Deficient QAPI Program and Environmental Maintenance Failures
Penalty
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.