Failure to Integrate Respiratory-Related Deaths and Tracheostomy Incidents into QAPI and Required Reporting
Summary
The deficiency involves the facility’s failure to use its QAPI and QAA processes to identify, report, investigate, analyze, and prevent adverse events related to three respiratory‑related resident deaths, and to document corrective actions. Surveyors found that the facility did not include all three deaths, particularly one resident’s death, in its QAPI review despite the events involving serious clinical issues with ventilators and tracheostomies. Two residents on ventilators experienced critical tracheostomy events: in one case, respiratory staff changed a tracheostomy when they were not supposed to, and in another, a tracheostomy flange broke, causing the tracheostomy to become dislodged. Both residents went into cardiac arrest and died. The facility also failed to ensure residents had access to outside provider appointments for tracheostomy care and did not follow verbal orders for tracheostomy changes. The report further notes that the facility did not ensure residents were free from neglect and did not meet reporting requirements for incidents involving serious bodily injury. For two residents, the facility did not provide access to outside tracheostomy care as ordered, and verbal orders for tracheostomy changes were not followed. One comatose resident in a vegetative state experienced a broken tracheostomy flange, resulting in a dislodged tracheostomy, cardiac arrest, and death. For this same resident, the State Survey Agency and Adult Protective Services were not notified when the tracheostomy flange broke and the resident died, despite the requirement to report such events within two hours. During interview, the Administrator stated that deaths were reviewed in QAPI with a focus on staff adherence to procedure and reported that residents associated with the immediate jeopardy events had been addressed in QAPI, but one resident’s death had not been reviewed. The Administrator also stated he was not informed of one resident’s death and the broken flange until the following morning and indicated that the contracted respiratory company was responsible for respiratory equipment and had not reported any equipment issues.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
QAPI committee minutes showed department data being presented, but the DON and administrator did not document analysis, measurable goals, benchmarks, or a plan of action. Topics such as falls, alarms, skin issues, weights, antipsychotic use, infection control, and a 2026 PIP on moderate to severe pain in long stay residents were reviewed without resident-specific discussion, evaluation of prior actions, or evidence of how goals would be achieved.
QAA Committee Failed to Address Multiple Deficient Practices: Surveyors found that the facility's QAA/QAPI process did not adequately identify or correct multiple deficient practices affecting residents. Deficiencies included failure to post survey results, provide bed hold policy information, develop a comprehensive wound care plan, ensure accurate treatment documentation, provide ordered edema care, supervise for elopement, follow infection control practices, verify insulin competency and labeling, maintain RN coverage, provide required in-service training, employ a certified Dietary Manager, provide a nourishing evening snack, and properly store, prepare, and serve food.
A facility's QAPI committee did not develop a PIP to address a choking incident involving a resident with dysphagia on a Level 6 soft and bite-sized diet. Staff confirmed the resident ate regular-sized marshmallows kept in the room, and the resident was later found on the floor with marshmallow-like material removed during suctioning. The facility's QAPI process had monitored food temperatures but not diet accuracy, and the dietary QAPI process did not include diet accuracy.
Repeat deficiencies were identified in F812, F880, F725, and F684 after review of the State Agency Website, Federal Provider History Report, QAPI, staff interview, and policy review. The facility had prior citations in each category across multiple surveys, and the Administrator acknowledged the repeated issues and attributed them to staff turnover.
QAPI Program Failed to Track MDS Errors and Ongoing Legionella Detection. The facility did not identify, monitor, or correct facility-wide issues involving inaccurate MDS submissions and continued legionella pneumophila detection in the kitchen cooling tower. The MDSC was unfamiliar with PASRR and could not explain inaccurate assessments submitted for most residents reviewed, while the DON was unaware of the errors. Quality Council minutes showed no PIP, audit findings, trend review, or tracking for either the MDS issue or the ongoing legionella findings, and the DON stated these issues had not been identified or tracked in QAPI.
The facility failed to identify and correct a resident’s significant medication errors involving blood sugar checks, heparin, and insulin injections, and also failed to identify and correct quality issues related to the resident’s nutrition and hydration status that led to emergent hospitalization. The NHA confirmed these issues during the QAPI interview, and the findings were reviewed with the NHA, DON, and CRN at exit conference.
QAPI Committee Failed to Document Data Analysis, Measurable Goals, and Action Plans
Penalty
Summary
The facility failed to ensure data submitted to the QAPI committee was analyzed and documented with measurable goals, benchmarks, and a plan of action. Review of quarterly QAPI meeting minutes from June 2025 through April 2026 showed departments were submitting data, but the minutes did not show meaningful discussion of the information, resident-specific review, or documentation of how the facility intended to achieve its stated goals. The facility’s QAPI plan identified the administrator and DON as responsible for leading the program and stated that evidence-based practices and data were to be used to define goals and implement plans of action. At the June 18, 2025 QAPI meeting, falls were reported as 13 falls with 4 residents having repeated falls, but the minutes did not identify the residents, whether interventions were being monitored, whether interventions needed to change, or whether common factors such as time of day or shift were reviewed. Alarms were noted to have decreased, but no goal, benchmark, or implementation plan was documented. Skin concerns were discussed with 2 residents having pressure ulcers, but the minutes did not identify a benchmark or goal. Weight charting was discussed as improved, but there was no resident-specific discussion about whether the weights reflected high-risk issues such as severe weight loss. Antipsychotic use was also reviewed, with 9 residents noted to be on antipsychotics and 2 on hospice, but there was no documentation that specific residents were reviewed for appropriateness, monitoring, or non-pharmacological interventions. The July 25, 2025, September 17, 2025, December 2025, March 2026, and April 2026 QAPI minutes showed similar patterns of department data being presented without documented analysis, measurable goals, benchmarks, or evidence that prior actions were evaluated for effectiveness. Infection control data listed the number of infections, but there was no documented evaluation of commonalities, surveillance, or goals. Skin and antipsychotic topics continued to be reviewed in the same limited manner. The 2026 PIP on moderate to severe pain in long stay residents also lacked documentation of the need for the project, rationale for selection, measurable goals, or a plan of action. During interview, the administrator and DON stated that department heads provided data for the meetings, but there was no documented discussion, measurable goal setting, or action plan in the minutes, and the administrator acknowledged the 2026 PIP had no documented discussion, analysis, action plan, or measurable goal in the first five months of the year.
QAA Committee Failed to Address Multiple Deficient Practices
Penalty
Summary
The facility failed to ensure its QAA Committee adequately identified deficient areas of practice and developed and implemented appropriate plans of action to correct deficient practices for the 68 residents residing in the facility. The report states that the facility's QAPI plan was intended to use data collection tools and monitoring systems for proactive analysis, system failure analysis, and corrective action, and that at least annually or as needed a QAPI self-assessment would be completed with input from the QAPI team and organizational leadership to identify gaps in care and service delivery. Survey findings identified multiple deficient practices that were not adequately addressed through the facility's QAA/QAPI process. These included failure to post the most recent survey results in a readily accessible location, failure to provide written bed hold policy information when a resident was transferred to the hospital, failure to develop a comprehensive care plan for surgical wound care, staff documenting treatments as provided when they had not been performed, failure to wrap a resident's legs for dependent edema as ordered, failure to provide adequate supervision for elopement, failure to follow infection control practices with nebulizer and oxygen tubing, failure to ensure staff competency for insulin administration, failure to use an RN for at least eight consecutive hours a day seven days a week, failure to provide regular in-service education and required nurse aide training hours, failure to label and discard insulin properly, failure to employ a certified Dietary Manager, failure to consistently provide a nourishing evening snack, failure to store, prepare, and serve food properly in the kitchen, and failure to follow infection control practices including PPE use and cleaning in an isolation room.
QAPI Failed to Address Diet Accuracy After Choking Incident
Penalty
Summary
The facility's QAPI committee failed to develop a Performance Improvement Project to decrease or prevent adverse events and ensure compliance with federal requirements related to a resident choking incident. The facility's QAPI plan stated that PIPs are used to examine and improve care or services in specifically identified areas, but during interviews an administrative nurse stated that QAPI had previously monitored food temperatures and not the accuracy of diets served to residents, and a dietary supervisor confirmed the dietary QAPI process did not include diet accuracy. The choking incident involved a resident with dysphagia who was on a mechanically altered diet, Level 6 soft and bite-sized, and was at risk for aspiration and choking. The facility investigation stated the resident had been eating lunch and had a bag of marshmallows on the over-bed table, which he had been snacking on before lunch. Staff later heard a loud crash and found him prone on the floor next to his wheelchair; suctioning was performed and small white pieces of material that looked like marshmallow were removed. Surveyor review and staff interview confirmed the resident ate regular-sized marshmallows, and the State Survey Agency determined the incident resulted in an Immediate Jeopardy when staff failed to remove snack items not consistent with the resident's diet order from the room.
Repeat deficiencies not adequately addressed in QAPI/QAA process
Penalty
Summary
The facility failed to adequately address repeat regulatory violations in F812, F880, F725, and F684, despite multiple prior citations in those same categories. A review of the State Agency Website and the Federal Provider History Report showed repeated deficiencies for F684 on 8/11/22, 8/28/24, 10/7/25, and again with the survey ending 5/20/26; for F725 on 8/11/22, 2/26/24, and again with the survey ending 5/20/26; for F812 on 8/11/22, 8/28/24, 10/7/25, and again with the survey ending 5/20/26; and for F880 on 8/11/22, 2/26/24, 8/28/24, and again with the survey ending 5/20/26. The facility’s QAPI and QAA activities, staff interview, and policy review were cited as part of the review, and in an interview on 5/20/26 at 4:05 PM, the Administrator acknowledged the repeat deficiencies and stated the facility would implement performance improvement plans to address the four repeated categories, citing staff turnover as the cause for the repeated issues.
QAPI Program Failed to Track MDS Errors and Ongoing Legionella Detection
Penalty
Summary
The facility failed to ensure its QAPI program was comprehensive and data-driven when it did not identify, monitor, or correct facility-wide non-compliance involving inaccurate MDS submissions and continued detection of legionella pneumophila in the kitchen cooling tower. During a concurrent observation and interview, the list of all SNF residents in iQIES showed 16 of 22 residents as not having the mandatory PASRR level II evaluations. The MDS Coordinator stated she was not familiar with PASRR and could not explain the inaccuracies in the patient assessments she submitted, and the DON confirmed she oversaw the MDS Coordinator but was not aware that inaccurate assessments had been submitted for 16 of 22 residents. Review of the facility’s Quality Council meeting minutes for the prior three quarters showed no PIP was initiated to address inaccurate resident assessment submissions for SNF residents. There was also no evidence of MDS audit findings, tracking of error rates, or trend review by the committee. During interview, the DON stated she was responsible for identifying issues affecting SNF residents that required improvement and developing PIPs for QAPI, but her focus in the prior year had been limited to 2025 recertification survey findings related to staff annual health exams and staff performance reviews. She stated that because she was unaware inaccurate resident assessments were being transmitted, the issue had not been identified or tracked in QAPI. The facility also had ongoing legionella pneumophila detection in the kitchen cooling tower. A review of legionella test results showed the bacteria was still detected, with a recommendation that the kitchen cooling tower persisted in testing positive and that the Waste Management Program procedure dictated further remediation. Quality Council minutes for the prior three quarters showed no PIP was initiated for the ongoing detection, and there was no evidence of data tracking or remediation evaluations by Infection Prevention. The DON stated that the Infection Preventionist participated in Quality Council meetings, but the continued detection of legionella pneumophila had not been identified or tracked in QAPI.
Failure to Identify and Correct Significant Medication Errors
Penalty
Summary
The facility failed to identify and correct R11’s significant medication errors involving blood sugar checks, heparin injections, and insulin injections from 2/15/26 to 3/18/26. During the QAPI interview, the NHA confirmed that the facility also failed to identify and correct quality issues related to R11’s nutrition and hydration status, which resulted in emergent hospitalization on 3/26/26. The report further states that these issues were reviewed with the NHA, DON, and CRN during the exit conference.
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