Neighborhoods at Quail Creek, the

Inspectors wroteBased on interview, and record review, the facility failed to provide residents with a complete and fully functional call light system when the facility failed to have a process in place to notify staff of call light notifications when call light pagers where not functioning, when the nursing station notification terminal was not receiving notifications, and when the system would reset a call light without it being answered by staff for four residents (Resident #16, #107, #115, and #62). The census was 96. Review of the facility policy titled, Call Lights: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep all food safe from potential contamination at all times when staff failed to where hairnets properly while in working in the facilities kitchens. The facility census was 99. Review of the facility's policy titled Dietary Employee Personal Hygiene, dated 01/01/24, showed the following information: -The purpose was to prevent contamination of food by food service employees; -All dietary staff must wear hair restraints (e.g., hairnet, hat and/or beard restraint) to prevent hair from contacting food; -Head coverings must be clean. Review of the Food and Drug Administration (FDA) 2013 Food Code showed the following: -Consumers are particularly sensitive to food contaminated by hair. Hair can be both a direct and indirect vehicle of contamination. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a sanitary environment for all residents and staff when staff failed to ensure ceiling vents, light covers, walls, and non-contact food surfaces were clean. The facility census was 99. Review of the facility's policy titled Standard Operating Procedure, Cleanliness and Sanitation of the Dining Room, dated 01/01/24, showed staff to routinely clean all areas of the dining room, including equipment such as service refrigerators, etc. Review of the facility's policy titled Equipment Cleaning and Sanitizing, dated 01/01/24, showed the following: -Equipment is washed, rinsed and sanitized after each use to ensure the safety of food served to residents; -Employees who use equipment will be responsible for washing and sanitizing after each use; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the hot water temperatures at sinks at a temperature to prevent that reduced the possibility of burns when hot water in multiple resident access areas measured in access of 120 degrees Fahrenheit (F). The facility had a census of 99. Review of the the US Consumer Product Safety Commission (CPSC) document Avoiding Tap Water Scalds, dated 03/2012, showed the following: -The majority of injuries involving tap water scalds are to the elderly and children under the age of five; -The CPSC urges all users to lower their water heaters to 120 degrees F; -Most adults will suffer third-degree burns if exposed to 150 degreed F water for two seconds; -Burns will also occur with a six-second exposure to 140 degreed F water or with a thirty second exposure to 130 degree F water; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe and effective medication administration system for all residents when staff failed to maintain an accurate reconciliation and accounting for controlled medications (substances that have an accepted medical use (medications which fall under US Drug Enforcement Agency (DEA) Schedules II-V), have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence) for one resident (Resident #356) and when staff failed to destroy expired or unused medications for [NAME] and Chestnut Neighborhoods. The facility census was 99. 1. Review of a facility policy entitled Medication Storage, dated 01/01/24, showed the following: -Any discrepancies which cannot be resolved must be reported immediately. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all medications were stored and labeled in accordance with standards of practice when staff failed to store controlled substances under two locks, when medication carts were left unlocked when unattended, when staff left medications on the nightstand of one resident (Resident #70), and when staff removed prescription labels from medications. The facility census was 99. Review of a facility policy entitled Medication Storage, dated 01/01/24, showed the following: -It is the policy of the facility to ensure all medications housed on the premises are stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement an effective program of infection control when staff failed to communicate an infection control plan to all staff and implement a consistent infection control plan for one resident (Resident #17) who had a current diagnosis of Clostridium difficile (C. Diff - a highly contagious germ that causes diarrhea and inflammation of the colon). Facility staff also failed to perform hand hygiene per standards of practice when providing cares to two residents (Resident #17 and Resident #67) and when administering medication per a feeding tube for one resident (Resident #2). [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their abuse and neglect policy regarding screening staff members when the facility failed to complete an Employee Disqualification List (EDL - a list that lists staff who are unable to work in long-term care in the state) check and a Nurse Aide (NA) Registry (registry which shows if someone has a Federal Indicator (indicates individuals the person cannot work in long-term care)) check for one employee (Registered Nurse (RN) A). The facility had a census of 99. Review of the facility's policy titled Abuse, Neglect, and Exploitation Policy and Procedure, updated 07/2022, showed the following: -The names of all potential employees will be checked against the list maintained by the state of persons who may not be eligible for employment within a long-term care facility; -CNA registry will be checked on all new hires. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide all necessary activities of daily living (including assistance with meals) to all residents ensure good nutrition when facility staff failed to assist one resident (Resident #17) with eating in a timely fashion. The facility census was 99. 1. Review of Resident #17's face sheet (brief resident profile sheet) showed the following information: -admission date of 11/07/22; -Diagnoses included unspecified protein-calorie malnutrition (a wasting condition resulting from a diet inadequate in either protein or calories or both). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument filled out by facility staff), dated 05/10/24, showed the following: -Moderate cognitive impairment; -Dependent with eating; -At risk for malnutrition. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure diets were provided as ordered when staff failed to to care plan and provide physician ordered dietary supplements to one resident (Resident #54) who experienced weight loss and one resident (Resident #67) at risk for weight loss. The facility census was 99. Review of the facility's policy titled SNAR (Skin, Nutrition, And At Risk) Policy and Procedure, dated 12/23, showed the following information: -The facility will ensure that the resident maintains, to the extent possible, acceptable parameters of nutritional status to refuse risk of weight loss; -If weight loss/gain of five percent in thirty days is noted on monthly weights, the resident will be added to the weekly SNAR meeting for review; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all allegations of possible abuse were reported immediately, but not later than two hours after the allegation was made, to the State Survey Agency (Department of Health and Senior Services - DHSS) when staff failed to report an allegation of possible physical abuse made my one resident (Resident #1) out of seven sampled residents. The facility census was 97. Review of the facility's policy titled, Abuse, Neglect and Exploitation, dated 01/01/23, showed the following: -It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property; [...]

Inspectors wroteBased on record review and interview, the facility failed to keep all residents free from misappropriation when one staff member (Certified Nurse Aide (CNA) A) asked for and then took money from one resident (Resident #1). The facility census 99. On 03/20/24, at approximately 9:45 A.M., the Administrator was notified of the Past Non-Compliance that occurred on 01/24/24. The Administrator immediately started an investigation, notified DHSS by self-report on 03/20/24, at 12:29 P.M., and notified the police on 03/20/24, at 11:47 A.M. All facility staff were notified of required training and completed the computer misappropriation training 03/20/24. CNA A was terminated on 03/20/24 due to not following the facility's policy. The facility implemented continued abuse and neglect training at orientation and quarterly. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving abuse were reported immediately to management and to the State Survey Agency (Department of Health and Senior Services -DHSS) within two hours of the allegations being made when staff were aware of reports of possible abuse involving four residents (Resident #1, Resident #32, Resident #55, and Resident #71). The facility census was 81. Record review of the facility policy Preventing Abuse/Reporting/Incidents/Investigation and Protection, updated on 4/2020 and last reviewed on 01/2022 , showed the following: -All staff will demonstrate familiarity with the signs of abuse, neglect. Any such signs of abuse and neglect will be reported to the Administrator and/or Director of Nursing (DON)/designee immediately. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete full and documented investigation in a timely manner when staff were made aware of allegations of possible abuse/neglect involving four residents (Resident #1, Resident #32, Resident #55, and Resident #71). The facility census was 81. Record review of the facility policy Preventing Abuse/Reporting/Incidents/Investigation and Protection, updated on 4/2020 and last reviewed on 01/2022 , showed the following: -This facility has developed and implemented this policy and procedure to prohibit abuse, neglect, exploitation or misappropriation of property by any perpetrator; -Investigation process will proceed after the state notification as indicated and required. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a transfer to the hospital, including the reason for the transfer, for four residents (Residents #46, #53, #59, and #65). The facility census was 81. Record review of the facility's policy entitled Notice Requirements Before Transfer/Discharge, undated, showed the following information: -It is the policy of the facility to notify the resident and/or their legal guardian before transfer and/or discharge according to state and federal regulations; -Before the facility transfers or discharges a resident, the facility will obtain a physician's order for the transfer and/or discharge; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all residents were free from abuse and neglect when one staff member (LPN K ) reviewed to assist one resident (Resident #71) with his/her bowel regimen and when one staff member (LPN K) spoke to one resident (Resident #32) in a harsh manner that included profane language. The facility's total census was 81. Record review of the facility policy Preventing Abuse/Reporting/Incidents/Investigation and Protection, updated on 4/2020 and last reviewed on 01/2022 , showed the following: -This facility has developed and implemented this policy and procedure to prohibit abuse, neglect, exploitation or misappropriation of property by any perpetrator; -All staff will demonstrate familiarity with the signs of abuse, neglect; [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed ensure all residents received supervision and assistance devices to prevent possible elopements when staff failed to check the daily functioning status of one resident's (Resident #42) wanderguard bracelet. The facility had a census of 81. Record review of the facility policy, titled Preventative Action Plan for Wandering/Elopement of Residents, dated April 2020, showed the following: -All residents who enter the facility will have an Elopement Risk Assessment completed at the time of admission; -If the assessment determines the resident to be at risk for exit seeking behavior or attempting an elopement, the facility will begin immediate action to prevent the elopement, such actions included: [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to document and track residents' grievances and failed to make prompt efforts to resolve the residents' grievances for four residents (Resident #31, #40, #54 and #76) out of a selected sample of 20 residents. The facility census was 72. 1. Record review of the facility's policy Right to Voice Grievances undated, showed the following: -An elder, his/her responsible party and family have the right to express a grievance or complaint about care and services provided by the facility without fear of discrimination or reprisal, including grievances with respect to treatment, care or services provided as well as those which have not been provided; -Elders and their families may also report a complaint or grievance in writing to any team member in the facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff administered medications with an error rate less than five percent when the staff made six errors out of 34 opportunities, resulting in an error rate of 17.6%. This affected six residents (Resident #26, Resident #37, Resident #48, Resident #229, Resident #280 and Resident #284). The facility census was 72. 1. Record review of facility's policy titled Insulin Pen Devices for Insulin Administration, undated, showed the following: -The facility will ensure that each elder receives proper and appropriate treatment and care for insulin administration per pen devices or insulin vials as ordered by a licensed physician; -Prior to administration, authorized clinical staff will verify that the medication is being administered at the proper time, in the prescribed dose, by the correct route; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free of significant medication errors when staff failed to prime insulin pens prior to administering insulin to three residents (Resident #37, #280, and #284) and failed administer insulin per physicians' orders for two residents (Resident #280 and #284). The facility census was 72. Record review of facility's policy titled Insulin Pen Devices for Insulin Administration, undated, showed the following: -The facility will ensure that each elder receives proper and appropriate treatment and care for insulin administration per pen devices or insulin vials as ordered by a licensed physician; -Prior to administration, authorized clinical staff will verify that the medication is being administered at the proper time, in the prescribed dose, by the correct route; -Attached disposable needle to pen; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise care plans for two residents (Resident #49, and Resident #283) to include exit seeking behaviors and use of a seatbelt. The sample size was 20. The facility census was 72. Record review of the facility's policy titled Goals and Objectives, Care Plans, dated April 2009, showed: -Care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence. -Care plan goals and objectives are defined as the desired outcome for a specific resident problem. -When goals and objectives are not achieved, the resident's clinical record will be documented as to why the results were not achieved and what new goals and objectives have been established. Care plans will be modified accordingly. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain a physician order for oxygen for two residents (Resident #27 and Resident #78) in a selected sample of 20 residents. The facility's census was 72. Record review of the facility's Oxygen Administration policy, undated, showed the following: -It is the policy of this community to appropriately provide and monitor oxygen for residents as ordered by the physician. Initiation of oxygen therapy will be performed by a licensed nurse. Direct care staff may reapply the nasal cannula and replace sterile water in the humidifier; -When oxygen is required, an order will be obtained from the physician. 1. Record review of Resident #78's face sheet showed the following: -admitted to the facility on [DATE], re-admitted to the facility on [DATE]; -Diagnoses included pneumonia and high blood pressure. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide ongoing communication with the dialysis (the cleaning of the blood with a machine due to the kidneys not working) center for one resident (Resident #34) who received dialysis. A sample of 20 residents was selected for review in a facility with a census of 72. Record review of the facility's End-Stage Renal Disease, Care of a Resident With Policy, revised September 2010, showed residents with end-stage renal disease (ERSD) will be cared for according to currently recognized standards of care. Staff will utilize dialysis communication form to and from dialysis. 1. Record review of Resident #34's face sheet (a general information sheet) showed the following: -The resident admitted to the facility on [DATE], and re-admitted on [DATE]; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious contaminants when the facility failed to attach a cap on the end of a PICC (peripherally inserted central catheter) for one resident (Resident #229) in a selected sample of 20 residents. The facility census was 72. According to Clinical Nursing Skills and Techniques 8th edition, [NAME], [NAME], & [NAME], 2014, the rationale that securing connections and the use of protective covers reduces the risk of air emboli (abnormal presence of air in the cardiovascular system), infections and entrance of microorganisms. 1. Record Review of Resident #229 face showed the following -admission date of 10/04/19; [...]