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F0868
F

Failure to Ensure Medical Director Attendance at QAPI Meetings

Three Rivers, Michigan Survey Completed on 10-30-2025

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 failed to ensure that the medical director or their designee attended the Quality Assurance and Performance Improvement (QAPI) committee meetings at least quarterly, as required by facility policy. Review of QAPI committee sign-in sheets showed that neither the medical director nor a designee attended any meetings from April to August 2025. During an interview, the Nursing Home Administrator (NHA) stated that significant management turnover and a change in medical directors contributed to the lack of attendance, with the former medical director not attending as required and the new medical director missing meetings due to scheduling issues. Facility policy specifies that the QAPI committee must be interdisciplinary and include the medical director or designee, meeting at least quarterly.

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