Failure to Monitor Decolonization Program in QAPI
Summary
The facility failed to monitor the effectiveness of its performance improvement activities to ensure that improvements were sustained. Survey findings showed there was no evidence that the facility tracked, trended, or monitored its decolonization program, which was described by the Medical Director as a performance improvement initiative. The deficiency was identified during interview and record review, and it involved the facility’s use of chlorhexidine gluconate as a soap substitute during shower days and mupirocin 2% topical nasal ointment given on a recurring schedule. Record review showed that multiple residents had orders for mupirocin topical ointment, with 17 residents having completed courses documented over varying lengths of time. The quarterly MDS records also showed 15 residents had antibiotics checked as being taken with an indication noted. In addition, the medical record review showed that 16 residents had a diagnosis of Encounter for Prophylaxis. The Medical Director stated the mupirocin was used for the facility’s decolonization protocol to remove bacteria in the nose and skin. During interviews, the Administrator stated QAPI was tracking and trending other projects such as pressure injuries, but the decolonization program was not discussed in QAPI meetings. The Infection Preventionist stated she was aware chlorhexidine was being used and that nasal swabs were being initiated, but she was not actively involved in monitoring the program. The Medical Director stated he had implemented the decolonization program after reviewing a webinar and article, that he was tracking and trending the program, and that he had not reported or updated QAPI on it. Review of QAPI minutes dated 12/18/25, 1/15/26, and 2/19/26 showed the decolonization program was not discussed, and the facility’s QAPI plan stated that ongoing monitoring of PIPs would be documented and reported to QAPI on a regular basis.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility did not ensure its QAPI committee identified and followed through on quality concerns in a timely manner. Action plans for late medication administration, incomplete wound and skin assessments, and resident falls were created, but there was no evidence of completed audits or continued corrective action. Leadership interviews confirmed a lack of oversight and documentation, resulting in ongoing deficiencies in medication administration, pressure areas, and falls with major injury.
The facility did not maintain an effective QAPI committee, as action plans for previously identified deficiencies—such as dignity, privacy, abuse reporting, medication errors, infection control, food storage, advance directives, and environmental concerns—lacked evidence of completion or follow-up. Repeat deficiencies were found during the annual survey, including issues with pressure ulcers, expired foods, and environmental hazards. Leadership interviews confirmed the absence of a reporting mechanism for staff and residents and a lack of documentation for QAPI activities.
The facility failed to maintain an effective QAPI program, resulting in repeated deficiencies in pressure ulcer management. A resident with multiple medical conditions was not repositioned as required, and another resident's dressing changes were neglected after refusal, leading to drainage and bleeding. These issues highlight the facility's ongoing failure to adhere to care plans and policies.
The facility's Quality Assurance policy was found deficient as it lacked comprehensive procedures, including the role of the Infection Control Preventionist, feedback mechanisms, and monitoring systems. The policy did not address how performance improvements would be evaluated and sustained, affecting all 89 residents. This was confirmed by the Director of Nursing and the Administrator.
The facility failed to maintain an effective QAPI program, resulting in repeated medication administration errors over four consecutive surveys. An LPN administered Novolog insulin to a resident without priming the pen, contrary to the package instructions, which is necessary to ensure proper dosing. This deficiency had the potential to affect all 44 residents.
The facility failed to maintain an effective quality assurance program, resulting in repeated deficiencies in providing ADL care to residents. Observations during the survey revealed a resident with dirty fingernails and another with long, jagged nails and heavy facial hair, indicating inadequate personal hygiene care. These issues were confirmed by staff interviews, highlighting a systemic problem in the facility's quality assurance processes.
Failure to Follow Through on QAPI Action Plans and Audits
Penalty
Summary
The facility failed to ensure its Quality Assurance and Performance Improvement (QAPI) committee identified and followed through on quality concerns in a timely manner, affecting all 59 residents. Review of QAPI minutes and Performance Improvement Plan (PIP) documentation showed that action plans addressing late medication administration, incomplete wound and skin assessments, and resident falls with fractures were created with root causes, responsible parties, and audit plans. However, there was no evidence of continued corrective action, revision of plans when necessary, or documentation of completed audits to verify the effectiveness of these plans. Deficiencies in medication administration, significant medication errors, pressure areas, and falls with major injury were cited during the current annual survey, indicating ongoing issues in these areas. Interviews with facility leadership revealed that the Administrator was responsible for implementing and overseeing audits as part of the QA process, but there was a lack of awareness and follow-through regarding the required audits and oversight. The Regional Director of Operations and Vice President of Operations confirmed that no audits corresponding to the QAPI plans were available for surveyor review. The facility's policy required systematic gathering of information and documentation of PIPs, but this was not followed, resulting in unaddressed and unverified corrective actions for identified quality concerns.
Failure to Implement Effective QAPI Committee and Follow Through on Corrective Actions
Penalty
Summary
The facility failed to ensure an effective Quality Assurance and Performance Improvement (QAPI) committee that identified and addressed quality concerns in a timely and effective manner. Review of QAPI meeting minutes and Performance Improvement Plan (PIP) documentation revealed multiple action plans related to previous survey citations, including issues with dignity, privacy, quality of care, abuse reporting and investigation, activities of daily living, nutrition, medication errors, infection control, food storage, advance directives, and environmental concerns. However, these plans lacked evidence of completion, revision, or follow-up, as columns for completion dates and follow-up actions were consistently left blank. There was also no documentation to verify that corrective actions or PIPs were completed or that ongoing monitoring was conducted to prevent recurrence of identified issues. During the most recent annual survey, repeat deficiencies were found in several of the same areas previously cited, such as privacy, homelike environment, abuse reporting and investigation, activities of daily living, quality of care, falls, significant medication errors, infection control, expired and undated foods, advance directives, and pressure ulcers. For example, a resident with an in-house acquired pressure ulcer did not have their wound measured weekly as required, and concerns regarding pressure ulcers persisted. Additionally, environmental issues continued despite the initiation of an environmental PIP, and expired or undated foods were still present in the facility. Interviews with facility leadership, including the Administrator, DON, and COO, revealed that the QAPI process was not being effectively implemented. The COO was unaware that full PIPs, evidence of auditing, education, or other corrective measures were not completed for identified concerns. The Administrator confirmed that there was no mechanism in place for residents and staff to report issues to the QAPI program. The facility's QAPI policy stated that a comprehensive, data-driven program should be maintained, but documentation and evidence of ongoing QAPI activities were lacking.
Repeated Deficiencies in Pressure Ulcer Management
Penalty
Summary
The facility failed to maintain an effective quality assurance and performance improvement (QAPI) program, as evidenced by repeated deficiencies related to pressure ulcer management over four consecutive comprehensive surveys. The CMS Provider History Profile document indicated that the facility had been cited for not providing adequate services or treatments to prevent or heal pressure ulcers in previous surveys and complaint investigations. This ongoing issue had the potential to affect all 54 residents in the facility. Resident #8, who was admitted with multiple complex medical conditions including a stage four sacral pressure ulcer, was observed multiple times over several days lying on her back without being repositioned by staff. Despite a care plan intervention requiring repositioning every two hours, observations and interviews revealed that staff did not consistently adhere to this protocol. The resident's Braden Scale assessment indicated a moderate risk for developing pressure ulcers, yet there was no documentation of refusal to be repositioned, highlighting a lack of adherence to the care plan and facility policy. Resident #11, who also had multiple medical conditions and was at risk for pressure ulcers, had a care plan that included specific interventions for skin impairment. However, after refusing a dressing change due to anxiety and pain, there was no documentation of attempts to re-approach the resident or notify the physician. Observations revealed that the resident's dressings were not changed for several days, resulting in drainage and fresh bleeding upon removal. This lack of documentation and follow-up on the resident's care plan further exemplifies the facility's failure to effectively manage pressure ulcer care and adhere to its own policies.
Deficiency in Quality Assurance Policy and Procedures
Penalty
Summary
The facility failed to establish comprehensive written policies and procedures related to the Quality Assurance (QA) process, which had the potential to affect all 89 residents. The existing Quality Assessment and Assurance policy, dated September 2021, outlined that the committee would include the Administrator, the Director of Nursing Services, a physician designated by the facility, and other staff members. This committee was tasked with identifying issues affecting the quality of care and services provided to residents, meeting at least quarterly to address these issues, and developing and implementing corrective plans for identified deficiencies. However, the policy was found lacking in several critical areas. The policy did not include the role or participation of the Infection Control Preventionist (ICP) in the QA process. Additionally, it failed to address procedures for feedback, data collection, and monitoring, including adverse event monitoring. The policy also lacked information on how actions taken to ensure performance improvement would be evaluated and tracked to ensure that improvements were realized and sustained. These deficiencies were confirmed by the Director of Nursing and the Administrator, who verified that the facility did not have any additional policies regarding QA beyond the corporate policy from September 2021.
Repeated Medication Administration Errors in Facility
Penalty
Summary
The facility failed to maintain an effective quality assurance and performance improvement (QAPI) program, as evidenced by repeated deficiencies in medication administration identified during four consecutive comprehensive surveys. The CMS Provider History Profile document and CASPER system data revealed that the facility was cited for significant medication errors in August 2023, January 2024, and July 2024, with the same issue persisting in the current survey. This deficiency had the potential to affect all 44 residents in the facility. During the current survey, a specific incident involving a resident with multiple diagnoses, including epilepsy and type two diabetes mellitus, was observed. The resident was prescribed Novolog insulin to be administered subcutaneously before meals and per a sliding scale. An LPN was observed administering 12 units of Novolog insulin to the resident without priming the insulin pen, contrary to the instructions in the Novolog FlexPen package insert. The LPN confirmed the failure to prime the pen, which is necessary to avoid injecting air and ensure proper dosing. The facility's policy on administering medications, revised in 2012, mandates that medications be administered safely, timely, and as prescribed.
Failure in Quality Assurance Program and ADL Care
Penalty
Summary
The facility failed to maintain an effective quality assurance program to address repeated quality concerns, as evidenced by deficiencies identified during three consecutive annual surveys. The CASPER Report dated August 2, 2024, highlighted deficiencies in providing activities of daily life (ADL) care to dependent residents during the annual surveys conducted in August 2019 and August 2022. This issue affected all 61 residents in the facility, indicating a systemic problem in the facility's quality assurance processes. Specific observations during the current annual survey revealed that Resident #24, who had intact cognition and was dependent on staff for personal hygiene, had dirty fingernails with dark debris under them on multiple occasions. Similarly, Resident #44, with moderately impaired cognition and dependent on staff for ADLs, was observed with long, jagged fingernails with black/brown debris and heavy facial hair growth. These observations were confirmed by staff interviews, indicating a failure to provide adequate personal hygiene care to these residents. The facility's policy on Quality Assurance and Performance Improvement (QAPI) stated that performance improvement activities should be monitored in QAA Committee meetings, but the repeated deficiencies suggest that these activities were not effectively implemented or sustained.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
