Repeated Staffing Deficiencies Not Addressed Through QAPI/PIP
Penalty
Summary
The deficiency involves the facility’s failure to ensure an effective QAPI/QAA process to address previously identified quality deficiencies related to insufficient nursing staff. Review of the State Survey Agency’s public website showed that the facility had been cited for staffing deficiencies on four separate surveys within a roughly two-year period, with survey end dates of 06/27/2024, 04/03/2025, 07/21/2025, and 09/17/2025, resulting in an Insufficient Nursing Staff deficiency for the fifth time in that timeframe. The facility’s QAPI plan, created on 02/26/2025, outlined how the QAPI team would identify issues and specifically listed staff retention as a QAPI improvement focus. However, during an interview with the Executive Director and Assistant Executive Director, they acknowledged that the QAPI plan did not currently include a Performance Improvement Plan (PIP) related to staffing, despite the repeated staffing-related deficiencies identified by surveyors.
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