Repeated Deficiencies in Dignity, Food Safety, and Equipment Despite QAPI Oversight
Penalty
Summary
The facility failed to demonstrate that effective plans of action were implemented to correct previously identified quality deficiencies. Repeated deficiencies were cited in the areas of resident dignity during dining (F550), food procurement, storage, preparation, and sanitary practices (F812), and essential equipment in safe operating condition (F908). These deficiencies were observed during both the previous and current recertification surveys, indicating that the same issues persisted over time. The survey history shows that the facility was cited for F550 and F812 in both surveys, and F908 was added in the most recent survey. During a review of the Quality Assurance and Performance Improvement (QAPI) committee activities, it was found that the committee, which includes the NHA, DON, Assistant DON, Medical Director, Pharmacy Representative, and all department heads, had last met on 08/15/2025. Despite the existence of a QAPI committee and a policy outlining its purpose and scope, the facility did not provide evidence that effective corrective actions were implemented to address the recurring deficiencies. The report is based on observations, interviews, and record reviews conducted by surveyors.