Failure to Correct Staffing Deficiencies and Implement Effective QAPI
Penalty
Summary
The facility failed to correct previously cited deficiencies related to staffing and compliance with state regulations, as evidenced by repeated findings across multiple surveys. Documentation review showed that the facility's QAPI program was intended to establish and implement performance improvement projects and monitor corrective actions, but the same deficiencies were cited in several consecutive surveys. Specifically, the facility did not maintain state-required staffing minimums for nurse aides, LPNs, and per patient day hours, despite having plans of correction that included regular audits and QAPI committee reviews. During the survey process, it was confirmed through staff interview, including with the Nursing Home Administrator, that the facility did not effectively address or resolve the identified quality deficiencies. The repeated failure to meet staffing requirements and to implement effective corrective actions as outlined in their QAPI plans led to ongoing noncompliance with state regulations.