Repeated Failure to Address Sufficient Staffing Deficiency
Penalty
Summary
The facility failed to identify and address an ongoing quality deficiency related to insufficient staffing, which had been cited in multiple previous surveys. Despite the existence of a Quality Assurance and Performance Improvement (QAPI) plan, the facility's QAPI meetings and documentation primarily focused on tracking terminations, new hires, and open positions, without evidence of implemented interventions or systemic changes to resolve the staffing issue. The QAPI workbook lacked documentation of corrective actions or monitoring of interventions for the continued deficiency. Staffing records revealed inconsistent staffing patterns, with periods where only one nurse and one aide were scheduled per villa, and instances during night shifts where a single nurse was responsible for multiple villas, sometimes also covering aide duties due to call-ins. These staffing shortages were not adequately addressed through the QAA process, and the repeated deficiency had the potential to affect all 64 residents in the facility. The report does not mention specific residents' medical histories or conditions at the time of the deficiency.