F0867

E

Failure to Sustain QAPI Oversight for Homelike Environment Requirements

Orlando, Florida Survey Completed on 01-22-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to fully implement its Quality Assurance and Performance Improvement (QAPI) program so that previously identified quality concerns were comprehensively monitored and sustained. Survey history showed a prior deficiency under F584 for failure to provide a homelike environment during the last recertification survey. The facility’s Plan of Correction at that time focused on re-educating staff about maintaining a clean and homelike dining environment, including providing centerpieces, and on educating new and agency staff during orientation. During the current survey, a repeat deficiency under F584 was identified, demonstrating that the earlier improvement efforts were not adequately monitored or sustained.

The Administrator reported that the prior homelike environment concern had been interpreted narrowly as an issue with missing centerpieces in the dining room, and the QAPI-driven Plan of Correction focused mainly on common areas related to the dining experience. The Administrator acknowledged that the homelike environment was not evaluated or monitored throughout the facility, and that shower rooms and residents’ rooms were not included in the POC or auditing process. She also described significant turnover and operational challenges, including three DON changes in six months, a new Maintenance Director, and periods without a Staffing Coordinator, as well as ongoing housekeeping issues and limited progress in that area. The facility’s written QAPI policy stated that the program was intended to be comprehensive and data-driven, addressing all care and services and ensuring ongoing monitoring and sustained improvement, but the survey findings showed this was not carried out in practice for the homelike environment requirement.