staffing issues were discussed in QAPI, including the need to find solutions for tired staff and no call/no shows, and that the facility discussed using a remote staffing agency and placing job advertisements for CNAs and nurses. Despite these discussions, multiple interviews confirmed that no staffing PIP had been developed because the owner said the facility did not have a staffing issue.
QAPI Committee Failed to Address Long Call Light Wait Times
Penalty
Summary
The facility’s QAPI committee failed to address resident concerns related to call light wait times, and the issue was associated with cares not being performed and toileting tasks not being completed in a timely manner. The deficiency was identified through observation, interview, and document review, and it was noted that this had the potential to affect all residents in the facility who required staff assistance with activities of daily living. During review of the 2026 QAPI notes with the administrator, staffing-related concerns were discussed across several months. The administrator stated that January notes identified concerns related to staffing and new hires, February had no notes related to call lights, March included discussion of call light times and training staff to leave lights on until cares were completed with a goal response time of nine minutes, and April and May noted long call light times with nurse managers expected to follow up. In June, long call light wait times were again identified, with discussion of pulling call light reports daily and increasing management staff on the floor around mealtimes, but the administrator stated there had not been discussion about increasing the amount of staff in the facility related to the concerns.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility was cited for failing to provide and maintain a clean, comfortable, and homelike environment for residents. During the survey ending May 8, 2026, surveyors found environmental cleanliness concerns in resident rooms, shower rooms, and common areas, including black buildup in grout, damaged grout, chipped floor tiles, and ceiling vents with accumulated dust. The cited deficiency was tied to the facility’s failure to maintain the environment in accordance with the regulatory requirement. On revisit survey ending June 25, 2026, the facility again failed to maintain a clean, comfortable, and homelike environment under the same requirement. The same environmental deficiency recurred, showing that the facility’s monitoring process did not identify that the corrective actions had not been sustained and did not prevent the return of the previously cited environmental problems.
QAPI Program Failed to Analyze Repeated Incontinence Care Neglect
Penalty
Summary
The facility failed to implement an effective, comprehensive QAPI program to track and measure performance, analyze the underlying causes of a systemic quality deficiency, and evaluate whether corrective actions were effective. South Dakota DOH facility-reported incidents substantiated multiple episodes of neglect involving incontinence care: resident 56 did not receive incontinence care, resident 55 did not receive incontinence care, resident 37 did not receive incontinence care, and resident 62’s preference to use a bedpan was not accommodated and the resident was instructed to urinate in an incontinence brief. The provider’s corrective action plan included staff disciplinary action, staff education, and audits of residents’ incontinence care, but the audit tool used for each incident contained a blank Summary of Findings section and did not document the resident concerns that were marked as reported. Review of the April and May 2026 QAPI meeting minutes showed that incident investigations were listed as a systems review topic, but the minutes did not include data analysis, root cause analysis, or a performance improvement plan/action plan related to the incontinence care incidents. The minutes also did not identify who was responsible for completing the incident investigations portion of the systems review, and there was no documented analysis of the underlying causes for the ongoing incidents of untimely and improper incontinence care. Interview with the regional nurse consultant and assistant administrator confirmed that the audit response regarding resident concerns was believed to be incorrect and that the provider had not used the incident information to identify or rule out causes or provide staff education. They also stated that a QAPI committee should have been formed several months earlier to address the incontinence care issue.
Ineffective QAPI Oversight and Tracking of 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 plans for issues such as check and changes, narcotic issues, staffing, human resources, hand hygiene, care conferences, isolation precautions, incontinence care, tray accuracy, staff competencies, family concerns regarding showers, and a fall with major injury. The documentation showed that many of these PIPs were listed as ongoing without dates, measurable goals, or a clearly identified point person, and some were marked resolved or ongoing without evidence of continued tracking or revision when needed. The record review also showed that prior QAPI action items were not revisited or followed up on after later meetings. Concerns identified in earlier QAPI meetings, including monthly and weekly weights, dietary services, clinical admission assessments, in-house pressure ulcers, maintenance, and staffing, were not shown to have been re-evaluated or completed through corrective action in the subsequent minutes reviewed. The facility policy stated that the Administrator had direct responsibility for oversight and resolution of concerns, that PIPs should be written, actively worked through to completion, revised if needed, and routinely re-evaluated, but the reviewed minutes did not show that process being consistently followed. During interview, the Administrator, DON, and Corporate RN stated the facility met monthly for QAPI but did not make all concerns into PIPs, prioritizing what they heard about most. The Administrator, DON, and Corporate RN were informed that many PIPs lacked measurable goals, dates, and assigned point persons, and that several issues later appeared as deficiencies during the annual survey, including incontinence care, medication misappropriation, staffing, personnel records, infection control, monthly and weekly weights, dietary services, medication storage, in-house pressure ulcers, care conferences, environment, staff training, performance evaluations, showers, falls, tray accuracy, and isolation precautions.
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