Quinn Meadows Rehabilitation and Care Center

Inspectors wroteBased on interview and document review, the facility failed to report 2025 4th quarter Payroll Based Journal (PBJ) information for the facility as required. This failure created the potential for CMS not to confirm adequate nurse staffing and potential for residents to experience longer waiting times for needed cares.

Inspectors wroteBased on policy review, observation, record review, and staff interview, it was determined the facility failed to ensure a resident's call light was within reach for 1 of 14 residents (Resident #47) reviewed for resident rights. This deficient practice had the potential to cause harm if the resident could not call for assistance when needed or experienced an adverse medical event that required attention.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to provide the Notice of Medicare Non-Coverage (NOMNC CMS-10123) within the CMS required timeframe to 1 of 3 residents (Resident #54) reviewed for beneficiary protection notification. This deficient practice had the potential to cause financial harm or distress for residents when they were not informed of their potential liability for payment when their Medicare Part A benefits ended.

Inspectors wroteBased on facility standing orders, record review and staff interview, it was determined the facility failed to follow facility bowel care standing orders for delivering specific medications when residents do not have BM for over 72 hours for 2 of 4 residents (#5 and #7) who records were reviewed for bowel and bladder care. This failed practice created the potential for residents to experience discomfort when medications were not administered according to the physician's order.

Inspectors wroteBased on observation, record review, and interviews, it was determined the facility failed to provide respiratory services as ordered by the physician. This was true for 1 of 2 residents (Resident #52) whose records were reviewed for respiratory services. This failure created the potential for residents to experience increased fatigue.

Inspectors wroteBased on policy review, record review, and staff interview, it was determined the facility failed to ensure residents were assessed appropriately for adequate indications for the use of opioid pain medications. This was true for 1 of 4 residents (Resident #23) reviewed for unnecessary medications. This failure created the potential for residents to experience adverse consequences or increased risk of death.

Inspectors wroteBased on observation, policy review, and staff interview, it was determined the facility failed to maintain the kitchen in a sanitary manner. This deficiency had the potential to affect the 37 residents residing in the facility who consumed food prepared by the facility. This placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses. The facility's Sanitation Inspection policy revision date 12/3/24, documented it was the policy of the facility, as part of the department's sanitation program, to conduct inspections to ensure food service areas are clean, sanitary and in compliance with applicable state and federal regulations. All food service areas shall be kept clean, sanitary, free from litter, rubbish and protected from rodents, roaches, flies, and other insects. [...]

Inspectors wroteBased on policy review, record review, and staff interview, it was determined the facility failed to ensure residents resuscitation code status was up to date in their medical records and residents and their representatives received assistance to exercise their right to formulate an advanced directive. This was true for 1 of 12 residents (Resident #188) whose records were reviewed for advanced directives. This deficient practice created the potential for harm or adverse outcomes if residents' wishes were not followed or documented.

Inspectors wroteBased on observation, policy review, and staff interview, it was determined the facility failed to ensure residents were provided with a clean, safe, homelike environment. This was true for all 37 residents who resided in the facility whose equipment and environment were observed for cleanliness and proper lighting in their rooms. This deficient practice created the potential for harm if residents were embarrassed by and/or felt the disrepair in the facility was unacceptable, disrespectful, or undignified or residents were injured due to inadequate lighting in resident rooms.

Inspectors wroteBased on review of the State Operations Manual, record review, and staff interviews, it was determined the facility failed to ensure a Significant Change of Status Assessment (SCSA) MDS was completed when residents were newly diagnosed with a major mental disorder. This was true for 2 of 12 residents (#27 and #33), whose MDS records were reviewed for accuracy. This had the potential for harm if the facility staff did not recognize changes in the resident's health status and mental health needs.

Inspectors wroteBased on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure resident's care plans were revised to reflect current needs and interventions. This was true for 1 of 12 residents (Resident #16) whose care plans were reviewed. This placed resident at risk of adverse outcomes if care and services were not provided due to care plans not being revised as residents' needs changed.

Inspectors wroteBased on policy review, Up-To-Date review, observation, record review, and interviews, it was determined the facility failed to provide respiratory services as ordered by the physician. This was true for 1 of 2 residents (Resident #189) whose records were reviewed for respiratory services. This failure created the potential for residents to experience increased fatigue, poor sleep quality, and low oxygen levels.

Inspectors wroteBased on record review, policy review, and staff interview, it was determined the facility failed to ensure controlled medications were tracked and kept secure from potential theft and/or diversion. This was true for 1 of 2 medication carts reviewed. This failure created the potential for undetected misuse and/or diversion of controlled medications and had the potential to affect all residents who received controlled medication in the facility.

Inspectors wroteBased on record review, policy and State Operations manual review, and staff interview, the facility failed to ensure physician ordered psychotropic medications were necessary to treat a specific diagnosed condition documented in resident's medical records. This was true for 1 of 6 residents (Resident #27) reviewed for psychotropic medication administration. This failure created the potential for Resident #27 to experience negative side effects related to receiving psychotropic medication without a proper diagnosis.

Inspectors wroteBased on observation, interview, Idaho Administrative rules, and U.S. Food and Drug Administration 2022 Food Code review, the facility failed to ensure garbage cans were properly closed with lids to minimize attracting pests and rodents into the kitchen. This deficient practice had the potential to affect all residents and staff in the facility.

Inspectors wroteBased on observation, policy review, and staff interview, it was determined the facility failed to ensure infection control and prevention practices were maintained to provide a safe and sanitary environment. This was true for 1 of 6 residents (Resident #28) reviewed for IV medication administration. This failure had the potential of placing residents at risk for cross-contamination and infection.

Inspectors wroteBased on observation and staff interview, it was determined the facility failed to monitor, discard outdated food items, and maintain the kitchen in a sanitary manner. These deficiencies had the potential to affect the 36 residents residing in the facility who consumed food prepared by the facility. This placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses. The facility's Date Marking for Food Safety policy, revised 12/18/23, stated the facility adhered to a date marking system to ensure safety of food. The policy also stated the food should be clearly marked to indicate the date by which the food shall be consumed or discarded. 1. a. On 4/15/24 at 1:20 PM, the following seasoning containers had a sticker with the following dates on it: - All Spice - 9/4/18 - Cream of Tartar: 1/31/20 - Whole Fennel seeds: [...]

Inspectors wroteBased on policy review, record review, and staff interview, it was determined the facility failed to ensure a resident and their representative received assistance to exercise their right to formulate an Advanced Directive. This was true for 6 of 12 residents (Resident # 13, 14, 18, 22, 27, and 141) whose records were reviewed for advanced directives. This deficient practice created the potential for harm or adverse outcomes if residents' wishes were not followed or documented regarding their advance care planning.

Inspectors wroteBased on record review, policy review, and staff interview, it was determined the facility failed to provide a summary of residents' baseline care plans to residents or their representative. This was true for 5 of 12 residents (#13, #14, #22, #27, and #141) reviewed for baseline care plans. This failure placed residents and their representative at risk of not being informed and having input in their care plan.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure residents' care plans were revised and updated. This was true for 1 of 6 residents (Resident #15) whose care plans were reviewed. This created the potential for harm if cares/or services were not provided appropriately due to inaccurate information in the care plans.

Inspectors wroteBased on policy review, observation, record review, and staff interview, it was determined the facility failed to ensure residents received bathing assistance consistent with their needs. This was true for 1 of 4 residents (Resident #28) reviewed for ADLs. This failure created the potential for residents to experience embarrassment, isolation, and decreased sense of self-worth, due to lack of personal hygiene.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure residents receiving opioid pain medications were monitored appropriately and offered non-pharmacologic pain interventions. This was true for 1 of 5 residents (Resident #15) reviewed for unnecessary medications. This failure created the potential for residents to experience adverse reactions due to lack of appropriate monitoring or experienced increased pain due to not offering non-pharmacologic pain interventions.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure residents receiving psychoactive medications had resident-specific target behaviors identified and monitored. This was true for 1 of 5 residents (Resident #28) reviewed for psychoactive medications. This deficient practice created the potential for harm if residents received medications that may result in negative outcomes without clear indication of need.

Inspectors wroteBased on observation, policy review, and staff interview, it was determined the facility failed to ensure the medication error rate was less than 5%. This was true for 2 of 33 medications (6.06%) which affected 1 of 4 residents (Resident #27) whose medication administration were observed. This failed practice placed residents at risk of not receiving their prescribed medication or dosage of their medication.

Inspectors wroteBased on observation, policy review, and staff interview, it was determined the facility failed to ensure medications available for residents were labeled and dated. This was true for 2 of 2 medication carts inspected. This failure created the potential for residents to receive expired medications with decreased efficacy.

Inspectors wroteBased on record review, observation, policy review, and staff interview, it was determined the facility failed to ensure infection control prevention practices were maintained to provide a safe and sanitary environment. This was true for 3 of 12 residents (#2, #19, and #27) observed for infection control. These failures had the potential to impact all residents in the facility by placing them at risk for cross contamination and infection.