Repeated Deficiencies in QAPI, Pressure Sores, Staffing, and Infection Control
Penalty
Summary
The facility failed to correct its own deficiencies and did not maintain an effective quality assurance program to ensure quality care for its residents and compliance with federal and state regulations. Over the past two and a half years, repeated deficiencies were cited in areas including pressure sores (F686), services to meet professional standards (F658), sufficient nursing staffing (F725), and infection control (F880). These deficiencies were identified during multiple surveys, including recertification, complaint, and incident surveys, with the same issues recurring across several survey cycles. The facility's QAPI plan outlined a systematic approach for identifying and addressing problems, but the repeated citations indicate that these processes were not effective in preventing recurrence of the same issues. Despite documentation of a QAPI plan and acknowledgment from the Administrator that various measures had been implemented, the facility continued to experience repeat deficiencies in critical areas affecting resident care. The Administrator confirmed that the facility had ongoing issues with pressure wounds, infection control, and staffing, and that these concerns persisted despite efforts to track and address them. The repeated nature of these deficiencies suggests that the facility's quality assurance activities were insufficient to achieve and sustain compliance with regulatory requirements.