Failure to Measure and Track QAPI Performance
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 implement and document effective mechanisms for monitoring and evaluating resident care as part of its Quality Assurance and Performance Improvement (QAPI) program. Record review of the facility's QAPI plan for 2024 and 2025 showed no evidence of actions, measurements, or tracking systems to ensure that efforts for improvement in identified problem areas were being made or sustained. During an interview, the Administrator was unable to provide documentation demonstrating that the facility had developed or used any actions, measurements, or tracking systems to monitor performance in these areas. This deficiency was identified through both record review and staff interview.