§483.75(c) Program feedback, data systems and monitoring.
A facility must establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring. The policies and procedures must include, at a minimum, the following:
§483.75(c)(1) Facility maintenance of effective systems to obtain and use of feedback and input from direct care staff, other staff, residents, and resident representatives, including how such information will be used to identify problems that are high risk, high volume, or problem-prone, and opportunities for improvement.
§483.75(c)(2) Facility maintenance of effective systems to identify, collect, and use data and information from all departments, including but not limited to the facility assessment required at §483.71 and including how such information will be used to develop and monitor performance indicators.
§483.75(c)(3) Facility development, monitoring, and evaluation of performance indicators, including the methodology and frequency for such development, monitoring, and evaluation.
§483.75(c)(4) Facility adverse event monitoring, including the methods by which the facility will systematically identify, report, track, investigate, analyze and use data and information relating to adverse events in the facility, including how the facility will use the data to develop activities to prevent adverse events.
§483.75(d) Program systematic analysis and systemic action.
§483.75(d)(1) The facility must take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements are realized and sustained.
§483.75(d)(2) The facility will develop and implement policies addressing:
(i) How they will use a systematic approach to determine underlying causes of problems impacting larger systems;
(ii) How they will develop corrective actions that will be designed to effect change at the systems level to prevent quality of care, quality of life, or safety problems; and
(iii) How the facility will monitor the effectiveness of its performance improvement activities to ensure that improvements are sustained.
§483.75(e) Program activities.
§483.75(e)(1) The facility must set priorities for its performance improvement activities that focus on high-risk, high-volume, or problem-prone areas; consider the incidence, prevalence, and severity of problems in those areas; and affect health outcomes, resident safety, resident autonomy, resident choice, and quality of care.
§483.75(e)(2) Performance improvement activities must track medical errors and adverse resident events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the facility.
§483.75(e)(3) As part of their performance improvement activities, the facility must conduct distinct performance improvement projects. The number and frequency of improvement projects conducted by the facility must reflect the scope and complexity of the facility's services and available resources, as reflected in the facility assessment required at §483.71. Improvement projects must include at least annually a project that focuses on high risk or problem-prone areas identified through the data collection and analysis described in paragraphs (c) and (d) of this section.
§483.75(g) Quality assessment and assurance.
§483.75(g)(2) The quality assessment and assurance committee reports to the facility's governing body, or designated person(s) functioning as a governing body regarding its activities, including implementation of the QAPI program required under paragraphs (a) through (e) of this section. The committee must:
(ii) Develop and implement appropriate plans of action to correct identified quality deficiencies;
(iii) Regularly review and analyze data, including data collected under the QAPI program and data resulting from drug regimen reviews, and act on available data to make improvements.
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Observations:
Based on a review of the Statement of Deficiencies from the survey ending May 8, 2026, the facility ' s Plan of Correction, revisit survey findings, and staff interview, it was determined the facility ' s Quality Assurance and Performance Improvement committee failed to implement and maintain an effective corrective action plan to prevent the recurrence of deficiencies related to providing residents with a safe, clean, comfortable, and homelike environment.
Findings include:
During the survey ending May 8, 2026, the facility was cited for failing to provide and maintain a clean, comfortable, and homelike environment for residents.
In response, the facility submitted a Plan of Correction that included immediate cleaning of identified resident rooms, shower rooms, and common areas. Shower rooms located on A Hall, B Hall, and C Hall were deep cleaned. Black buildup was removed from the grout (the material that fills the spaces between floor tiles), damaged grout was repaired, chipped floor tiles were replaced, and ceiling vents were cleaned to remove accumulated dust.
The Plan of Correction further indicated the Maintenance Director and Housekeeping Supervisor would conduct facility-wide environmental audits of resident rooms, bathrooms, and shower and tub rooms to ensure floors were free of sticky residue, bathrooms were clean and free of visible dust, toilet bases were properly sealed, shower rooms remained clean, and floor tiles were maintained in good condition. Housekeeping staff were assigned weekly deep-cleaning schedules that included shower and tub rooms, ceiling vent inspections, and floor inspections. Grout and tile inspections were to be completed monthly.
The facility also provided education to housekeeping, maintenance, and nursing staff regarding environmental cleaning standards and procedures for reporting environmental concerns.
The Plan of Correction further required the Nursing Home Administrator, or designee, to conduct environmental rounds three times each week for four weeks, weekly for an additional four weeks, and monthly thereafter. Audit results were to be reviewed during monthly QAPI (Quality Assurance and Performance Improvement) meetings to evaluate the effectiveness of the corrective actions and ensure the improvements were maintained.
The facility indicated all corrective actions would be implemented by June 23, 2026.
However, during the revisit survey ending June 25, 2026, the facility again failed to maintain a clean, comfortable, and homelike environment for residents under the same regulatory requirement.
The recurrence of the deficient practice demonstrated the facility ' s QAPI monitoring process did not effectively identify that the corrective actions had not been sustained and failed to prevent the recurrence of the previously cited environmental deficiencies.
Cross Ref. F584
28 Pa. Code 211.12 (d)(1)(5) Nursing Services.
28 Pa. Code 201.18 (b)(1) Management.
| | Plan of Correction - To be completed: 07/20/2026
Step 1. Corrective Action for Residents Affected
- The facility cannot retroactively correct.
Step 2. Corrective Action for Residents Potentially Affected
- The Nursing Home Administrator, Housekeeping Director, and Maintenance Director completed a facility-wide environmental walk-through of all units — including areas not specifically cited — to identify and correct any additional environmental concerns before they could affect other residents
*EVS staff were reeducated on the facility's QAPI program goals, structure, and their role in identifying and reporting quality concerns to the QAA committee
Step 3. Systemic Changes to Prevent Recurrence
- The facility will update the QAPI plan to include environmental monitoring as a high-risk, high-volume area.
- Environmental monitoring will be added to the new hire QAPI training curriculum
- The facility will Implement a standardized environmental monitoring checklist and integrate it into the facility performance improvement plan
- A standardized QAPI Project Tracking Form was implemented to document:
o Problem statement
o Root cause analysis
o Action plan
o Measurable goals
o Completion date and outcomes
Step 4. Monitoring and Quality Assurance
- The NHA or designee will audit QAPI documentation monthly for 6 months, then quarterly thereafter.
- Audit results will be reported to the QAPI Committee and incorporated into the facility's ongoing performance improvement plan.
- Any deficiencies found will trigger immediate corrective action.
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