Failure to Conduct QA Activities for Identified Facility-Wide Concerns: The facility did not carry out QA activities to obtain feedback, use data, or analyze underlying causes for facility-wide issues affecting quality of care, quality of life, and resident safety. The QAPI policy called for a systematic, interdisciplinary, data-driven approach, but staff did not discuss resident personal funds or activities in QA. A PIP for the dementia unit noted inactivity, wandering, falls, and inconsistent participation in structured activities, yet the records lacked further evaluation of the PIP and lacked documentation of QA activities related to resident access to personal funds.
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.
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.
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.
Failure to Monitor QAPI and Resident Care: The facility had repeated survey deficiencies and multiple SQOC tags despite ongoing QAPI/QAA oversight, consultant reviews, and grievance tracking. Surveyors cited repeat issues with resident rights, care planning, med errors, staffing, records, and infection control, and found immediate jeopardy for lack of comprehensive nursing assessment and intervention for 7 residents, lack of pressure sore interventions and care for 4 residents, and inadequate pain management for 1 resident. Leadership also did not identify problems with staffing levels, repositioning, pressure sore interventions, pain assessments, incontinence care, or urine odor.
Failed QAPI Program and Repeated Deficiencies: The facility failed to maintain an effective QAPI program and had repeated deficient practices across multiple areas, including resident rights, reporting and investigating allegations, care planning, ADL care, quality of care, pressure ulcer prevention, staffing, pharmacy services, unnecessary drugs, nutrition, records confidentiality, and infection prevention and control. The Administrator stated QAPI meetings had occurred without his involvement and noted the facility had PIPs in place and planned additional plans due to repeat deficiencies.
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.
Ineffective QAPI Program With Re-cited Deficiencies: The facility failed to ensure an effective QAPI program to address previously cited deficiencies, and five deficiencies were re-cited on the recertification survey, including F641, F684, F689, F812, and F880. The Administrator stated the facility had worked on the prior deficiencies in QAPI, but they remained ongoing and had been tracked for years. The QAPI policy assigned the Administrator and QAPI Committee responsibility for identifying priorities, using resident and staff input, and analyzing QAPI performance.
The facility failed to complete QAA activities to gather feedback, use data, and conduct structured analysis of problems affecting quality of care, quality of life, and resident safety. Review of QAPI meeting documentation, policy, and staff interview showed no documentation of QA activities focused on restorative services and staffing, despite the QAPI/QAA plan stating that survey findings and other data would be used for systematic action and analysis. Prior CMS and current survey findings identified related concerns.
QAPI program failed to address repeated deficiencies. Review of the facility’s visit history showed repeated F689, Free of Accident Hazards/Supervision/Devices, and F880, Infection Prevention and Control, across multiple annual surveys and complaint investigations. The QAPI plan stated it would review sources of information for gaps or patterns in care systems, and the Administrator acknowledged the repeated deficiencies and said the facility would review and discuss plans to improve.
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