Repeated QAPI Failures in Food Safety, Infection Control, and Program Oversight
Penalty
Summary
The facility failed to maintain an effective Quality Assurance Performance Improvement (QAPI) process, as evidenced by repeated deficiencies in three key areas: food procurement, storage, preparation, and service (F812); the quality improvement program itself (F868); and infection prevention and control (F880). These deficiencies were cited in surveys conducted in April 2023, June 2024, and the current survey, indicating ongoing issues that were not adequately addressed or prevented by the facility's QAPI program. The facility had a reported census of 32 at the time of the survey. A review of facility policy and staff interviews revealed that, despite having a QAPI policy in place that emphasizes data-driven improvement and adherence to evidence-based practices, the facility did not ensure consistent implementation or effectiveness of these processes. The Director of Nursing and Interim Administrator acknowledged high staff turnover and stated that additional staff training had been provided, but the repeated citations suggest that the QAPI program was not functioning as intended to prevent recurrence of deficiencies in the identified areas.