QAPI Committee Lacked Required Medical Director Attendance
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to ensure that the Quality Assurance Performance Improvement (QAPI) meetings included all required members, specifically the Medical Director. During the last QAPI meeting, as evidenced by the attendance record dated 4/25/25, the line for the Medical Director's attendance was left blank, and the Administrator confirmed that the Medical Director was not present due to the meeting being scheduled at the last minute. The facility's own policy requires that each area, including the Medical Director, be represented on the Quality Assessment and Assurance (QAA) committee. At the time of the survey, the facility census showed 57 residents residing in the facility.