Health inspection·July 26, 2023

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure that the facility's Medical Director attended the QAA/QAPI Committee meetings, for 3 of 3 quarterly meetings ( July, August, September 2022, October, November, December 2022 and January,February, March 2023), reviewed for QAA/QAPI. Residents Affected - Many The facility failed to ensure the Medical Director attended their QAA and QAPI meetings for the months of July 2022 through March 2023. This failure could place residents at risk for quality deficiencies being unidentified and no appropriate plans of actions developed or implemented, and no appropriate guidance developed. Findings included: Review of the facility's QAA/QAPI meeting signature logs for the months of July 2022 through May 2023, revealed the Medical Director had not attended any of the meetings for the QAA/QAPI Committee, during those months. There were no notation indicating the Medical Director had attended any of the meetings by telephone or zoom. During an interview on 07/25/2023 at 11:35 AM, the Administrator said the QAA/QAPI met monthly, but no less than once per quarter. She said she realized the Medical Director was not in attendance for the QAA/QAPI meetings for the months of July 2022 through May 2023, but she could not say why he was not in attendance. She said she was not the Administrator at that time, she became the Administrator in September 2022 and could not speak to anything prior to that. She said there was no indication the Medical Director had attended any of the meetings between July 2022 and May 2023, nor by telephone or zoom, nor did he have a designee assigned to attend in his place. During an interview on 07/25/2023 at 12:15 PM, the medical director said he thought he had attended at lease two QAA/QAPI meetings. He was shown the sign in sheets and agreed that if he had not signed in there was no proof that he was there, he said if it wasn't signed it wasn't done. He also said he did not attend via telephone and did not have a designee assigned to attend in his place. Review of the facility's Quality Assurance and Performance Improvement (QAPI Plan Revised April 2014) revealed, Policy Statement: This facility shall develop, implement, and maintain an ongoing, facility-wide, QAPI Plan designed to monitor and evaluate the quality and safety of resident care, pursue methods to improve care quality, and resolve identified problems. Authority: 1. The owner and/or governing board(body) of our facility shall be ultimately responsible for the QAPI Program. 2. The Administrator is responsible for assuring that this facility's QAPI Program complies with federal,state and local regulatory agency requirements. Implementation: 2. This committee shall meet monthly to Page 1 of 2 675581 675581 07/26/2023 The Village at Heritage Oaks 3002 W 2nd Ave Corsicana, TX 75110

F 0868 Level of Harm - Minimal harm or potential for actual harm review reports, evaluate the significance of data, and monitor quality-related activities of all departments, services, or committees .§483.75(g)(1) A facility must maintain a quality assessment and assurance committee consisting at a minimum of: Residents Affected - Many (i) The director of nursing services; (ii) The Medical Director or his/her designee; (iii) At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role; and (iv) The infection preventionist. 675581 Page 2 of 2