Deficient QAPI Program and Environmental Maintenance Failures
Summary
The facility failed to maintain a functioning Quality Assurance and Performance Improvement (QAPI) program, as evidenced by ongoing deficiencies in the timely repair and maintenance of essential equipment and the failure to provide a safe, sanitary, and comfortable environment for residents. Multiple observations revealed that several resident rooms had malfunctioning overhead lights, with one resident reporting a flickering light and another stating their light did not work at all. In another instance, a resident received a replacement bed that was also not functioning properly, specifically the head adjustment feature. Staff confirmed these issues during interviews and observations. Environmental concerns were also documented throughout the facility. The activities room had a ceiling tile with visible mold and water damage, loose baseboards, and bio growth both inside and outside the room. Water accumulation was observed in a garbage can placed under the damaged ceiling. The pantry room in the east hallway had a refrigerator and freezer with temperatures outside the normal range, resulting in thawed and lukewarm food items. The inside of the pantry cabinet showed significant mold growth, and a ceiling tile was partially hanging down. Additionally, a wall fan vent had an opening to the outside, allowing debris and leaves to enter. Flooring in several areas was loose and could be lifted easily, posing a tripping hazard, and a bathroom had a missing ceiling tile with exposed pipes. Air conditioning issues were persistent, with one unit (A/C #11) reported as non-functional since the previous October. Residents reported discomfort due to non-working A/C units, with one resident's room measured at 80 degrees Fahrenheit and the A/C filter covered in black bio growth. Staff interviews confirmed that the maintenance issue had been ongoing and that the facility lacked a policy for A/C maintenance and repairs. The administrative team was unaware of some of these issues until they were pointed out during the survey. These findings demonstrate a lack of effective systems for identifying, tracking, and correcting quality deficiencies, as required by the facility's QAPI program.
Plan Of Correction
This Plan of Correction constitutes this facility's written allegation of compliance for deficiencies cited. However, submission of this Plan of Correction is not an admission that the deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by state and federal law. F867 What corrective actions(s) will be accomplished for those residents found to have been affected by the deficient practice: 1. Quality Assurance Performance Improvement Plan meeting was held 6/13/2025 and 6/18/2025 to review F908. 2. By 7/12/2025, Roof top Air Conditioning Unit (#11) repaired by 7/12. 3. By 7/12/2025, Residents #5, #6, #7, #11, #12, and #13 interviews completed and rooms audited. 4. By 7/12/2025, Residents #5, #6, and #11 overbed light repaired. 5. By 7/12/2025, Resident #7 bed replaced, with head of bed working properly. 6. By 7/12/2025, the ceiling tile in the activities room on the south hallway replaced. 7. By 7/12/2025, the loose baseboard along the perimeter of the activities room replaced. 8. By 7/12/2025, the green bio-growth substance outside of the sliding glass door to the left of the activities room exiting the courtyard was cleaned. 9. By 7/12/2025, the ceiling outside of the activities room adjacent to the ceiling file was repaired and repainted. 10. By 7/12/2025, the refrigerator in the nourishment room on east hallway was removed, discarded, and replaced. The cupboard under the sink of the east pantry room was cleaned. The ceiling tile above the door was replaced. The exhaust fan in the wall with the collection of debris was cleaned. 11. By 7/12/2025, the air conditioning was replaced in Resident #12 and #13 shared room, and the missing ceiling tile in the bathroom was replaced. 12. By 7/12/2025, the flooring in room 215 was replaced. 13. By 7/12/2025, the loose flooring was replaced in the east 200 hallway. 14. By 7/12/2025, common areas, to include food storage pantry areas, were audited to ensure equipment is safe, sanitary, comfortable, and operational. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: By 7/12/2025, resident interviews, resident rooms, and common areas will be audited to ensure equipment is safe, sanitary, comfortable, and operational. The audit includes roof top AC units, resident room HVAC, refrigerators and cupboards in pantry rooms, ceiling tiles, flooring, beds for proper function, resident room overbed lights, and fans in the pantry rooms. Maintenance equipment and/or environmental items identified on the audit will be repaired or replaced as/or designee educated staff on the Quality Assurance Performance Improvement process. Additional corrective actions include: - Resident #7 bed replaced, with head of bed working properly. - The ceiling tile in the activities room on the south hallway replaced. - The loose baseboard along the perimeter of the activities room replaced. - The green bio-growth substance outside of the sliding glass door to the left of the activities room exiting the courtyard was cleaned. - The ceiling outside of the activities room adjacent to the ceiling file was repaired and repainted. - The refrigerator in the nourishment room on east hallway was removed, discarded, and replaced. The cupboard under the sink of the east pantry room was cleaned. The ceiling tile above the door was replaced. The exhaust fan in the wall with the collection of debris was cleaned. - The air conditioning was replaced in Resident #12 and #13 shared room, and the missing ceiling tile in the bathroom was replaced. - The flooring in room 215 was replaced. - The loose flooring was replaced in the east 200 hallway. - Common areas, including food storage pantry areas, were audited to ensure equipment is safe, sanitary, comfortable, and operational. How you will ensure the practice does not recur: 1. By 7/12/2025, the Administrator and/or designee will educate staff on the Quality Assurance Performance Improvement (QAPI) process. 2. By 7/12/2025, the Administrator and/or designee will educate staff on reporting of safe, sanitary, comfortable, and operational equipment concerns via TELS. 3. Newly hired staff will be educated on QAPI and reporting equipment, maintenance, and environmental concerns via TELS. How the corrective action will be monitored to ensure the practice will not recur: The Administrator and/or designee will conduct an interview of 5 residents and audit 5 resident rooms on each unit to ensure equipment is safe, sanitary, comfortable, and operational. This audit will be completed weekly for 4 weeks, then monthly for 3 months. The maintenance director and/or designee will audit the roof top AC units weekly for 4 weeks and then monthly for 3 months. The findings of the audits will be reported to the Quality Assurance Performance Improvement committee monthly until the committee determines substantial compliance is maintained.
Penalty
Resources
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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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