Failure to Hold Required QAA Meeting with All Committee Members
Penalty
No penalty information released
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 conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all required committee members for one of four quarterly meetings in Quarter One of 2025. Review of the facility's QAPI policy and attendance records revealed that the Director of Nursing (DON) was not present at the QAA meeting for that quarter. This was confirmed during an interview with the DON, who acknowledged the absence and the failure to meet the federal requirement for QAA committee composition and meeting frequency as outlined in facility policy and state code. No information regarding specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.