ROSLYN, SD - State inspectors found that the administrator at Strand-Kjorsvig Community Rest Home failed to participate in required quality assessment meetings for more than a year, attending only two meetings out of 15 months of documented sessions between February 2024 and May 2025.
Leadership Absence Undermines Quality Oversight
The inspection revealed a significant breakdown in administrative oversight at the 801 S Main facility, where the Quality Assessment and Assurance (QAA) committee operated without consistent leadership participation. Federal regulations require nursing homes to maintain QAA committees with specific membership that must include at least one administrator, owner, board member, or other individual in a leadership role.
According to inspection records, Administrator A attended QAA meetings on only two occasions during the 15-month review period - once on June 25, 2024, and again on May 6, 2025. The facility's Director of Nursing reported that "Administrator A attended the QAPI meeting that week for the first time in quite a while," referring to the May meeting that occurred during the inspection week.
The medical director, identified as MD N, confirmed the pattern of administrative absence during her interview with inspectors. She stated that she "did not recall seeing administrator A present at those meetings routinely" and was "unaware of how often administrator A was at the facility or how often he attended the QAPI meetings in the past two years."
Critical Gap in Quality Management Structure
Quality Assessment and Performance Improvement (QAPI) programs serve as the backbone of nursing home safety and care standards. These committees are responsible for identifying problems, analyzing data, implementing corrective actions, and monitoring outcomes to ensure resident safety and quality of care.
The facility's own policy documents emphasize that "the governing body, administrator, and/or management firm are responsible for the development and implementation of the QAPI program." This includes identifying and prioritizing problems based on performance data, incorporating resident and staff input, ensuring corrective actions address system gaps, setting clear expectations for safety and quality, and ensuring adequate resources exist for quality improvement efforts.
Without consistent administrative participation, nursing homes face significant challenges in implementing effective quality improvements. Administrators typically have the authority to allocate resources, make policy changes, and coordinate between departments - functions that are essential for addressing systemic issues identified through quality assessment processes.
The medical director expressed concern about the lack of administrative support, indicating that "she expected that the administrator would be involved in identifying and correcting areas of concern identified in the QAPI program" and noted that "the facility could use his support."
Staffing Patterns Compound Leadership Challenges
The inspection also revealed concerning patterns in administrative presence at the facility. Director of Nursing C reported that Administrator B, who appears to be another administrative figure, "had been at the facility approximately three hours a week for the last couple of months, but she had not attended a QAPI meeting."
This limited administrative presence raises questions about day-to-day oversight and management of facility operations. Effective nursing home administration requires consistent on-site presence to monitor care quality, address staff concerns, respond to emergencies, and ensure compliance with regulatory requirements.
The Director of Nursing indicated that she "had requested that another QAA member be assigned the responsibility for overseeing the QAPI program," suggesting that the lack of administrative participation had created additional burdens for nursing staff who were attempting to maintain quality oversight functions.
Impact on Resident Care and Safety
Quality assessment programs directly impact resident outcomes by identifying and addressing systemic issues before they escalate into serious problems. When administrators are absent from these critical meetings, facilities may struggle to implement necessary changes that require resource allocation, policy modifications, or interdepartmental coordination.
Federal regulations establish specific requirements for QAA committee composition precisely because effective quality improvement requires leadership commitment and authority. Administrators possess the organizational power to remove barriers to improvement, authorize expenditures for necessary changes, and hold staff accountable for implementing corrective actions.
The facility's QAPI policy acknowledges this principle, stating that the program should "incorporate input, participation, and responsibility at all levels" and that leadership should seek "input from nursing center staff, residents, their families, and other stakeholders" while encouraging "staff participation in QAPI initiatives when necessary."
Regulatory Framework and Expectations
The Centers for Medicare & Medicaid Services requires nursing homes to maintain QAA committees that meet at least quarterly and include representation from various disciplines as well as leadership. The committee composition at Strand-Kjorsvig was supposed to include the Medical Director, Director of Nursing, Administrator, Infection Control Officer, Environmental Manager, Activities Director, Social Services Designee, Dietary Manager, and Business Manager.
This multidisciplinary approach ensures that quality improvement efforts consider all aspects of resident care and facility operations. However, without consistent administrative participation, the committee lacks the authority and resources necessary to implement meaningful changes identified through the quality assessment process.
The policy framework emphasizes that leadership should "hold staff accountable for taking ownership and responsibility of assigned QAPI activities and duties." This accountability function becomes significantly compromised when administrators are not present to participate in identifying problems, developing solutions, and monitoring implementation progress.
Industry Standards for Administrative Engagement
Best practices in nursing home administration emphasize regular participation in quality improvement activities as essential for maintaining high standards of care. Administrators who are actively engaged in QAPI processes are better positioned to understand operational challenges, identify resource needs, and coordinate solutions across departments.
The pattern of minimal administrative presence documented at Strand-Kjorsvig represents a departure from industry standards that expect nursing home leaders to be actively involved in quality oversight. Effective administrators typically participate not only in required meetings but also in regular facility rounds, staff communications, and ongoing quality monitoring activities.
Implications for Facility Operations
The extended period of administrative absence from quality meetings suggests potential broader issues with facility governance and oversight. When administrators are not consistently present for quality assessment activities, it may indicate insufficient attention to other critical management functions such as staff supervision, regulatory compliance, and operational planning.
The facility's medical director and nursing staff appeared to recognize the negative impact of this leadership gap, with multiple staff members noting the need for greater administrative involvement in quality improvement efforts. This recognition suggests that the absence was not merely procedural but had practical implications for the facility's ability to address operational challenges effectively.
Moving Forward
The violation identified during the May 2025 inspection highlights the need for Strand-Kjorsvig Community Rest Home to restructure its administrative engagement with quality improvement processes. Effective resolution will require not only ensuring administrator attendance at required meetings but also establishing sustainable patterns of leadership involvement in ongoing quality oversight activities.
The facility must demonstrate that its leadership is committed to maintaining the governance structure necessary for effective quality improvement, resident safety, and regulatory compliance. This includes regular participation in QAA committee meetings, active involvement in identifying and addressing quality issues, and providing the resources and authority necessary for implementing meaningful improvements to resident care and safety.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Strand-kjorsvig Community Rest Home from 2025-05-08 including all violations, facility responses, and corrective action plans.
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