Repeated Infection Control Deficiency Due to Ineffective QAPI Process
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective Quality Assurance Performance Improvement (QAPI) process to identify and correct a previously cited infection control problem. A prior CMS 2567 dated 9/25/2025 documented a deficiency for staff failure to use Enhanced Barrier Precautions during resident care for residents identified as at risk. During a subsequent complaint and facility-reported incident survey on 1/28/2026, surveyors again identified the same infection control deficiency under F880, indicating that staff continued not to use Enhanced Barrier Precautions as required for at-risk residents. In an interview on 1/28/2026, the Administrator stated that she monitors and audits the effectiveness of the QAPI process and acknowledged the concern about the repeated pattern of the F880 deficiency. The facility had a reported census of 47 residents at the time of the current survey.
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