Quinton Mem Hc & Rehab Center

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the License Practical Nurse and Registered Nurse (Charge Nurse) Job Descriptions, the facility failed to ensure residents received care in accordance with physician orders for one of 39 sampled residents (R) (R6). Specifically, the facility failed to ensure lab tests, and assessment of hemorrhoids were conducted as ordered by the physician. The deficient practice had the potential to place R6 at increased risk of adverse clinical outcomes related to blood loss.

Inspectors wroteBased on observations, record review, staff interviews, and review of facility's electronic Work Order system's cleaning schedule titled, Oxygen Concentrators: In-House Maintenance, the facility failed to ensure respiratory equipment was maintained in a clean and sanitary manner by not cleaning the oxygen concentrator filter for two of 30 residents (R)(R58 and R67), on respiratory care. This deficient practice had the potential to cause ineffective oxygen delivery, respiratory complications, and increased risk of infection. Findings Include:Record review of facility's electronic Work Order System's cleaning schedule titled, Oxygen Concentrators: In-House Maintenance, dated 05/15/2026 documented under section titled, Cleaning the Cabinet Filter - Risk of Damage: To avoid damage to the internal components of the unit: [...]

Inspectors wroteBased on observations, resident and staff interviews, and review of the facility policies titled, HLTC Oxygen (O2) Administration and HTLC Administering Medications Through Nebulizer, the facility failed to bag and store unused O2 and nebulizer tubing, and cannulas/masks for four of 28 residents (R) (R52, R68, R39, and R287) receiving respiratory services . The deficient practice had the potential to allow unhealthy organisms to contact the equipment and of spreading infection in the facility.

Inspectors wroteBased on interviews, record review, and review of the facility policy titled Falls, the facility failed to provide the necessary supervision to prevent falls to the extent possible for one of three sampled residents (R) (R3) reviewed for falls. R3 sustained six falls at the facility from [DATE] through February 2024 when attempting to get out of bed unassisted and/or ambulating without assistance, with four of the first five falls resulting in injuries to the head. The facility documented contributing factors for the falls but failed to identify and address the need for increased supervision related to the resident's declining cognition and failed to conduct and document a root cause analysis for each fall to facilitate the ability to develop specific fall prevention interventions that would address the causative factors of the falls. [...]

Inspectors wroteBased on observations, interviews, and review of the facility's policies titled, Food Receiving and Storage, Preventing Foodborne Illness-Food Handling, and Food Brought by Family/Visitors, the facility failed to ensure opened food items in the kitchen were labeled and dated; failed to discard expired food items, failed to monitor refrigerator temperatures in two of two resident pantries, and failed to properly date and store food left for a resident. These deficiencies had the potential to affect 74 residents receiving an oral diet. The census was 74.

Inspectors wroteBased on observations, staff interviews, review of the facility policy titled, Hamilton Long Term Care [HLTC] Non-Controlled and Controlled Medication Ordering, Receiving, and Storage, and review of the facility document titled, HLTC Medication Administration Competency Evaluation, the facility failed to ensure one of four medication carts were locked and secure when unattended that permitted only authorized personnel to have access on two occasions. The facility failed to ensure that narcotics were counted and documented at the beginning of each shift on two of four medications carts. In addition, the facility failed to ensure medications were stored with proper identification/labeling for three residents on one medication cart. These failures placed residents at risk of having their unsecured medications diverted and being administered incorrect medications.

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility's policies titled, Medication Self-Administration Medications and Medication Administration-General, the facility failed to assess one resident (R) (R#51) of 31 sampled for the ability to self-administer medications prior to leaving medications at the bedside. This deficient practice had the potential to adversely affect the safety of R#51 and other residents in the facility.

Inspectors wroteBased on record review, staff interviews, and review of the facility's policy Advanced Directives, the facility failed to ensure that the Do Not Resuscitate (DNR) document was signed by a physician for one resident (R) (R#52) of 31 sampled residents reviewed for advanced directives.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled, HLTC [[NAME] Long Term Care] Care Planning, the facility failed to follow the care plan for splint application for one resident (R) (R#60), failed to develop a care plan for splint application and passive range of motion (PROM) for one resident (R#57), and failed to develop a care plan for splinting for one resident (R#73). This deficient practice had the potential to affect the delivery of the proper care and services provided to R#60, R#57, and R#73. The sample size was 31.

Inspectors wroteBased on observations, record review, staff interviews, and review of facility policy titled, HLTC [[NAME] Long Term Care] Restorative Nursing Policy, the facility failed to provide restorative services as related to range of motion exercises for one resident (R) #13 of 31 sampled residents and related to splint use and contracture management for three residents (R#73, R#60, and R#57) of 31 sampled residents. These failures had the potential to cause a decline in R#13, R#73, R#60, and R#57's functional abilities.