F0867

E

Failure of QAPI Program to Address Change in Condition Leading to Immediate Jeopardy

Longmont, Colorado Survey Completed on 03-10-2026

Penalty

Fine: $53,550

Summary

The deficiency involves the facility’s failure to maintain an effective, comprehensive, data‑driven QAPI program that identified and addressed quality of care concerns, particularly related to changes in resident condition. The facility’s QAPI policy required ongoing tracking and measuring of performance, identification and prioritization of quality deficiencies, systematic analysis of underlying causes, and development and monitoring of corrective actions, with a focus on resident safety, health outcomes, and high‑risk or problem‑prone areas. Despite this written policy, the facility did not operate its QA program in a manner that prevented repeat deficiencies, as evidenced by prior citations at F684 (quality of care) in consecutive annual recertification surveys.

Surveyors found that the QAPI committee failed to identify and address concerns related to quality of care by not ensuring that resident changes in condition were assessed, monitored, documented, and communicated when indicated. This failure rose to the level of immediate jeopardy and was associated with a serious adverse outcome resulting in a resident’s death. The cross‑referenced F684 citation states that the facility failed to provide quality care by not assessing, monitoring, documenting, and communicating a resident’s change in condition when indicated. The facility’s regulatory history showed that F684 had been cited twice previously at a D scope and severity, indicating a potential for more than minimal harm, isolated, without effective QA‑driven prevention of recurrence.

Interviews further demonstrated gaps in the QAPI program’s functioning and oversight. The medical director reported he visited at least twice a month, reviewed cases and policies presented to him, and made changes based on what was brought forward in QAPI, but he was not informed that the DON was also serving as the full‑time temporary emergency licensed NHA for several months, and he described multiple leadership changes. The DON/acting NHA stated that QAPI meetings were held monthly and covered standard topics such as admissions, discharges, falls, staffing, abuse, infection control, and grievances, with use of audit tools and tracking spreadsheets. However, she acknowledged that while change of condition evaluations were being done for skin alterations and falls, staff were “new to the other types of change of condition assessments” that required thorough assessment and notification of the physician and family/guardian, and that change of condition evaluations beyond those limited areas had not been a focus of QAPI until after the incident that led to the immediate jeopardy finding.