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F0868
F

Lack of Required Physician Attendance at QAPI Meetings

Spring Lake, Michigan Survey Completed on 06-13-2025

Penalty

No penalty information released
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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 required attendance of a Medical Director or designated physician was maintained at the Quality Assessment and Assurance (QAPI) meetings at least quarterly. Review of QAPI monthly sign-in sheets from June 2024 to June 2025 showed that a physician was present only at three meetings, leaving eight months without physician representation. During an interview, the Nursing Home Administrator confirmed that monthly QAPI meetings are held but could not explain the absence of the Medical Director or a designated physician at least quarterly. This deficiency affected all 74 residents residing in the facility, as there was a lack of required medical oversight during the QAPI process.

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