QAPI Program Failed to Identify Systemic Deficiencies
Summary
The facility’s QAPI/QAA program did not identify and correct systemic deficiencies before the survey. Survey findings documented 27 deficiencies during the recertification, complaint, and extended survey, including actual harm at F686 for treatment and services to prevent and heal pressure ulcers, F689 for freedom from accident hazards, and F744 for treatment and services for dementia. The scope and severity at F606 and F686 were identified as substandard quality of care, and widespread deficient practice was cited at multiple tags including F865 for the QAPI program, F868 for the QAA committee, F880 for infection prevention and control, F881 for the antibiotic stewardship program, F882 for designation of a dedicated infection preventionist, and F944 for QAPI training. The facility’s QAPI plan stated that it should focus on systems and processes, identify and improve system gaps, and use data to guide operations. Appendix A listed quality improvement measures for community acquired pressure injuries, rehospitalizations/ED visits, and falls with major injuries, with approaches such as reviewing Braden assessments, skin checks, dietician evaluation, fall risk assessments, and tracking and trending data at QAPI meetings. However, the surveyor noted that the 2026 QAPI plan did not document systemic problems related to infection control and prevention, including the antibiotic stewardship program and infection preventionist role, dementia care and treatment, or timeliness of medication administration. During interviews, the NHA stated the facility was planning to implement a paper log for behavior monitoring and had identified gaps in clinical oversight, but this monitoring had not already been in place. The NHA also stated the facility had recently identified concerns with falls and wounds and had started PIPs for those areas, but they were not yet fully implemented. When asked about infection prevention, the NHA stated the facility was recruiting for an IP and that the NHA, DON, and quality director or corporate support were covering the role, with no single person designated as the IP at QAPI meetings. The NHA further stated the facility had multiple problems since starting in October 2025, including falls and wounds, but did not identify all issues found during the survey, and there was no evidence the QAPI program had made a good faith attempt to correct the systemic problems related to late medications and infection control.
Penalty
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QAPI oversight failed to ensure continued monitoring of an IJ removal plan after a prior IJ related to CPR response. Although the facility audited code status and CPR certification and conducted a mock code, there was no documentation showing staff were verified as competent and confident in responding to a code blue or performing CPR. In one event, two CPR-certified CNAs failed to check a resident's pulse and breathing, obtain immediate help, activate a code blue, or call 911 when the resident was found unresponsive.
Ineffective QAPI Process With Repeat Deficiencies: The facility failed to maintain an effective QAPI process to address repeated deficiencies cited on prior recertification and complaint surveys, including repeat F760 and F880 citations. The Administrator reported daily QA meetings and monthly QAPI committee meetings, with infection control identified as a focus area and staff education, PPE competency checks, and audits already in place, but the repeat citations showed the facility had not achieved substantial compliance.
QAPI failed to identify, monitor, and correct ongoing activity program deficiencies. The Administrator stated activity programming and staffing concerns were being reviewed through QAPI, but survey observations found residents on multiple units with little to no staff-facilitated engagement, individualized programming, one-to-one activities, or organized activities despite the posted calendar. Record review also showed the person functioning as Activities Director lacked documentation of the required qualifications, and the Activities Director reported that one-to-one visits, weekend activities, and resident-specific programming were not being consistently documented or completed.
The facility failed to show good faith efforts to correct repeat quality deficiencies during the survey process. The CMS 2567 showed a prior F725 for insufficient nursing staff, and the ADON reported ongoing call light audits and on-the-spot education when staff were observed sitting at the nurse’s station while active call lights were present. The QAPI policy required the committee to analyze data, identify and resolve quality problems, use root cause analysis, and help implement systems to correct issues.
The facility failed to maintain an effective QAPI program for repeated resident-to-resident altercations in the secured dementia unit. QAPI identified increased incidents and implemented staff in-services, a hall monitor, and added activity staffing, but the DON, ADM, and other staff stated the facility did not track or trend key data such as time, location, injuries, repeated involvement, or staffing patterns. The unit had frequent physical and sexual altercations involving the same residents, and staff reported that the long hallway, limited hall monitoring, and insufficient CNA activity staffing made observation and redirection difficult.
QAPI failed to sustain oversight after a prior F584 citation for a homelike environment issue, and the facility was cited again for the same deficiency. Surveyors observed stained hallway vents and wall surfaces, damaged walls with exposed underlying material, and recurring roof leaks in multiple halls, along with prior findings of holes in resident room walls and leaks in the dining room and hallways.
QAPI Oversight Failed to Ensure CPR Response Competency
Penalty
Summary
The facility's QA/QAPI committee failed to maintain continued oversight of an IJ Removal Plan related to a previously identified deficient practice that had resulted in an Immediate Jeopardy. During review of the QAPI plan, the facility documented audits of all current residents' code status, licensed nurses' and CNAs' CPR certification and competency, and a mock code after the prior IJ. However, continued review of the QAPI showed no documentation verifying that staff were competent and confident in actually responding to a code blue and performing CPR, with only paperwork compliance and audits documented. This deficiency was reflected in the care of one resident who was found unresponsive at approximately 7:30 a.m. on [DATE]. CNA 1 and CNA 2, both CPR certified, failed to check the resident's pulse and breathing, obtain immediate assistance to initiate CPR, activate a code blue, and call 911. During an interview, the Administrator stated staff were educated on how to respond during a code blue per the QAPI plan, but staff were not consistently monitored to determine whether they were confident and comfortable initiating and conducting CPR.
Ineffective QAPI Process With Repeat Deficiencies
Penalty
Summary
The facility failed to maintain an effective QAPI process to address previously identified quality deficiencies and support substantial compliance with Federal regulations and State rules. Review of the facility’s visit history showed repeated deficient practices cited on the recertification survey and multiple complaint investigations, including repeat citations for F760 and F880 across several surveys and the current revisit survey and complaint investigations. The facility had a census of 81 residents at the time of the survey. During interview, the Administrator stated that QA meetings were held daily with the leadership team and that the QA committee met monthly. The Administrator also reported that the QAPI Committee had identified infection control as a performance improvement area and that staff had received education on PPE use, competency checks, and audits on donning and doffing PPE and handwashing. When asked how the facility was addressing the repeat deficiencies from prior surveys and complaints, the Administrator described plans to increase staff education, observe PPE use, conduct audits, implement peer-to-peer training, interview residents about staff PPE use, and assign a more experienced CNA to a leadership role on duty.
QAPI Program Failed to Correct Activity Service Deficiencies
Penalty
Summary
The facility failed to implement and maintain an effective QAPI program by not identifying, monitoring, and correcting deficiencies in its activity program. During interview, the Administrator stated the QAPI committee routinely reviewed quality measures, resident concerns, staffing concerns, activity programming, employee retention, and operational issues affecting resident care, and that activity programming and staffing concerns were being monitored through the QAPI process. The Administrator also stated concerns were identified through resident and family complaints, audits, quality measure data, staffing concerns, and trends identified by department managers. Despite those identified concerns, observations throughout the survey showed residents on multiple units were frequently sitting in common areas with limited to no staff-facilitated engagement, individualized programming, one-to-one activities, or organized activity programming occurring even though activities were scheduled on the facility calendar. Review of personnel records showed the individual functioning as Activities Director did not have documentation demonstrating the required qualifications for the position. The Activities Director stated one-to-one activity visits were not consistently documented, weekend activities were not being tracked, and resident-specific activity programming was not being completed consistently.
QAPI Process and Repeat Quality Deficiency
Penalty
Summary
The facility failed to demonstrate good faith attempts to correct quality deficiencies related to repeat deficiencies identified during the current survey process and corrections that remained incomplete within a reasonable time frame. Review of the CMS Form 2567 showed the facility had previously received deficiency F725 for insufficient nursing staff, with a correction date of 11/29/25. During the current survey, the Assistant Director of Nursing reported that the facility was continuing to monitor call lights through audits and stated that staff were educated on the spot when surveyors observed staff sitting at the nurse’s station while active call lights were present. The facility’s QAPI Program - Governance and Leadership policy, revised March 2020, stated that the QAPI Committee is responsible for collecting and analyzing performance indicator data, identifying and resolving negative outcomes and care quality problems, using root cause analysis, and helping departments implement systems to correct quality issues.
QAPI Failure to Track Repeated Resident Altercations in Dementia Unit
Penalty
Summary
The facility failed to maintain an effective QAPI program because the committee did not monitor, evaluate, or track the outcomes of its performance improvement efforts related to repeated resident-to-resident altercations in the secured dementia unit. The facility’s QAPI policy required a data-driven program that identifies quality deficiencies, analyzes information from multiple sources, and monitors corrective action plans, including at least one annual performance improvement project in a high-risk or problem-prone area. Despite this, the facility identified an increase in resident-to-resident incidents in November 2025 and implemented interventions, but the plan was not changed or expanded as the problem continued. Facility-reported incidents showed 25 resident-to-resident abuse allegations from June 2025 through March 2026, including three allegations of sexual abuse. The secured dementia unit had an average daily census of 41 residents out of 42 possible beds. The incidents included sexual conduct between residents, physical assaults, and repeated altercations involving the same residents. One resident was involved in eight resident-to-resident altercations as the perpetrator and one as a victim, and another resident was the victim of three altercations. QAPI meeting minutes showed the facility recognized the increase in incidents and identified contributing factors such as insufficient staff education, a higher number of residents who ambulated and paced in the hallways, and the need for enhanced dementia-specific activities. The facility implemented measures including staff in-services, a hall monitor, and increased activity staffing, but interviews with the ADM, AD, DSD, LN, and DON showed the facility did not track or trend key data such as time of day, location, injuries, repeated involvement, or staffing patterns. Staff stated the unit had a long hallway, one hall monitor was not enough, two CNA activity staff were insufficient, and additional direct care staffing had helped, but the facility had not reached out to corporate clinical consultants for further assistance.
QAPI Failed to Prevent Repeat Homelike Environment Deficiency
Penalty
Summary
The facility's QAPI Committee failed to sustain corrective actions after a prior citation for F584, Safe/Clean/Comfortable/Homelike Environment, was issued during the previous recertification survey. The facility was cited again for the same deficiency during the current survey, showing that ongoing monitoring and oversight did not prevent recurrence of the environmental concerns identified previously. Surveyors found that the facility did not ensure residents' right to a clean, comfortable, and homelike environment. Observations and interviews identified dark-colored staining and residue on hallway vents and wall surfaces, damaged wall surfaces with paint scraped away exposing underlying wall material, and recurring roof leaks affecting three of six halls, specifically the Northeast, North Central, and South Central halls. The prior survey had also identified resident rooms with holes in the walls and leaks in the ceilings in the dining room and hallways.
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