Failure to Conduct QA Activities for Identified Facility-Wide Concerns
Summary
The facility failed to carry out Quality Assurance (QA) activities to obtain feedback, use data, and take action to conduct structured, systematic investigations and analysis of underlying causes or contributing factors of problems affecting facility-wide processes that impact quality of care, quality of life, and resident safety. The Quality Assurance and Performance Improvement (QAPI) policy dated April 2025 directed staff to continually assess facility performance using a systematic, interdisciplinary, comprehensive, and data-driven approach to maintain and improve safety and quality. The CMS Form 2567 dated 6/26/25 identified concerns related to residents having access to personal funds and activity provision. During record review and interviews from 7/13/26 to 7/16/26, the same concerns were identified. On 7/16/26, the Administrator stated staff did not discuss personal funds or activities in QA. A Performance Improvement Plan dated 5/26/26, sent by the Administrator on 7/17/26, identified increasing activities in the dementia unit and documented unit observations of inactivity, increased wandering behaviors, increased falls, and inconsistent participation in structured activities. The facility records lacked further evaluation of the activity PIP and lacked documentation of QA activities related to resident access to personal funds.
Penalty
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The facility failed to maintain an effective QAPI program to address multiple quality deficiencies before survey. Staff did not obtain informed consent for bedrails for several residents, did not properly train CNAs on safe Hoyer lift use during a transfer, and did not ensure a planned fall-prevention intervention was in place for a resident whose care plan called for a bed overlay to define the bed edges. The QAPI team was reportedly meeting regularly and tracking several improvement areas, including UTI/ABX stewardship, hand hygiene, hydration, and CNA documentation.
QAPI committee failed to identify and address resident call light wait time concerns, despite meeting minutes noting call lights were the #1 issue. The concern was not documented in subsequent QAPI meetings, and the administrator stated there was no documentation showing follow-up, audit results, or staff feedback related to the issue. The VPO said the facility’s QAPI process should include data analysis, root cause review, action planning, and monitoring, but the administrator acknowledged the issue had not been on her radar and staff had not been informed or asked for input.
The facility failed to use its QAPI process to review a medication diversion incident involving an LPN who entered unauthorized med orders for two residents and took one medication for personal use. The event was investigated and discussed with corporate leadership, but it was not brought to the QAPI committee to review system failures, develop corrective actions, or monitor the effectiveness of interventions.
QAPI Program Failed to Correct Prior Deficiencies: The facility's QAPI program did not correct previously cited deficiencies after prior survey findings and plans of correction were reviewed. The POC for food safety issues included staff education, removal of items stored on the floor, and ongoing monitoring of dietary practices, but the DON later confirmed the facility failed to correct the quality deficiencies and did not ensure plans to improve care and services effectively addressed the identified concerns.
QAPI failed to correct 3 repeat areas of concern identified on the current recertification survey that matched prior complaint and recertification citations: Infection Prevention and Control, Reporting of Alleged Violations, and Investigate/Prevent/Correct Alleged Violation. The facility's QAPI policy required data review, root cause analysis, system improvement, benchmarks, and communication of QAPI activities, and the Administrator acknowledged the repeat concerns and stated the QAPI committee needed more extensive audits to address them.
Incomplete QAPI Documentation Provided to Surveyors: The facility failed to provide the survey team with the complete QAPI plan, including the specific quality concerns the facility had identified during its QAPI process. The DON was observed redacting those concerns with a sharpie, and later stated the facility would not share the specific problems with the state survey team, saying they could be inferred from in-service training and audit reports. The QI Nurse confirmed the Mock Survey was the document used to identify and correct problems, but the version shown to surveyors had blank spaces and handwritten additions that were inconsistent with the plan of corrections.
QAPI Program Failed to Address Consent, Transfer, and Fall-Prevention Deficiencies
Penalty
Summary
The facility failed to maintain an effective quality assessment and assurance program to address quality deficiencies before survey. The report states that the facility did not obtain informed consent from residents or their legal representatives for the installation of bedrails for four residents. It also states that the facility failed to properly train staff on the use of the Hoyer total body mechanical lift for safe resident transfer, and that one resident was transferred while suspended in the air after both staff members removed their hands from the lift and the resident during the move. The report further states that the facility failed to ensure interventions were being used to prevent resident injury and falls. One resident did not have an overlay on the bed to define the edges as directed by the plan of care. Administrative staff said the QAPI team met at least quarterly and usually monthly, and that current improvement plans included UTI and antibiotic stewardship, staff engagement communication breakout sessions, room-to-room activities, handwashing, snacks and hydration, and CNA documentation. The next QAPI meeting was to include discussion and implementation of an improvement plan for accident and fall prevention.
QAPI Committee Failed to Address Call Light Response Time Concerns
Penalty
Summary
The facility’s QAPI committee failed to identify resident call light wait time concerns before survey and did not make a good faith attempt to correct the deficiency. QAPI meeting minutes dated 3/31/25 stated that call lights tended to be the #1 issue, but call light response times were not included or mentioned again in the next six QAPI meeting minutes. The deficiency had the potential to affect all 42 residents residing in the facility. During interviews, the administrator stated she assumed the QAPI committee had followed up on call light wait time concerns, completed an audit, and determined it was not an issue, but there was no documentation to support that. The vice president of operations stated the organization uses a standardized QAPI meeting format and that facilities are expected to analyze data, discuss findings, review audit results, perform root cause analyses, develop action plans, and monitor the effectiveness of interventions. The administrator later stated the long call light response times found during survey had not been on her radar and admitted there had been no staff meetings where QAPI activities were communicated to employees or where employees were asked for feedback about resident care concerns.
Failure to Use QAPI to Review Medication Diversion Incident
Penalty
Summary
The facility failed to implement its QAPI program to address a medication diversion event involving unauthorized medication orders and misappropriation of resident medications. The facility had a policy requiring an ongoing, facility-wide, data-driven QAPI program focused on indicators of outcomes of care and quality of life, but there was no documented evidence that the incident was presented to the QAPI committee for review, system failures were identified, corrective actions were developed, or the effectiveness of interventions was monitored. Through staff reporting and investigation, the facility learned that an LPN admitted to entering unauthorized medication orders into the electronic medical record under one resident's record, discontinuing those orders, and taking the medication for personal use in December 2025. The same LPN also admitted to entering another unauthorized medication order for a second resident with the intent to obtain that medication, although the medication was removed from the medication cart before it could be taken. The Administrator stated the incident was discussed with corporate leadership and that the LPN was placed on probation with weekly audits, but the matter was not brought to the QAPI Committee because of concerns regarding employee rights and personnel matters.
QAPI Program Failed to Correct Prior Deficiencies
Penalty
Summary
The facility's QAPI program failed to correct previously cited deficiencies after prior State Survey and Certification surveys and the related plans of correction were reviewed. The facility policy for QAPI, dated 1/6/26, stated that the program is a proactive, systematic approach to improving quality of care, quality of life, and services, and that the facility would take action based on findings, measure success, and track performance to ensure improvements are sustained. However, review of the facility's deficiencies and plans of correction for surveys ending 4/15/26 and 4/24/26 showed that the facility had developed quality assurance systems to maintain compliance with cited nursing home regulations, yet the deficiencies were not corrected. The plan of correction for the survey ending 4/24/26 included education for dietary staff on food handling, food safety, and food storage; immediate removal of items stored on the floor during truck delivery; education of a staff member on food safety and cross contamination; and monitoring of cooks and dietary storage by the dietary manager or designee. It also stated that education, audit, and monitoring would be reported during the next QAPI meeting. During an interview on 7/9/26 at approximately 7:00 p.m., the DON confirmed that the facility failed to correct quality deficiencies and did not ensure that plans to improve the delivery of care and services effectively addressed the identified concerns.
QAPI Program Failed to Correct Repeat Deficiencies
Penalty
Summary
The facility failed to correct its own deficiencies for 3 of 3 areas of concern identified during the current recertification survey. The concerns matched citations from the previous complaint survey and the previous recertification survey and involved Infection Prevention and Control, Reporting of Alleged Violations, and Investigate/Prevent/Correct Alleged Violation. The facility had a census of 39 residents at the time of the survey. The facility's QAPI Program policy, revised March 2020, directed the QAPI committee to collect and analyze performance indicator data, identify and monitor facility systems and processes, use root cause analysis, help departments implement systems to correct issues in quality of care, establish benchmarks and goals, coordinate performance improvement projects, and communicate QAPI activities to the Administrator and governing body. On 7/9/26 at 2:30 PM, the Administrator stated the QAPI committee reviews prior surveys and prior deficiencies to determine root cause and develop a plan to address and correct repeat deficiencies, and acknowledged the repeat concerns identified during this survey and prior surveys. The Administrator stated the QAPI committee must complete more extensive audits to address them.
Incomplete QAPI Documentation Provided to Surveyors
Penalty
Summary
The facility failed to provide surveyor staff with the complete QAPI documentation requested during the survey, including the facility’s identified quality concerns needed to evaluate the effectiveness of the QAPI program. The facility’s undated QAPI Program policy stated the facility shall develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that identifies systems and processes that may have led to avoidable negative outcomes, and that QAPI plans and documents shall be presented to the state survey agency when needed to determine regulatory compliance. On 07/01/2026, the Administrator and DON were asked for the complete QAPI Plan, but the facility provided a version that did not include the identified quality concerns. Surveyors observed the DON using a sharpie marker to redact the specific problems identified by the facility in the QAPI plan. The DON stated the redacted information was the specific practices the facility had identified as problematic before providing the plan to the survey team, and later stated the facility would not provide the specific problems identified by the QAPI committee to the state survey team. The QAPI plan titled Mock Survey, dated 05/12/2026 through 05/13/2026, contained blank spaces where the specific concerns had been removed, and when handwritten information was later added, it was inconsistent with the plan of corrections on the same QAPI plan. The QI Nurse confirmed the Mock Survey was what the facility had used to identify and correct problems and stated the facility would not present the state survey agency with the specific problems identified.
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