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.
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.
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.
The QAPI Committee failed to sustain corrective actions for infection control, resulting in repeat deficiencies. Two residents were affected when a nurse did not perform hand hygiene or use appropriate PPE during PEG tube medication administration, and an LPN did not follow enhanced barrier precautions or glove-changing protocols during wound care.
The facility was cited for failing to ensure incontinent residents received proper care to prevent urinary tract infections and for not consistently following infection control practices during perineal care. These deficiencies were previously identified and recurred during the current survey, with interviews confirming staff awareness of the repeat issues.
The facility's QAPI committee failed to maintain and monitor interventions after a recertification survey, leading to repeated deficiencies. Significant staff turnover, including the Infection Control Nurse/Educator, contributed to the halting of EMBRACE rounds, which are designed to identify and correct issues. While issues were identified, follow-up was insufficient, resulting in persistent deficiencies.
The facility's QAA committee failed to maintain and monitor interventions after a recertification survey, leading to repeated deficiencies in areas such as ADL care. Despite implementing EMBRACE rounds to identify issues, the facility struggled with follow-up and addressing root causes, resulting in a pattern of ineffective quality assurance efforts.
The facility's QAPI/QAA committee failed to maintain and monitor interventions, resulting in repeated deficiencies in ADL care, psychotropic medication monitoring, and infection control. Despite efforts to implement a Performance Improvement Plan, issues persisted due to ineffective communication, lack of accountability, and oversight within the facility.
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