Failure to Maintain QAPI Program and Address Food Temperature Concerns
Penalty
Summary
The facility failed to maintain a Quality Assurance and Performance Improvement (QAPI) program with adequate documentation of the development, implementation, and evaluation of corrective actions or performance improvement activities. Specifically, the facility did not develop and implement appropriate plans of action in response to resident concerns regarding food temperatures. Although the QAPI policy required regular meetings, documentation, and monitoring of performance improvement projects, there were no meeting minutes for several months, and the QAPI manual lacked evidence of ongoing monitoring or evaluation of corrective actions related to food temperature issues. Residents repeatedly raised concerns about cold food being delivered to their rooms, and observations confirmed that some meals continued to be served from open push carts, which did not maintain food temperature. Despite the purchase of a new food truck, there was no documentation of audit results, goals for food temperature compliance, or evaluation of the effectiveness of corrective actions. The Administrator was unaware that open push carts were still in use, and the Food Service Director had not reported this as part of the QAPI process.