Quail Ridge Living Center, Inc

Inspectors wroteBased on observation, record review, and interview, the facility failed to:a. ensure residents did not fall during a transfer for 1 (#84) of 2 sampled residents reviewed for accident hazards; b. ensure safety interventions were in place while smoking for 1 (#6) of 2 sampled residents reviewed for accident hazards; andc. ensure the electrical room door was secured for 1 of 1 electrical room observed. The DON identified 29 residents required two person assistance with transfer, 18 residents smoked, and 85 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the ice machine was maintained in a sanitary manner. The administrator identified 85 residents received nourishment from the kitchen.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents were free from physical abuse for 1 (#76) of 1 sampled resident reviewed for abuse. The DON stated 85 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure an allegation of physical abuse was reported for 1 (#76) of 1 sampled resident reviewed for abuse. The DON reported 85 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure urinary catheter bags were not on the floor for 1 (#41) of 5 sampled residents reviewed for urinary catheters. The DON identified five residents with urinary catheters.

Inspectors wroteBased on record review and interview, the facility failed to inform the residents and their representatives of their right to rescind an arbitration agreement within 30 calendar days of signing it. The administrator reported the census was 84 and all the residents had signed an arbitration agreement.

Inspectors wroteBased on record review and interview, the facility failed to provide written notices of transfer or discharge prior to residents being transfer or discharged from the facility for three (#2, #9, and #228) of four sampled residents reviewed for hospitalizations. The DON denitrified 71 residents who had been discharged or transferred to from the facility to a hospital in the previous six months.

Inspectors wroteBased on record review and interview, the facility failed to have RN coverage for two days, 01/22/24 and 01/26/24. The administrator identified 84 residents living in the facility.

Inspectors wroteBased on record review and interview, the facility failed to submit accurate direct care staffing payroll data for the PBJ report for 01/01/24 to 03/31/24 (Quarter 2). The Administrator identified 84 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure resident assessments were submitted to CMS for one (#69) of one resident reviewed for assessments. The administrator reported the census was 84.

Inspectors wroteBased on observation, record review, and interview, the facility facile to ensue staff implemented interventions in a resident care plan for one (#9) of 18 sampled residents reviewed for care plans. The DON reported 84 resident resided at the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident who required a non-flammable apron to be worn during smoking was wearing one when smoking for one (#9) of three residents reviewed for accident hazards. The DON identified 15 resident that required supervision while smoking who resided at the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure the physician documented a rationale for not implementing a GDR for one #63 of five residents reviewed for unnecessary medications. The DON reported five residents were on antipsychotic medication.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident who received an antipsychotic medication had an appropriate diagnosis/indication for the use of the medication for one (#63) of five residents sampled for unnecessary medications. The DON identified five residents who received antipsychotic medications.

Inspectors wroteBased on record review and interview, the facility failed to complete a significant change assessment after a resident started hospice services for two (#15 and #48) of 18 sampled residents whose assessments were reviewed. The Resident Census and Conditions of Residents form, dated 07/13/23, documented 82 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to complete a new PASRR level I assessment when a new diagnosis was received for two (#1 and #43) of four sampled residents reviewed for PASRR assessments. The Resident Census and Census and Conditions of Residents report, dated 07/13/23, documented 82 residents resided in the facility. 1. A level I PASRR, dated 04/12/22, documented Res #1 did not have a serious mental illness. On 03/29/23, the resident had a new diagnosis of bipolar disorder. There was no documentation the OHCA had been contacted to see if a level II PASRR was required. On 07/17/23 at 3:07 p.m., the DON was asked to provide documentation the OHCA was notified when the resident had a new diagnosis of bipolar disorder to see if a level II PASSAR was required. On 07/17/23 at 3:28 p.m., the DON stated they did not reach out to the OHCA. 2. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure the physician responded to a MRR in a timely manner for one (#29) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents form, dated 07/13/23, documented 82 residents resided in the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure the kitchen was maintained to promote food safety and sanitation. The Resident Census and Conditions of Residents report, dated 07/13/23, documented 82 residents resided in the facility. The DON identified one resident who received nutrition and hydration solely through a feeding tube.

Inspectors wroteBased on record review and interview, the facility failed to ensure a PASRR level I assessment included the resident had a serious mental illness for one (#54) of four sampled residents reviewed for PASRR assessments. The Resident Census and Census and Conditions of Residents report, dated 07/13/23, documented 82 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a physician order was followed to prevent a resident from elopement for one (#42) of one sampled resident reviewed for wandering. The Resident Census and Conditions of Residents report, dated 07/13/23, documented 82 residents resided in the facility. The DON identified eight residents who had wander guards.