Repeat Deficiencies Due to Ineffective QAPI Process
Penalty
Summary
The facility failed to maintain an effective Quality Assurance Performance Improvement (QAPI) process, resulting in the recurrence of three specific deficiencies—F690 (Bowel/Bladder, Incontinence, Catheter, UTI), F812 (Food Procurement, Store/Prepare/Serve-Sanitary), and F865 (QAPI Program/Plan, Disclosure/Good Faith Attempt)—that were previously cited during the 2024 recertification survey and cited again in the most recent recertification survey. The facility had a census of 51 residents at the time of the survey. Staff interviews revealed that the Quality Assurance Committee met monthly and selected focus areas based on grievances, resident council feedback, and 5-star report data, but did not prevent the recurrence of these deficiencies. Review of the facility's QAPI policy indicated a commitment to a comprehensive, data-driven program with specific processes for developing performance indicators, data collection, goal setting, and communication of findings. However, despite these outlined procedures, the facility continued to experience repeat deficiencies in the same areas, indicating that the QAPI process as implemented was not effective in preventing the reoccurrence of issues related to bowel/bladder care, kitchen sanitation, and the QAPI program itself.