Failure to Identify and Correct Repeated Deficiencies in Accident Hazards and Menu Compliance
Penalty
Summary
The facility failed to implement effective plans of action to correctly identify and address quality deficiencies, specifically in the areas of accident hazards (F689) and ensuring menus meet resident needs and are followed (F803). Despite having a Quality Assurance and Performance Improvement (QAPI) policy in place since June 2021, which requires systematic review of data, root cause analysis, and corrective actions, the facility continued to have repeated deficient practices in these areas. During a recertification survey, these deficiencies were cited again, indicating ongoing issues with the facility's ability to recognize and resolve these problems. Records show that the facility held monthly QAPI committee meetings with attendance from key leadership and department heads, including the Administrator, Medical Director, DON, and others. However, the ongoing citations for the same deficiencies suggest that the QAPI process was not effective in identifying or correcting the underlying issues related to accident hazards and dietary menu compliance, potentially affecting all 211 residents in the facility at the time of the survey.