Failure in QAPI and Pharmaceutical Services Leads to Immediate Jeopardy
Summary
The facility failed to implement an effective Quality Assurance and Performance Improvement (QAPI) program, which resulted in inadequate identification, analysis, and addressing of issues impacting resident care, particularly in pharmaceutical services. This deficiency had the potential to affect all 85 residents in the facility. The facility's QAPI plan, revised in 2019, was designed to monitor and evaluate the quality and safety of resident care, but it was not effectively executed. The facility did not adequately collect, monitor, or improve initiatives related to pharmaceutical services, leading to potential serious harm to residents. One specific incident involved the misappropriation of narcotic medication for a resident, which was part of a sample of 21 residents reviewed for misappropriation. This failure to monitor, protect, and prevent drug diversion placed all residents receiving narcotic pain medication at risk of serious harm due to uncontrolled pain. The facility's lack of accountability and proper documentation for narcotic medications was highlighted by discrepancies noted in the Medication Administration Record (MAR) and narcotic sheets during pharmacy audits. Interviews with facility staff, including the Director of Nursing (DON) and the Administrator, revealed that excess narcotics were improperly stored in the DON's office without proper accountability or double verification. The facility had not addressed pharmacy reports in their QAPI meetings, and there was a lack of documentation on discussions regarding pharmacy quality assurance reports. These lapses in procedure and oversight contributed to the facility's failure to provide and maintain adequate pharmaceutical services, which had the potential to cause serious harm to residents.
Removal Plan
- The resident's medications were replaced and the MAR shows no doses of the medication were missed.
- The facility system for monitoring, identifying, reporting, tracking, and investigating adverse events related to pharmacy services after noted discrepancies in narcotic medication reconciliation were reviewed and updated as necessary to ensure the safety and wellbeing of the facility residents receiving narcotic medications.
- Education for all staff was initiated on resident abuse, neglect, and misappropriation of property. This education includes the need for immediate reporting of suspicious behavior in relation to narcotic medications and is being provided to staff from all shifts and PRN and agency staff as well and will be conducted prior to their next shift. All new hires will receive this education during their orientation, prior to resident contact.
- Policies and procedures were reviewed by the Admin, DON, RDO, and RNC to identify any necessary revisions to aid in control of narcotic diversion. As a result of the review, updates on the narcotic count sheet process and accounting were revised on the policy titled Controlled Substance Administration and Accountability. These changes included updating how the total number of meds is noted on the sheets and it now requires two nurses' signatures to add or remove medications and for receiving medications from the pharmacy.
- The controlled substance card count sheet was updated to include a full count of on-hand medications, with two nurses' signatures required to add or remove medications from the cart.
- The DON and/or Admin will audit narcotic counts and medications three times weekly until no further instances of non-compliance are found to exist. Once compliance is achieved, the audits will be conducted weekly going forward.
- All audit results will be provided to the facility QAPI committee for review.
- The pharmacy report will also be reviewed by the committee.
- The facility QAPI committee will review the narcotic count audits with no issues noted. Pharmacy reports will also be reviewed by the QAPI Committee to ensure timely reporting is accomplished.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Surveyors found that the facility’s QAPI/QAA program was ineffective in correcting repeated deficiencies related to improper medication storage (F0761). Despite having a written QAPI policy, holding monthly QAA Committee meetings attended by the administrator, DON, medical director, and other department heads, and reporting that direct care staff were invited to participate, the same medication storage deficiency previously cited during an earlier survey recurred. With 94 residents in care, the facility’s QAPI activities did not produce an effective plan of action to resolve and prevent the ongoing medication storage problem.
QAPI Failure Related to Resident Smoking Material Supervision: A resident with dementia, schizophrenia, severe cognitive impairment, and continuous O2 was observed with cigarettes and a lighter in a plastic bag while on the smoking patio. Records showed the resident was supposed to have smoking materials stored by staff, and the Medical Director stated residents were not allowed to keep cigarettes or lighters. The FA stated smoking concerns had been identified earlier, but they were never brought to QAPI and no PIP was in place.
QAPI/QAA activities failed to show an effective plan of action to correct repeated deficiencies for F689 and F867. Survey history showed the facility had been cited previously for these tags, and QAA committee records showed monthly meetings with the Administrator, DON, Medical Director, and other department heads. The facility's QAPI policy stated the committee was to review quality indicators, incident reports, cited deficiencies, and grievances and develop plans of action to correct identified quality deficiencies.
The facility failed to sustain effective QAPI processes related to pharmacist medication regimen reviews, resulting in repeated noncompliance with F756. Surveyors found that medical records for four residents lacked documentation showing that a pharmacist had reviewed medications, identified potential irregularities, or made recommendations to attending physicians, an issue previously cited. The DON reported she did not have time to maintain this documentation, and the Administrator acknowledged there was no formal performance improvement project in place, though some plans were noted in QAPI minutes, and no supporting documents were produced to demonstrate ongoing compliance.
The facility lacked a functioning QAPI program and active performance improvement projects for most of the four reviewed quarters, affecting all residents. Surveyors conducting an extended survey for substandard quality of care found no documentation of QAPI activities from the prior administrator and no current performance improvement projects. An assistant administrator reported having no QAPI information before early 2026 and stated that, although the facility was expected to hold monthly Quality Assurance and quarterly QAPI meetings, three of four quarters reviewed contained no QAPI information. Facility leadership, including the administrator, assistant administrator, regional nurse consultant, and DON, were informed of these findings during survey debriefings.
The facility’s QAPI committee did not effectively identify or address lack of supervision and inadequate nurse staffing as contributing factors to multiple resident falls, most of which were unwitnessed. A UM assigned as the QA nurse for falls tracking recognized a pattern of falls related to insufficient supervision, including for two residents, but reported that staffing was only discussed generally and was not treated as a QAPI action item or performance improvement project. Although an undated QAPI plan referenced CNA and LVN staffing instability and its impact on short staffing and resident care, the interim DON and administrator acknowledged that falls, supervision, and staffing were not made a focused part of QAPI, and that supervision needs were not met when many residents were left near nurses’ stations while staff were occupied with other tasks.
Ineffective QAPI Program Fails to Correct Repeated Medication Storage Deficiencies
Penalty
Summary
The deficiency involves the facility’s failure to demonstrate an effective Quality Assurance and Performance Improvement (QAPI/QAA) program to correct repeated deficiencies related to medication storage (F0761). Surveyors identified that the facility had previously been cited for failing to properly store medications during a recertification and re-licensure survey with an exit date of October 31, 2024. Despite this prior citation, the same deficient practice of improper medication storage was again identified, indicating that the facility did not effectively correct or prevent recurrence of the problem area. Record review showed that the facility held monthly QAA Committee meetings, as evidenced by sign-in sheets dated 02/10/2026, 03/10/2026, and 04/14/2026. Attendees included the Administrator, DON, Medical Director, and other department heads. The facility’s written QAPI policy, implemented on 9/1/2022 and revised on 1/1/2026, stated that it was the facility’s policy to maintain an effective, comprehensive, data-driven QAPI program focusing on outcomes of care and quality of life, and that the QA Committee was to develop and implement appropriate plans of action to correct identified quality deficiencies. During an interview, the Administrator reported that the QAA Committee membership included the Medical Director, nursing home administrator, other department heads, and invited direct care staff, and that they met monthly and as needed to assess ways to make improvements. However, the survey findings indicated that, despite these meetings and the written QAPI policy, the facility’s QAPI/QAA activities did not result in an effective plan of action to correct the repeated deficiency in medication storage. At the time of the survey, there were 94 residents residing in the facility, and the Administrator was informed of concerns related to the repeated deficiencies and the facility’s QAPI activities.
Plan Of Correction
The facility continues to ensure that the quality assurance and improvement program is used to identify and track areas for improvement throughout the facility. IMMEDIATE CORRECTIVE ACTION Ad hoc QA meeting performed on 5/15/26 to address QAPI/QAA concerns and plan of action for current alleged deficiencies including alleged noncompliance with QAPI/QAA Improvement Activities. IDENTIFICATION OF OTHER RESIDENTS HAVING POTENTIAL TO BE AFFECTED All active residents in the facility can potentially be affected by the alleged deficient practice. Administrator/Risk Manager reviewed and audited previous 6 months of QA meetings on 5/18/26 to ensure areas of concern were addressed. SYSTEMATIC CHANGES On 5/19/26, ongoing in-services was conducted by Regional Consultant with facility Quality Assurance Committee about Quality Assurance and Performance improvement Policy with emphasis on implementation, monitoring, and evaluation of performance improvement projects. The Quality Assessment and Assurance Committee will meet monthly and conduct random audit of 1 current performance improvement project monthly to validate reported substantial compliance. MONITORING The Interdisciplinary Team as well as Regional Consultant will attend monthly QAPI meeting to ensure QAA Committee compliance with QAPI process. Regional Consultant will assist with random audit process for 3 months. Any and all findings will be reported during monthly quality assurance meeting until substantial compliance is achieved.
QAPI Failure Related to Resident Smoking Material Supervision
Penalty
Summary
The facility failed to develop, implement, and maintain an effective QAPI program after identifying smoking material concerns for residents, including a resident with dementia, schizophrenia, and continuous oxygen use. Resident #15’s record showed chronic obstructive pulmonary disease requiring oxygen at 2 liters per minute via nasal cannula, impaired cognitive function related to dementia, and a supervised smoker status with instructions to return all smoking materials to the Activities Department after smoking. A quarterly smoking assessment documented that staff were responsible for storing the resident’s lighter and cigarettes, and the resident’s BIMS score was 6, indicating severe cognitive impairment. During observation of the designated smoking patio, Resident #15 was seen sitting in a wheelchair with a plastic bag on her lap. Closer observation showed the bag contained cigarettes and a lighter. Staff B, a CNA and Activities Director, stated the resident required a smoking apron and that they were in the process of removing the cigarettes from her possession. Review of the smoking records for all 27 residents identified as smokers showed care plan interventions requiring return of smoking materials to the Activities Department after re-entering the building after smoking. The Medical Director stated that residents were not permitted to keep cigarettes or lighters and that smoking materials were to be supervised by staff regardless of BIMS score. He also stated that residents with a low BIMS score or those receiving oxygen should not have access to smoking materials. The Facility Administrator stated she had identified smoking concerns when she was hired, including residents smoking whenever they wanted, a nonworking fire alarm, and no fire watch, but she never brought the issue to QAPI and had no active or completed PIPs for identified quality deficiencies. The DON stated the smoking concerns related to residents keeping smoking paraphernalia on their person were planned for the next QAPI meeting.
QAPI/QAA Deficiency Review and Corrective Planning
Penalty
Summary
The facility's QAPI/QAA activities failed to demonstrate an effective plan of action to correct repeated deficiencies in the problem area, as evidenced by repeated deficient practices for F689-Free of Accident and Hazards/Supervision/Devices and F867; QAPI/QAA improvement activities. The facility had 147 residents at the time of survey. Record review of the facility's survey history showed it was cited for F689 and F867 during the recertification and re-licensure survey with an exit date of October 24, 2024. Review of the QAPI Committee Meeting sign-in sheets dated 02/17/2026, 03/17/2026, and 04/21/2026 showed the QAA Committee met monthly and included the Administrator, Medical Director, DON, other department heads, and staff members. During interview, the Administrator stated the members included the Medical Director, nursing home administrator, pharmacist, compliance director, infection preventionist, and some nurses, and that the group met every month and as needed to identify trends and improve quality of care and quality of life. Review of the facility's QAPI Plan policy stated the committee was to assess resident care practices, review facility quality indicators, incident reports, deficiencies cited by AHCA, and resident grievances, and develop plans of action to correct and respond quickly to identified quality deficiencies.
Failure to Sustain QAPI Actions and Documentation for Pharmacist Medication Reviews
Penalty
Summary
The deficiency involves the facility’s failure, as part of its performance improvement activities, to take actions aimed at performance improvement, measure the success of those actions, and track performance to ensure that improvements were realized and sustained, specifically related to F756. Record review and interviews showed that the facility did not maintain documentation in the medical records to demonstrate that a pharmacist reviewed residents’ medications, identified potential irregularities, or provided recommendations to the attending physician for four sampled residents, despite this same issue having been cited in the previous health survey in 2024. During an interview, the DON stated she did not have time to maintain this required documentation. In a separate interview, the Administrator stated he did not have a performance improvement project, though he had QAPI minutes that captured some improvement plans, and he believed the facility had achieved compliance with F756, which had been cited previously, but no documents demonstrating compliance were provided when requested by surveyors.
Failure to Maintain Comprehensive QAPI Program and Performance Improvement Projects
Penalty
Summary
The facility failed to implement and maintain a comprehensive QAPI (Quality Assurance Performance Improvement) program, including performance improvement projects, for at least three of four reviewed quarters, affecting all residents. During a survey in which substandard quality of care was identified and an extended survey was initiated, surveyors determined that the facility did not have evidence of ongoing QAPI activities or current performance improvement projects. In an interview, the Assistant Administrator reported having no information about QAPI prior to January 2026 and stated that the current administrative staff could not locate any documentation of QAPI activities from the previous administrator. She also stated that the facility was expected to meet monthly for Quality Assurance and quarterly for QAPI meetings, but four quarters of records were reviewed and three had no information. The Administrator and other leadership staff were informed of the substandard quality of care findings during end-of-day debriefings on multiple days of the survey. No specific resident medical histories or individual clinical conditions were described in the report; the deficiency was systemic, involving the absence of documented QAPI processes and performance improvement projects intended to monitor and improve care for all residents.
QAPI Committee Failed to Address Staffing and Supervision as Causes of Resident Falls
Penalty
Summary
The facility failed to ensure its Quality Assurance and Performance Improvement (QAPI) committee effectively identified and addressed lack of supervision and inadequate nurse staffing as contributing factors to resident falls. A facility list showed 46 resident falls between 1/1/26 and 3/30/26, of which 34 were unwitnessed, meaning staff were not present to see what happened. The unit manager (UM) assigned as the QA nurse for falls tracking since January 2026 stated she had identified a pattern of falls related to lack of supervision, including in the unwitnessed falls of Resident 1 and Resident 2. She reported that while staffing issues were discussed during monthly QA meetings, staffing had not been identified as contributing to the lack of supervision, was not included as part of the QAPI committee’s work, and was not an action item or performance improvement project, despite her belief that falls, supervision, and staffing should have been thoroughly examined by the QA/QAPI committee. During a joint interview and record review, another UM stated the QA/QAPI committee met for a quarterly meeting and that staffing had been part of QAPI, presenting an undated QAPI Performance Improvement Plan on CNA and LVN staffing stability that described staffing instability, call-offs, workers’ compensation absences, extended hiring processes, and new-hire turnover, with an impact of short staffing, increased workload, and risk to resident care and regulatory compliance. However, the interim DON stated that resident falls, supervision, and staffing should have been addressed and made a focused part of QAPI. The administrator acknowledged that residents’ supervision needs should have been met, that many residents were observed in front of the nurses’ stations while staff were occupied with other tasks, and that he had not realized staffing was such an issue. He confirmed that although staffing was discussed at every QA/QAPI meeting, it was not actively worked on by the QAPI committee, and that while falls were a QA/QAPI action item, supervision and staffing had not been identified as contributing factors, contrary to the facility’s QAPI policy requiring identification of issues, planning and implementation of actions, and monitoring and follow-up.
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