Inn at Quail Haven Village

Inspectors wroteBased on observation and staff interviews, the facility failed to label opened food items stored in 1 of 2 walk-in freezers with the date opened and use-by or expiration dates. This deficient practice had the potential to affect foods served to the residents.

Inspectors wroteBased on observations, record review, and interviews with staff, pharmacy consultant, pharmacy technician and the Medical Director, the facility failed to protect the resident's right to be free from misappropriation of controlled medications for 1 of 2 residents reviewed (Resident #158).

Inspectors wroteBased on record review and staff interviews the facility failed to attempt alternatives prior to installing side rails for 2 of 2 residents assessed for side rails (Resident #48 and Resident #102).

Inspectors wroteBased on observations, record review, and staff and Medical Director interviews, the facility failed to implement infection control policies when Nurse #1 did not perform hand hygiene before donning (putting on) gloves prior to assisting with wound care. The facility also failed to clean and disinfect an individually assigned glucometer stored outside the resident's room per manufacturer's recommendations. This was for 2 of 12 staff observed for infection control practices (Nurse #1 and Nurse #3).

Inspectors wroteBased on record review, observations, and staff interviews, the facility failed to protect the residents ' right to be free from misappropriation of a narcotic medication (oxycodone/acetaminophen) prescribed to treat pain for Resident #250. This was for 1 of 1 residents reviewed for misappropriation.

Inspectors wroteBased on record review and staff interviews, the facility failed to submit an initial report to the state regulatory agency and to report to Law Enforcement within 24 hours of discovery of misappropriation of resident property. They further failed to notify Adult Protective Services (APS) regarding an allegation of misappropriation of resident property. This was for 1 of 1 residents (Resident #250) reviewed.

Inspectors wroteBased on record review, observation, and interviews with the Physician Assistant (PA) and staff, the facility failed to provide supervision and effective interventions to prevent repeated falls to a resident who was assessed as high risk for falls for 1 of 5 sampled residents reviewed for accidents (Resident #9). On 12/5/22, Resident # 9 sustained an acute mildly displaced fracture of the right subtrochanteric femoral neck from a fall and underwent open reduction and internal fixation (ORIF) of the right periprosthetic femur fracture and revision of the right hip arthroplasty (a surgical procedure to replace damaged joint with an artificial joint) on 12/6/22. On 2/11/23, Resident #9 continued to fall and sustained a mild displacement of the previous subtrochanteric fracture of the right femur.

Inspectors wroteBased on observation and staff interviews the facility failed to date leftover food in 1 of 2 walk-in refrigerators; failed to maintain a clean kitchen floor; failed to store clean and dirty knives separately; and failed to thaw meat in sanitary conditions to prevent the potential for cross contamination. The failures had the potential to affect food served to residents.

Inspectors wroteBased on observation, record review and staff and resident interviews, the facility failed to resolve repeat grievances related to dietary services which were reported in the Resident Council meetings for 7 out of 9 months reviewed (June 2022, July 2022, August 2022, October 2022, December 2022, January 2023, and February 2023).

Inspectors wroteBased on record reviews, observations, Physician Assistant, residents and staff interviews, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor interventions the committee put into place following a focused infection control and complaint survey completed on 10/5/20. This was for two deficiencies that were cited in the areas of Respiratory Care and Infection Control. In addition, four additional deficiencies were cited during the annual recertification and complaint survey on 8/25/21 in the areas of Resident/Family Group and Response, Accuracy of Assessments, Treatment/Services to Prevent/Heal Pressure Ulcers and Resident Records. The duplicate citations during three federal surveys of record shows a pattern of the facility's inability to sustain an effective QAPI program.

Inspectors wroteBased on record review, observation and staff interview, the facility failed to shave a resident who needed extensive assistance or was dependent on the staff for activities of daily living (ADL) for 1 of 2 sampled residents reviewed for ADL (Resident #9).

Inspectors wroteBased on record review, observations, and staff interviews, the facility failed to ensure the low air loss mattress was set according to the resident's weight for 3 of 4 residents reviewed for pressure ulcers (Resident #21, #32, and #34).

Inspectors wroteBased on observations, staff, Registered Dietitian (RD) and Physician Assistant (PA) interviews and record review, the facility failed to identify a significant weight loss for Resident #17. This was for 1 of 2 residents reviewed for nutrition.

Inspectors wroteBased on observations, resident, staff and Physician Assistant (PA) interviews and record review, the facility failed to change the oxygen tubing weekly as ordered and failed to obtain oxygen saturation parameters for an order to titrate oxygen as tolerated. This was for 1 (Resident #250) 1 residents reviewed for respiratory care.

Inspectors wroteBased on record reviews, observations and resident, staff and Physician interviews, the facility failed to assess for level of pain and treat a resident with complaints of pain during wound care (Resident #21). This was for 1 of 4 residents reviewed for wound care.

Inspectors wroteBased on record review and staff interviews, the facility failed to maintain complete and accurate medical records in the areas of wound care (Resident #34) and weights (Resident #17 and Resident #41). This was for 3 of 13 resident records reviewed.

Inspectors wroteBased on record review, observations and staff interview the facility failed to disinfect multi use medical equipment between residents for 1 of 1 Nursing Assistant (NA) observed for infection control practices. (NA #4)

Inspectors wroteBased on record review and staff interviews, the facility failed to provide annual dementia training and mandatory twelve hours of annual in-servicing for 1 of 5 nursing assistants (NA) #2 reviewed for competent nursing staff.

Inspectors wrote2. Resident #43 was admitted to the facility on [DATE]. A review of Resident #43's nurses notes, and transfer form revealed she was transferred to the hospital on [DATE] due to abdominal pain and was admitted . There was no documentation discovered in the resident ' s medical record of written notice of transfer provided to the resident and/or Responsible Party (RP) regarding the transfer. Resident #43 di not return to the facility. A 5-day Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #43 was cognitively intact. An interview was conducted on 03/21/23 at 12:03 PM with Nurse #2. She stated she notified the RP verbally by phone when the resident was discharged to the hospital. The admission Staff was interviewed on 3/21/23 at 12:10 PM. She stated that she was not responsible for notifying the RP in writing when a resident was discharged to the hospital. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to accurately code the Minimum Data Set (MDS) assessments in the areas of medications (Resident #25), hospice and prognosis (Resident #53) for 2 of 20 sampled residents whose MDS were reviewed.