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F0867
D

Recurring Deficiencies Due to Ineffective QAPI Implementation

Hollidaysburg, Pennsylvania Survey Completed on 06-12-2025

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's Quality Assurance Performance Improvement (QAPI) committee failed to correct recurring quality deficiencies and ensure that plans to improve the delivery of care and services were effectively implemented. Despite developing plans of correction after a previous survey, the facility continued to have repeated deficiencies in several key areas, including protection of residents from abuse and neglect, accountability for controlled medications, proper food storage and serving, and maintenance of complete and accurate medical records. The QAPI committee was responsible for reviewing audit results and ensuring compliance, but the same deficiencies were identified again in the most recent survey. Specifically, the facility had previously committed to conducting audits and reporting the results to the QAPI committee for review in response to deficiencies related to abuse/neglect, controlled medication accountability, food storage/serving, and medical record accuracy. However, the current survey found that these plans were not successfully implemented, as evidenced by the recurrence of the same issues. The report cites deficiencies under F600 (abuse/neglect), F755 (controlled medications), F812 (food storage/serving), and F842 (medical records), indicating ongoing noncompliance in these areas.

See complete original report
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