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.
Repeated F880 infection prevention and control deficiency was identified when staff failed to store respiratory equipment in a plastic bag after use for a resident. The facility had previously been cited for the same deficiency, and the Administrator reported that monthly QAPI meetings reviewed multiple data sources, including survey results, infection control data, complaints, and utilization trends.
Surveyors found persistent unsanitary conditions in the kitchen and multiple nourishment rooms, including accumulated food debris, grease buildup, and dried food residue on floors, refrigerators, and microwaves. Staff, including the RD and kitchen manager, acknowledged that cleanliness was not acceptable. Leadership confirmed that a PIP focused on dietary sanitation and regulatory compliance had been initiated but that no meaningful progress or documented audits and education had occurred, and sanitation problems continued. The facility’s own QAPI plan and dietary sanitation policies required systematic monitoring, data use, and performance improvement for housekeeping and infection control, but these processes were not effectively implemented to correct the identified deficiencies.
QAPI/QAA failed to show an effective plan of action to correct repeated deficiencies after prior citations for F761 and F689. Survey findings again identified improper medication storage and labeling during med administration and failure to prevent accident hazards, with the issues affecting 78 residents. The facility's QAPI plan called for a data-driven program, and monthly QAA meetings were documented with the Administrator, DON, Medical Director, and other dept heads present.
QAPI/QAA failed to show an effective plan to correct repeated deficiencies involving F761, F689, F690, and F867. The facility had previously been cited for these issues, and QAA meetings were held quarterly with the Administrator, DON, Medical Director, and other dept heads. During interview, the Administrator and DON said QAPI was used to review whether PIPs were working using quantitative data, but the repeated deficiency concerns remained.
The facility failed to implement and document an effective QAPI program, as required by its policy. The NHA reported having no participation in QAPI meetings, and the DON, in place since the prior year, acknowledged concerns with lack of notification of changes in condition, incomplete and inaccurate baseline care plans, incomplete comprehensive care plans that omitted respiratory care, and incomplete or inaccurate medical records, with no active PIPs addressing these issues. Review of QAPI records showed multiple PIPs initiated for change‑in‑condition notification, risk management events, documentation, and care plans, including one started after a resident’s representative was not informed of a hospital transfer following cardiac arrest, but none had supporting documentation, end dates, or evidence of monitoring or evaluation.
A facility failed to use QAPI and adverse event data to address ongoing unsafe smoking and oxygen practices. A cognitively intact resident with COPD and continuous O2, who had a documented history of smoking in his room and refusing to relinquish cigarettes, again smoked in his room while on O2, igniting his nasal cannula and sustaining facial burns and respiratory distress requiring emergent hospital transfer. Other cognitively intact smokers, including two who used O2, routinely kept cigarettes and lighters on their person, admitted to smoking in rooms or bathrooms, and did not surrender smoking materials to staff despite posted no‑smoking/O2 signs and care plans that labeled them as safe smokers. CNAs reported that most smokers refused to give up supplies, that they had repeatedly informed leadership about in‑room smoking by O2‑dependent residents, and that leadership did not implement effective changes. Staff education on smoking and O2 safety was limited to self‑reading folders with sign‑in sheets, and there was no effective QAPI‑driven root cause analysis or performance improvement to prevent recurrence, resulting in Immediate Jeopardy at a widespread level.
The facility failed to ensure its QAA/QAPI committee carried out performance improvement activities to sustain prior improvement measures. The same issues cited on the prior survey reappeared, including medications left at bedside and infection control concerns involving PPE use for a resident on standard precautions. The Administrator stated monthly QAPI meetings were held, but she had only been at the facility for about 3 weeks and had not yet reviewed the prior survey results, plan of correction, or related audits.
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