State Findings:
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Based on staff interviews and record review, the facility’s quality assurance (QA) process failed to implement, monitor, and revise as needed the action plan developed for the recertification surveys dated 10/27/22 in order to achieve and sustain compliance. These were for recited deficiencies cited during a recertification survey on 1/12/24. The deficiencies were in the following areas: comprehensive assessment, quarterly assessment, and encoding. The continued failure during two federal surveys of record showed a pattern of the facility’s inability to sustain an effective quality assurance program.
The findings included:
This tag is cross-referenced to:
1. F636– Based on staff interviews and record review, the facility failed to complete a comprehensive Minimum Data Set (MDS) assessment within 14 days of the Assessment Reference Date (the last day of the assessment period) for 1 of 32 residents (Residents #51) whose MDS assessments were reviewed. During a previous recertification and complaint investigation on 10/27/22, the facility failed to complete admission Minimum Data Set (MDS) assessments within 14 calendar days after the residents’ admission to the facility for 3 of 36 residents whose MDS assessments were reviewed.
2. F637– Based on record review and staff interviews, the facility failed to complete a significant change Minimum Data Set (MDS) assessment within 14 calendar days after the facility determined there had been a significant change for 1 of 2 residents reviewed for significant change (Resident #69). During a previous recertification and complaint investigation on 10/27/22, the facility failed to complete a significant change Minimum Data Set (MDS) assessment within 14 calendar days after the facility determined there had been a significant change for 1 of 1 significant change MDS reviewed.
3. F638– Based on record review and staff interviews, the facility failed to complete quarterly Minimum Data Set (MDS) assessments within 14 days of the Assessment Reference Date (ARD, the last day of the look-back period) for 1 of 3 residents reviewed for resident assessment (Residents #58). During a previous recertification and complaint investigation on 10/27/22, the facility failed to complete quarterly Minimum Data Set (MDS) assessments at least every 92 days following the previous MDS assessment and/or within 14 days of the Assessment Reference Date (ARD, the last day of the look-back period) for 13 of 36 residents whose MDS assessments were reviewed.
4. F641– Based on staff interviews and record reviews, the facility failed to accurately complete a Minimum Data Set (MDS) assessment to reflect a resident’s admission to Hospice for 1 of 2 residents (Resident #13) reviewed who had received Hospice services.
During a previous recertification and complaint investigation on 10/27/22, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of discharge status for 2 of 8 discharged residents whose MDS assessments were reviewed.
During the phone interview on 1/12/24 at 2:30 PM, the Administrator stated the Quality Assurance (QA) committee 1) identifies areas of concern, 2) does a root cause analysis, 3) develops a plan, audits, and monitors that plan and 4) discusses the outcome. System changes and additional tasks would be put in place as needed to resolve the issue. Regarding the repeated citations the Administrator stated there was a high turnover with staff. The Administrator further stated there was also high turnover with the Director of Nursing staff and accountability was not present, leading to repeated deficiencies. The facility has a new management team, which has oversight and guidance from the corporate. The Administrator indicated the corporate was also directing and helping staff with daily issues and concerns, helping in identifying issues, helping with analysis the root cause, and putting monitoring systems in place. The facility’s new staff were working to ensure that high-quality resident care and services were provided. The Administrator stated the old plan would be revisited and analyzed to see where the failures and breakdowns happened. The repeated deficiencies would be monitored closely so that they do not recur.
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