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F0865
F

Failure to Address Repeated Quality Deficiencies in QAPI Process

Des Moines, Iowa Survey Completed on 09-11-2025

Penalty

Fine: $19,520
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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 failed to ensure an effective process for addressing previously identified quality deficiencies, as evidenced by repeated citations for infection control and maintaining a safe, clean, and homelike environment in both 2023 and 2024. Despite the facility's QAPI plan outlining a monitoring process using multiple data sources, it did not specify a method for addressing recurring deficiencies. Review of QAPI meeting minutes since November 2024 revealed that the same issues were repeatedly discussed without documented follow-through or resolution. During interviews, the DON, who serves as the acting QAPI designee, was unable to explain the lack of follow-through or documentation regarding these repeated issues, and the RDO acknowledged that previous leadership had not implemented the QAPI plan as intended.

See complete original report
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