Az Assisted Living & Memory Care

Based on documentation review and interview, the manager failed to submit a documented report to the governing authority per the frequency established in the facility quality management program. The deficient practice posed a risk as a quality management program documents the necessary information required to effectively manage services provided. Findings include: 1. Review of the facility's policies and procedures revealed a policy titled "Quality Management" reviewed and signed by E1 (2022). This policy stated "Evaluate the data collected from the quality management plan form on a Yearly Quality Management Plan Review form to identify any concern about the delivery of services related to resident care; At the end of the year, compile a line graph for each of the above to identify any trends...The YQMPR shall be submitted to the governing authority yearly..." 2. Review of the quality management program documentation revealed data collected on a monthly bases reflecting resident weight loss, falls, and errors in documentation of resident services. A review of the facility's quality management program revealed no Yearly Quality Management Plan Review was completed and submitted to the governing authority on a yearly basis. 3. In an interview, E1 acknowledged the quality management report was not completed and submitted per the frequency established in the quality management program.