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F0867
F

Lack of Documentation and Data Analysis in QAPI Performance Improvement Projects

Excelsior, Minnesota Survey Completed on 06-16-2025

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 provide evidence of a goal, action plan, or analysis of data for its identified Performance Improvement Projects (PIPs) as required by regulatory standards. Review of QAPI minutes from March through May 2025 showed that for several PIPs—including call light response times, notification of change in condition, enhanced barrier precautions, and air mattress monitoring—there was either no goal identified, no documentation of the action plan, or no analysis of data presented to the committee. In multiple instances, the documentation remained unchanged from month to month, and there was no indication that the committee had reviewed or analyzed any data related to these projects. Additionally, the QAPI minutes lacked documentation regarding the decision to end certain PIPs or the analysis of data that would support such decisions. Interviews and email communications confirmed that the facility had no additional material or details about the PIP projects beyond what was recorded in the QAPI minutes. Requests for relevant policies were not fulfilled by the end of the survey, and attempts to contact the medical director for further information were unsuccessful. This deficiency had the potential to affect all 35 residents residing at the facility.

See complete original report
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