Failure of QAA/QAPI and Supervised Care Processes to Address Staff Care Concerns and Adverse Events
Summary
The deficiency involves the facility’s failure to ensure that its Quality Assessment and Assurance (QAA)/Quality Assurance Performance Improvement (QAPI) program functioned as described in its own policies to identify, analyze, and correct quality problems, including adverse events and staff performance concerns. The facility’s QAPI policy required consistent data collection, monitoring, and analysis of care and services, including adverse event tracking and implementation of action plans to prevent recurrence. Despite this, the facility did not ensure that the QAA committee developed and implemented appropriate plans of action to correct identified quality deficiencies, and did not implement written policies and procedures for feedback, data collection systems, and monitoring related to performance improvement plans, staff correction, and resident safety. One resident, identified as having unspecified dementia with behavioral disturbances, hypothyroidism, and major depressive disorder, was found on an incident report to have a blue/gray bruise on the nose. The report attributed contributing factors to poor safety awareness, dementia, ill-fitting glasses, an unpadded wall, and the resident resting their head on the table when fatigued. The report also documented that a CNA described the resident as difficult during care, stated the resident swung their hands during personal care, and hit their head on the wall while rolling over, though the CNA reported not seeing an injury at that time. This event triggered the use of the facility’s “Supervised Care” process for the CNA, but the documentation and implementation of that process did not follow the facility’s own Supervised Work and Supervised Care policy, which required clear documentation of reasons, staff notification, and ongoing supervision and auditing until the staff member was deemed safe to perform their job. Another resident, with Parkinson’s disease with dyskinesia and unspecified dementia without behavioral disturbance, was involved in an incident where the CNA reported that the resident stood from their wheelchair, grabbed a handrail, and had to be lowered to the floor to prevent a fall. However, video footage reviewed during the facility’s abuse investigation showed the CNA entering the resident’s room without knocking, physically pulling the resident into a wheelchair despite apparent resistance, nearly causing a fall, and later pulling the wheelchair backward while the resident stood, resulting in the resident falling to the floor. The CNA then walked away, leaving the resident on the floor for approximately two minutes before returning with a mechanical lift and then leaving again as an LPN began attending to the resident. This sequence of events, combined with prior concerns about bruising, injuries, and falls on the CNA’s shift, demonstrated that the facility’s systems for monitoring adverse events, reconciling staff accounts with objective evidence, and escalating concerns through QAA/QAPI were not effectively implemented. The facility’s Supervised Care policy required that any employee who failed to follow resident care, medication, or treatment policies, or whose care was under review, be placed on Supervised Care with documented job responsibilities, supervisory sign-off each shift, and Department Head review with notification to the Administrator if problems were identified. In this case, the Supervised Care form for the CNA listed only vague “care concerns,” lacked detailed reasons such as bruising or rough care, and had signature discrepancies, including a misspelled version of the CNA’s name that did not match other documents. There was no documented evidence that any actual auditing of the CNA’s care occurred, and the CNA stated they were never informed they were on Supervised Care and were not supervised while working. The DON later stated they did not believe the CNA was truly placed on Supervised Care and that the form may have been retroactively documented or not appropriately implemented. Additionally, the Administrator reported that the last QAPI meeting did not address this investigation while they were present, and the DON acknowledged that video footage was only reviewed reactively after an increase in bruising and incident reports, rather than as part of a systematic monitoring process. These facts show that the facility did not operationalize its QAA/QAPI policies to ensure consistent monitoring, investigation, and corrective action for identified quality and safety concerns involving staff performance and resident adverse events. Interviews further underscored the breakdown in the facility’s quality systems. The DON reported noticing a notable increase in incident reports of bruising, injuries, and falls on the unit and during the CNA’s shift, with discrepancies between the CNA’s accounts and other staff reports or observed injuries, yet there was no evidence that these concerns were effectively brought through the QAA process or resulted in a properly implemented Supervised Care plan. The Assistant DON described Supervised Care in this case as primarily an educational tool without one-to-one supervision, while the DON described Supervised Care as meaning the staff member should not be alone and should receive hands-on instruction and audits. The CNA denied being placed on Supervised Care and alleged the Supervised Care form signature was forged. The Administrator stated they were not aware of the care concerns surrounding the CNA until suspicions of multiple cases of abuse arose and acknowledged that the incident and related concerns were not discussed in the QAPI meeting while they were present. Collectively, these actions and inactions demonstrate that the facility did not follow its own policies for Supervised Care, did not consistently monitor and track adverse events and staff performance issues, and did not ensure that the QAA/QAPI committee developed and implemented appropriate plans of action to correct identified quality deficiencies.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
QAPI monitoring was deficient when the facility failed to ensure performance improvement activities were properly implemented and tracked for incomplete skin assessments and food labeling issues in the snack room. The CEO stated there were three PIPs, but benchmark measurements were not consistently documented, one PIP remained active after completion because the facility did not want to fall off track, and the current measurement method did not adequately track whether improvement had occurred since implementation.
The facility failed to develop and implement a PIP for staffing concerns after those issues were identified in QAPI. The DON stated staffing had been discussed, but no current staffing PIP existed, and later said a PIP was not started because the owner said there was no staffing issue. The Administrator reported short staffing for about a month, with call outs and no shows worsening after delayed paychecks, and staff said staffing concerns were discussed in QAPI along with efforts to find solutions and hire CNAs and nurses.
QAPI failed to address resident concerns about long call light wait times, which were linked to cares not being performed and toileting tasks not being completed in a timely manner. QAPI notes showed repeated discussion of call light delays over several months, including a 9-minute response goal, follow-up by nurse managers, daily report review, and adding management staff around mealtimes, but there was no discussion about increasing facility staffing related to the concern.
Failure to Maintain Clean and Homelike Environment: Surveyors found that resident rooms, shower rooms, and common areas were not kept clean and homelike, with black buildup in grout, damaged grout, chipped floor tiles, and dusty ceiling vents. On revisit, the same environmental deficiency recurred, showing the facility did not sustain compliance with the cleanliness requirement.
QAPI Program Failed to Analyze Repeated Incontinence Care Neglect: Multiple FRIs substantiated repeated failures to provide incontinence care, including not honoring a resident’s bedpan preference and instructing the resident to urinate in an incontinence brief. Although the facility used audits, staff education, and disciplinary action, the audit tool lacked meaningful documentation, and QAPI minutes did not include data analysis, RCA, or a PIP/action plan for the recurring incontinence care issues.
Ineffective QAPI oversight and tracking of PIPs: The facility’s QAPI minutes showed multiple ongoing PIPs for concerns such as staffing, hand hygiene, incontinence care, care conferences, tray accuracy, narcotic counts, HR, and showers, but many lacked measurable goals, dates, or a designated point person. Prior action items were not shown to be revisited or followed through in later meetings, and the Administrator, DON, and Corporate RN acknowledged that not all concerns were turned into PIPs. Several of the same issues later appeared as survey deficiencies.
QAPI Monitoring Deficiencies for Skin Assessments and Food Sanitation
Penalty
Summary
The facility failed to ensure good faith efforts were made to implement and monitor performance improvement activities related to skin assessments and food sanitation. Based on the facility's QAPI Committee policy, QAPI Plan, and staff interview, the committee was expected to identify performance improvement opportunities through tracking and trending of data and to monitor progress toward goals by comparing results to benchmarks and historical performance. During interview, the CEO stated the facility had three performance improvement plans. He reported that PIP #1 addressed incomplete skin assessments and was initiated on 3/30/26 and completed the following week on 4/6/26, but it remained active because the facility did not want to fall off track. He also stated PIP #1 did not include documented benchmark measurements, although percentages were used. For PIP #2, which addressed food labeling issues in the snack room and was initiated on 5/2/26, he stated benchmark measurement was documented as improved, but percentages were not used. He stated PIP #3 was complete and no longer in place, but did not provide additional information about it. He further stated the current method used to measure performance improvement plans did not adequately track whether improvement had occurred since the date of implementation.
Failure to Develop a Staffing PIP
Penalty
Summary
The facility failed to develop and implement a performance improvement plan related to staffing concerns after those concerns were identified in QAPI. The QAPI agenda dated 6/10/2026 listed staffing concerns among the ongoing items for review, along with current PIPs and new issues/new opportunities, but the record showed no current PIP for staffing. During interviews, the DON stated that staffing had been discussed in QAPI but there was no current PIP for staffing, and later stated that low staffing levels were brought to QAPI but a PIP was not started because the owner said there were no issues with staffing. The Administrator stated that the Medical Director/owner attended QAPI meetings and was aware of the staffing issues, and that staffing had been short for about a month, with call outs and no shows worsening after delayed paychecks. The Administrator also stated there were two weekends in that month that were short. Staff reported that staffing issues were discussed in QAPI, including the need to find solutions for tired staff and no call/no shows, and that the facility discussed using a remote staffing agency and placing job advertisements for CNAs and nurses. Despite these discussions, multiple interviews confirmed that no staffing PIP had been developed because the owner said the facility did not have a staffing issue.
QAPI Committee Failed to Address Long Call Light Wait Times
Penalty
Summary
The facility’s QAPI committee failed to address resident concerns related to call light wait times, and the issue was associated with cares not being performed and toileting tasks not being completed in a timely manner. The deficiency was identified through observation, interview, and document review, and it was noted that this had the potential to affect all residents in the facility who required staff assistance with activities of daily living. During review of the 2026 QAPI notes with the administrator, staffing-related concerns were discussed across several months. The administrator stated that January notes identified concerns related to staffing and new hires, February had no notes related to call lights, March included discussion of call light times and training staff to leave lights on until cares were completed with a goal response time of nine minutes, and April and May noted long call light times with nurse managers expected to follow up. In June, long call light wait times were again identified, with discussion of pulling call light reports daily and increasing management staff on the floor around mealtimes, but the administrator stated there had not been discussion about increasing the amount of staff in the facility related to the concerns.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility was cited for failing to provide and maintain a clean, comfortable, and homelike environment for residents. During the survey ending May 8, 2026, surveyors found environmental cleanliness concerns in resident rooms, shower rooms, and common areas, including black buildup in grout, damaged grout, chipped floor tiles, and ceiling vents with accumulated dust. The cited deficiency was tied to the facility’s failure to maintain the environment in accordance with the regulatory requirement. On revisit survey ending June 25, 2026, the facility again failed to maintain a clean, comfortable, and homelike environment under the same requirement. The same environmental deficiency recurred, showing that the facility’s monitoring process did not identify that the corrective actions had not been sustained and did not prevent the return of the previously cited environmental problems.
QAPI Program Failed to Analyze Repeated Incontinence Care Neglect
Penalty
Summary
The facility failed to implement an effective, comprehensive QAPI program to track and measure performance, analyze the underlying causes of a systemic quality deficiency, and evaluate whether corrective actions were effective. South Dakota DOH facility-reported incidents substantiated multiple episodes of neglect involving incontinence care: resident 56 did not receive incontinence care, resident 55 did not receive incontinence care, resident 37 did not receive incontinence care, and resident 62’s preference to use a bedpan was not accommodated and the resident was instructed to urinate in an incontinence brief. The provider’s corrective action plan included staff disciplinary action, staff education, and audits of residents’ incontinence care, but the audit tool used for each incident contained a blank Summary of Findings section and did not document the resident concerns that were marked as reported. Review of the April and May 2026 QAPI meeting minutes showed that incident investigations were listed as a systems review topic, but the minutes did not include data analysis, root cause analysis, or a performance improvement plan/action plan related to the incontinence care incidents. The minutes also did not identify who was responsible for completing the incident investigations portion of the systems review, and there was no documented analysis of the underlying causes for the ongoing incidents of untimely and improper incontinence care. Interview with the regional nurse consultant and assistant administrator confirmed that the audit response regarding resident concerns was believed to be incorrect and that the provider had not used the incident information to identify or rule out causes or provide staff education. They also stated that a QAPI committee should have been formed several months earlier to address the incontinence care issue.
Ineffective QAPI Oversight and Tracking of Performance Improvement Plans
Penalty
Summary
The facility failed to ensure an effective QAPI committee was in place to identify and address concerns in a timely and effective manner. Review of QAPI minutes and PIP documentation showed multiple plans for issues such as check and changes, narcotic issues, staffing, human resources, hand hygiene, care conferences, isolation precautions, incontinence care, tray accuracy, staff competencies, family concerns regarding showers, and a fall with major injury. The documentation showed that many of these PIPs were listed as ongoing without dates, measurable goals, or a clearly identified point person, and some were marked resolved or ongoing without evidence of continued tracking or revision when needed. The record review also showed that prior QAPI action items were not revisited or followed up on after later meetings. Concerns identified in earlier QAPI meetings, including monthly and weekly weights, dietary services, clinical admission assessments, in-house pressure ulcers, maintenance, and staffing, were not shown to have been re-evaluated or completed through corrective action in the subsequent minutes reviewed. The facility policy stated that the Administrator had direct responsibility for oversight and resolution of concerns, that PIPs should be written, actively worked through to completion, revised if needed, and routinely re-evaluated, but the reviewed minutes did not show that process being consistently followed. During interview, the Administrator, DON, and Corporate RN stated the facility met monthly for QAPI but did not make all concerns into PIPs, prioritizing what they heard about most. The Administrator, DON, and Corporate RN were informed that many PIPs lacked measurable goals, dates, and assigned point persons, and that several issues later appeared as deficiencies during the annual survey, including incontinence care, medication misappropriation, staffing, personnel records, infection control, monthly and weekly weights, dietary services, medication storage, in-house pressure ulcers, care conferences, environment, staff training, performance evaluations, showers, falls, tray accuracy, and isolation precautions.
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