QAPI failed to sustain oversight after a prior F880 infection control citation, and the same issue recurred during the current survey. Surveyors observed failures in hand hygiene during incontinent care, failure to implement EBP during catheter care, and contamination of environmental surfaces during wound care. The DON stated hand hygiene had remained a recurring issue since the last survey and had not been monitored or tracked, and the Administrator said monthly QAPI meetings had not identified continued monitoring of hand hygiene since the prior POC.
QAPI failed to sustain correction of a prior F812 citation for food storage practices. Surveyors again found food items that were not dated, exposed foods, and expired foods, despite the facility's QAPI plan calling for quarterly measurement and trending of key performance indicators. The Administrator stated she was unsure why the dietary dept was cited again and reported that the Dietary Manager said everything was labeled and dated with no expired foods on the shelves.
The QAPI Committee failed to sustain corrective actions for previously cited food storage and sanitation deficiencies, resulting in expired and spoiled food not being discarded and improper refrigeration of items. Despite monthly QAPI meetings and existing policies, surveyors observed repeated noncompliance during kitchen inspections, confirming ongoing issues with safe and sanitary food handling.
QAPI failed to sustain oversight and corrective actions for repeat deficiencies involving PBJ staffing data reporting and the QAPI program itself. The facility was cited again for inaccurately submitting direct care staffing information to CMS and for not maintaining the QAPI program during leadership transitions, after having been cited for the same issues on a prior survey. The Administrator said QAPI meetings occur quarterly and as needed, and acknowledged the repeat PBJ issue continued, attributing the discrepancy to a possible IT processing glitch.
QAPI failed to sustain oversight after prior citations for F677 and F812 were repeated on the current survey. A resident was found with dark residue in the groin area during incontinent care, requiring multiple wipes to clean, and food items were observed improperly stored, dated, and labeled in the dry goods room, freezer, and cooler. The Administrator stated the facility had completed in-services and audits for a limited period, but the issues were not revisited after the facility believed they were resolved.
The QAPI Committee failed to prevent recurrence of a medication error rate above 5%, as evidenced by two medication errors out of 31 opportunities, including a resident not instructed to rinse after a steroid inhaler and another given an incorrect Thiamine dose. This repeated deficiency occurred despite previous citations and ongoing committee meetings.
QAPI Committee Failed to Sustain Oversight of Multiple Deficiencies: The facility's QAPI program did not remain effective during leadership changes and failed to maintain prior interventions or monitor ongoing issues. Surveyors found unresolved Resident Council grievances about pest control, linen shortages, and food quality, improper transfer/discharge notification for a resident, failure to complete PASRR follow-through for another resident, missed care plan and incontinent care interventions for a resident, and unsafe food storage and sanitation practices in the kitchen.
A resident was found with long, jagged toenails and reported not receiving assistance with nail care, despite requesting help. This repeated deficiency occurred due to staff overlooking grooming during ADL care and a lack of effective follow-through on the facility's QAPI plan, as confirmed by interviews with the Administrator and DON.
The QAPI Committee failed to sustain corrective actions for previously cited deficiencies in food storage, labeling, and dating. Despite audits and training, surveyors again found improperly stored, unlabeled, and expired food items, as well as failure to refrigerate products per manufacturer instructions. A new dietary team was in place, many of whom were not present during the last survey, contributing to the recurrence of these issues.
The QAPI Committee failed to maintain effective oversight and monitoring, resulting in a repeat citation for infection control deficiencies, including improper PEG tube and perineal care, as identified through record review, staff interviews, and policy review.
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