Inspection Reports for
Quail Run Health Care Center
1405 WEST GRAND AVE, CAMERON, MO, 64429-1118
Back to Facility ProfileDeficiencies (last 8 years)
Deficiencies (over 8 years)
17 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
209% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
40
30
20
10
0
Occupancy
Latest occupancy rate
38% occupied
Based on a January 2026 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Census: 32
Deficiencies: 1
Date: Jan 7, 2026
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulations regarding transfer and discharge procedures, specifically focusing on whether the facility allowed a resident to return after hospital transfer and documented reasons for denial of return.
Findings
The facility failed to allow one resident to return after hospital transfer without documenting the reason in the medical record why the resident's needs could not be met. The resident exhibited significant behavioral and psychiatric issues, and the facility cited safety concerns for other residents as the reason for non-admission, but did not properly document this in the resident's record.
Deficiencies (1)
Failure to allow a resident to return to the facility after hospital transfer without documented reason in the medical record.
Report Facts
Residents affected: 1
Facility census: 32
Inspection Report
Life Safety
Census: 56
Capacity: 84
Deficiencies: 6
Date: Nov 7, 2024
Visit Reason
An emergency preparedness survey was conducted to assess compliance with the Life Safety Code of the National Fire Protection Association and related regulations.
Findings
The facility was found to be in substantial compliance with emergency preparedness regulations but did not meet several requirements of the 2012 Life Safety Code, including issues with building construction type and height, vertical openings enclosure, cooking facilities procedures, fire alarm system maintenance, smoke barrier construction, and electrical equipment safety.
Deficiencies (6)
K161: The facility failed to ensure wall and ceiling penetrations were properly sealed, allowing fire and smoke to pass through. Observations included multiple penetrations in various rooms and walls.
K311: The facility failed to ensure vertical openings such as ceilings and shafts were properly enclosed to prevent fire and smoke spread. Observations showed penetrations and light visible through vents and cracks.
K324: The facility staff failed to ensure kitchen staff knew proper procedures to extinguish grease fires using the range hood suppression system and K-type fire extinguisher.
K345: The facility failed to ensure the annual fire alarm inspection included all components, such as magnetic door holds and range hood extinguishing system.
K372: The facility failed to ensure smoke barrier walls and dampers properly closed to prevent smoke and fire spread. Observations showed dampers did not close as required.
K920: The facility failed to ensure safe electrical practices for power cords and surge protectors in patient care areas, risking fire hazards.
Report Facts
Facility capacity: 84
Resident census: 56
Deficiency counts: 6
Inspection Report
Routine
Census: 56
Deficiencies: 1
Date: Nov 7, 2024
Visit Reason
The inspection was conducted to evaluate the facility's pest control program and ensure it effectively prevents and deals with flies and other pests within the nursing home.
Findings
The facility failed to maintain an effective pest control program to prevent flies in resident rooms and dining areas, resulting in flies landing on residents and their food. The facility had recently started a new pest control program and was working with an outside service to address the issue.
Deficiencies (1)
Failure to maintain an effective pest control program to prevent flies in the facility, resulting in flies landing on residents and their food.
Report Facts
Facility census: 56
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding the source of flies and pest control program | |
| Administrator | Interviewed regarding the pest control program and efforts to address flies |
Inspection Report
Annual Inspection
Census: 56
Deficiencies: 16
Date: Nov 7, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements and resident care standards.
Findings
The facility was found deficient in multiple areas including resident dignity and respect, call light accessibility, grievance process, advance directives, care planning, quality of care, medication management, staff competencies, infection control, food safety, and pest control. Deficiencies ranged from minimal harm to potential for actual harm affecting some or few residents.
Deficiencies (16)
Failed to treat residents with dignity and respect by not addressing residents by their preferred names and failing to assist with eating and dressing.
Failed to reasonably accommodate resident needs by not ensuring call lights were within reach for residents.
Failed to consider and respond to resident council grievances and failed to communicate back with residents regarding their concerns.
Failed to ensure staff invoked Durable Power of Attorney prior to allowing a resident to sign a Do Not Resuscitate form and failed to obtain advance directives for code status.
Failed to maintain a sanitary, orderly, and comfortable environment including housekeeping and maintenance issues such as dirty floors, broken tiles, odors, and missing call light cords.
Failed to provide call light cords in resident bathrooms and maintain doors accessible to residents.
Failed to develop comprehensive person-centered care plans for residents and failed to invite residents or responsible parties to care plan meetings.
Failed to ensure staff provided services meeting professional standards including lack of physician orders for dialysis and improper monitoring of low air loss mattress settings.
Failed to provide complete perineal care and ensure showers or bed baths were completed as scheduled.
Failed to ensure nurse aides completed competencies upon hire and annually.
Failed to ensure consultant pharmacist performed monthly drug regimen reviews and that physician was notified of recommendations.
Failed to ensure medication administration was free of errors including use of expired insulin and improper administration of eye drops, nasal sprays, and mixing of medications.
Failed to employ a dietary manager with appropriate competencies and skills to carry out food and nutrition service functions.
Failed to maintain kitchen and food storage in a sanitary manner including dirty equipment, food thawing improperly, and dirty dishes.
Failed to ensure staff practiced hand hygiene when performing resident care tasks.
Failed to maintain an effective pest control program to prevent flies in the facility.
Report Facts
Medication errors: 8
Resident census: 56
Staff hire dates: CNA E hired 2/21/24, CNA D hired 8/21/23, CNA C hired 4/15/24.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA C | Certified Nurse Aide | Named in deficient perineal care and hand hygiene findings. |
| CNA D | Certified Nurse Aide | Named in deficient perineal care and hand hygiene findings. |
| LPN B | Licensed Practical Nurse | Named in medication administration and low air loss mattress monitoring findings. |
| CMT A | Certified Medication Technician | Named in medication administration errors including eye drops and nasal spray. |
| Director of Nursing | Director of Nursing | Provided expectations and comments on multiple deficient areas including care planning, medication administration, hand hygiene, and grievance process. |
| Administrator | Administrator | Provided comments on grievance process, dietary manager training, kitchen maintenance, and pest control. |
| Maintenance Supervisor | Maintenance Supervisor | Named in kitchen maintenance and pest control findings. |
| Registered Dietitian | Registered Dietitian | Provided expectations on kitchen cleanliness and dietary manager training. |
| Regional Quality Assurance Nurse | Regional Quality Assurance Nurse | Provided comments on medication regimen reviews and low air loss mattress monitoring. |
Inspection Report
Annual Inspection
Census: 51
Deficiencies: 11
Date: May 2, 2023
Visit Reason
Annual inspection of Quail Run Health Care Center to assess compliance with federal and state regulations related to Medicaid/Medicare coverage, comprehensive care plans, medication administration, activities, and other resident care standards.
Findings
The facility was found non-compliant with several regulations including Medicaid/Medicare coverage notices, comprehensive care plans, care plan timing and revision, services meeting professional standards, activity programming, medication administration, trauma-informed care, nurse aide training, food service, and sanitation. Deficiencies affected multiple residents and involved failure to use current forms, incomplete care plans, inadequate staff training, and poor documentation.
Deficiencies (11)
F582 Medicaid/Medicare Coverage/Liability Notice: Facility failed to provide current Skilled Nursing Facility Advance Beneficiary Notices (ABN) to residents and did not have a policy regarding ABN.
F656 Develop/Implement Comprehensive Care Plan: Facility failed to develop and implement a comprehensive person-centered trauma informed care plan with measurable objectives and timeframes for one sampled resident.
F657 Care Plan Timing and Revision: Facility failed to follow policy and revise care plans to accurately represent care needs of five sampled residents, including activity and recreation needs.
F658 Services Provided Meet Professional Standards: Facility failed to provide care and treatments in accordance with professional standards for medication administration for three of four sampled residents.
F677 ADL Care Provided for Dependent Residents: Facility failed to ensure residents received necessary services to maintain good grooming and personal hygiene when showers were not provided twice weekly for four residents.
F679 Activities Meet Interest/Needs Each Resident: Facility failed to provide an ongoing program to support residents' choice of activities and failed to provide a policy regarding activity programming.
F680 Qualifications of Activity Professional: Facility failed to employ a qualified activity professional to oversee the activity program and provide training.
F699 Trauma Informed Care: Facility failed to assess residents for trauma history and provide trauma-informed care to one sampled resident.
F728 Facility Hiring and Use of Nurse Aide: Facility failed to ensure nurse aides completed required training and competency evaluation programs before employment.
F805 Food in Form to Meet Individual Needs: Facility failed to provide food in a form designed to meet individual needs and failed to follow standardized recipes for pureed foods.
F812 Food Procurement, Store, Prepare, Serve, Sanitary: Facility failed to maintain kitchen sanitation including missing floor tiles, food debris, and grease buildup.
Report Facts
Facility census: 51
Sampled residents: 13
Deficiencies cited: 11
Nurse aide hires: 5
Inspection Report
Life Safety
Census: 52
Capacity: 84
Deficiencies: 7
Date: May 2, 2023
Visit Reason
The inspection was conducted to assess compliance with emergency preparedness and life safety code requirements, including fire safety and emergency lighting, at Quail Run Health Care Center.
Findings
The facility was found deficient in emergency preparedness policies related to subsistence needs for staff and patients during emergencies. Additionally, multiple life safety code violations were identified, including doors with self-closing devices not functioning properly, inadequate emergency lighting testing and documentation, and failure to maintain proper records for electrical systems and exit signage.
Deficiencies (7)
Emergency preparedness policies did not adequately address subsistence needs for staff and patients, including alternate energy sources for emergency lighting, fire detection, and alarm systems.
Doors with self-closing devices were not held closed or were propped open, compromising smoke compartment integrity and fire safety.
Facility staff failed to properly document monthly 30-second and annual 90-minute emergency lighting tests, risking safety of residents and staff.
Facility failed to maintain proper records of internally illuminated exit signage testing and battery back-up maintenance.
Facility did not maintain or test generator and electrical systems according to National Fire Protection Association standards, risking power failure during emergencies.
Exit signage was not maintained to be clearly legible and electrically illuminated at all times, compromising safe egress.
Emergency lighting was insufficiently tested and maintained, with failure to document required inspections and functional testing.
Report Facts
Facility capacity: 84
Census: 52
Inspection Report
Annual Inspection
Census: 51
Deficiencies: 9
Date: May 2, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal regulations related to resident care, medication administration, activities, trauma-informed care, nurse aide training, food preparation, and kitchen sanitation.
Findings
The facility was found deficient in multiple areas including failure to provide proper Skilled Nursing Facility Advance Beneficiary Notices, incomplete trauma-informed care planning for residents with PTSD, inadequate care planning for resident activity preferences, failure to document medication administration properly, insufficient assistance with activities of daily living such as bathing and grooming, lack of a qualified activity professional, failure to provide appropriate pureed food consistency, and poor kitchen sanitation.
Deficiencies (9)
Failed to provide Skilled Nursing Facility Advance Beneficiary Notices (ABN) using the most current CMS-10055 form to residents.
Failed to develop and implement a comprehensive person-centered trauma informed plan of care for a resident with PTSD.
Failed to revise care plans to accurately represent the care needs including activity and recreation needs for multiple residents.
Failed to document administration of physician ordered medications on the Medication Administration Record (MAR) for three residents.
Failed to ensure residents received necessary services to maintain good grooming and personal hygiene when showers were not provided twice a week.
Failed to provide ongoing program of activities designed to meet residents' needs for five residents.
Failed to employ a qualified activity professional to oversee the activity program; the activity director had not completed approved training.
Failed to provide pureed foods at an appropriate texture and consistency; pureed foods were stringy and contained particles.
Failed to maintain the kitchen in a sanitary manner; missing floor tiles, food debris, grease buildup, and dust were observed in multiple areas.
Report Facts
Residents affected: 3
Residents affected: 1
Residents affected: 5
Residents affected: 3
Residents affected: 4
Residents affected: 5
Staff affected: 5
Facility census: 51
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA B | Nurse Aide | Mentioned as employed without completed nurse aide training and involved in care deficiencies |
| NA C | Nurse Aide | Mentioned as employed without completed nurse aide training and involved in care deficiencies |
| NA D | Nurse Aide | Mentioned as employed without completed nurse aide training and involved in care deficiencies |
| NA E | Nurse Aide | Mentioned as employed without completed nurse aide training and involved in care deficiencies |
| NA F | Nurse Aide | Mentioned as employed without completed nurse aide training and involved in care deficiencies |
| Cook A | Cook | Observed preparing pureed food not meeting consistency standards |
| Director of Nursing | Director of Nursing | Interviewed regarding medication administration and nurse aide training deficiencies |
| Administrator | Administrator | Interviewed regarding ABN forms, activity program, nurse aide training, and other deficiencies |
| Certified Medication Technician A | Certified Medication Technician | Interviewed regarding medication administration documentation |
| Licensed Practical Nurse C | Licensed Practical Nurse | Interviewed regarding medication administration and PTSD care |
| Certified Nurse Aide E | Certified Nurse Aide | Interviewed regarding PTSD care and resident behaviors |
| Social Services Director | Social Services Director | Interviewed regarding PTSD care and training |
| Activity Director | Activity Director | Interviewed regarding activity program and training |
| Dietary Manager | Dietary Manager | Interviewed regarding pureed food preparation and kitchen sanitation |
| Registered Dietician | Registered Dietician | Interviewed regarding pureed food preparation and kitchen sanitation |
| Nurse Aide B | Nurse Aide | Interviewed regarding bathing and grooming care |
| Nurse Aide C | Nurse Aide | Interviewed regarding bathing and grooming care |
| Nurse Aide D | Nurse Aide | Interviewed regarding bathing and grooming care |
| Licensed Practical Nurse B | Licensed Practical Nurse | Interviewed regarding bathing and grooming care |
Inspection Report
Plan of Correction
Census: 43
Deficiencies: 2
Date: Oct 4, 2022
Visit Reason
The inspection was conducted to assess compliance with professional standards of care following unwitnessed falls involving two residents and to evaluate the facility's neurological assessment and care planning practices.
Findings
The facility failed to complete neurological assessments and update care plans for two residents after unwitnessed falls. Documentation and interventions were inadequate, and required neurological assessments were not initiated or completed within the expected timeframes.
Deficiencies (2)
F658 Services Provided Meet Professional Standards CFR(s): 483.21(b)(3)(i). The facility failed to complete neurological assessments for two residents after unwitnessed falls and did not update the care plan for one resident after a second fall.
A4075 Nursing Care per Resident Condition. Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice. This regulation was not met as evidenced by the deficiencies cited under F658.
Report Facts
Facility census: 43
BIMS score: 9
BIMS score: 11
Fall risk evaluation score: 10
Inspection Report
Plan of Correction
Census: 44
Deficiencies: 2
Date: Apr 18, 2022
Visit Reason
The inspection was conducted to assess compliance with resident rights related to personal property and dignity, specifically investigating missing clothing and personal items for two residents.
Findings
The facility failed to ensure one resident's missing clothing was found, affecting two residents. Deficiencies included incomplete personal inventory sheets upon admission and inadequate follow-up on missing items.
Deficiencies (2)
F 557 Respect, Dignity/Right to have Personal Property. The facility failed to ensure one resident's missing clothing was found, affecting two residents. Staff did not complete personal inventory sheets for residents upon admission.
A8037 Personal Clothing/Possessions. The facility did not maintain proper records of personal items accompanying residents upon admission, resulting in missing items. This deficiency is linked to F557 and classified as Class II.
Report Facts
Facility census: 44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brandy Neal | Administrator | Signed the statement of deficiencies and plan of correction |
Inspection Report
Routine
Census: 48
Deficiencies: 15
Date: Dec 3, 2021
Visit Reason
The inspection was conducted as a routine regulatory survey of Quail Run Health Care Center to assess compliance with healthcare facility regulations and standards.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity during insulin administration, improper management of resident funds, failure to complete required assessments such as MDS and PASARR, inadequate care planning, medication administration errors, improper transfer techniques, inadequate personal care, failure to treat constipation appropriately, failure to reposition residents timely, unsafe respiratory care practices, and improper food storage and labeling.
Deficiencies (15)
Failure to assure staff maintained resident dignity during insulin administration in a non-private setting.
Failure to provide personal funds and final accounting within thirty days upon discharge for residents.
Failure to purchase a surety bond with sufficient amount to cover residents' personal funds.
Failure to utilize correct Skilled Nursing Facility Beneficiary Notice of Non-coverage (SNF ABN) form for residents.
Failure to provide timely notification of transfer or discharge including required contact information.
Failure to complete Minimum Data Set (MDS) assessment upon admission and periodically as required.
Failure to identify and complete significant change MDS for resident with decline in condition.
Failure to complete PASARR Level II screening for residents with serious mental illness as indicated.
Failure to update comprehensive, person-centered care plan to address resident needs including falls and hospice admission.
Failure to follow professional standards of care in medication administration including blood pressure monitoring, eye drop administration, and medication storage.
Failure to provide adequate perineal care and complete morning care for residents unable to perform ADLs.
Failure to provide appropriate treatment for constipation and failure to reposition resident every 2 hours.
Failure to ensure safe resident transfers including improper use and placement of gait belts.
Failure to provide safe and appropriate respiratory care including failure to date oxygen and nebulizer tubing.
Failure to prepare and store food in accordance with professional standards including failure to label and date food items.
Report Facts
Residents affected: 1
Residents affected: 3
Residents affected: 3
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 3
Residents affected: 3
Residents affected: 2
Residents affected: 3
Residents affected: 4
Food items: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN B | Licensed Practical Nurse | Named in findings related to insulin administration, eye drop administration, and oxygen tubing |
| CNA A | Certified Nurse Aide | Named in findings related to perineal care and resident transfers |
| CNA B | Certified Nurse Aide | Named in findings related to perineal care and resident transfers |
| CNA C | Certified Nurse Aide | Named in findings related to perineal care and resident transfers |
| CNA D | Certified Nurse Aide | Named in findings related to resident repositioning and feeding |
| Administrator | Facility Administrator | Provided interview statements regarding expectations for care and compliance |
| Business Office Manager | Business Office Manager | Named in findings related to resident funds and beneficiary notices |
| Director of Nursing | Director of Nursing | Named in findings related to care planning, transfers, and staff training |
| Social Services Director | Social Services Director | Named in findings related to PASARR screenings and medication administration |
| Restorative Aide A | Restorative Aide | Named in findings related to resident transfers and perineal care |
Inspection Report
Life Safety
Census: 48
Capacity: 84
Deficiencies: 19
Date: Dec 3, 2021
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association and related regulations.
Findings
The facility failed to meet several Life Safety Code requirements including fire hazard prevention, delayed egress door signage and operation, emergency lighting testing, sprinkler system maintenance, corridor door smoke resistance, smoking regulations, and electrical equipment safety. Multiple deficiencies were identified affecting residents, staff, and visitors.
Deficiencies (19)
K100 General Requirements - The facility failed to ensure the exterior minimized fire emergency risks, including pallets leaned against the building and lint buildup near dryer discharges.
K222 Egress Doors - Delayed egress doors lacked required signage, failed to release properly, and were locked improperly, affecting four of five exits.
K291 Emergency Lighting - The facility failed to conduct required monthly and annual emergency lighting tests, and some emergency lights did not work during testing.
K353 Sprinkler System - The facility failed to maintain sprinkler heads free of corrosion, dust, and debris, potentially affecting residents and staff safety.
K363 Corridor Doors - Corridor doors did not resist smoke passage due to gaps and improper maintenance, compromising fire safety.
K372 Smoke Barrier - The facility failed to maintain smoke barrier walls complete from outside wall to roof deck, affecting two of five smoke compartments.
K511 Utilities - Gas and Electric - The facility failed to ensure dryers were free of lint buildup, creating a fire hazard near gas dryers.
K741 Smoking Regulations - The facility failed to ensure smoking areas were free of hazards and properly maintained ashtrays and smoking policies.
A2003 No Fire Hazard - The building presented fire hazards as referenced in K100 and K511.
A2034 Sprinkler System-Test/Maintain - The sprinkler system was not properly maintained as referenced in K353.
A2041 Door Locks - Door locks did not meet requirements for delayed egress as referenced in K222.
A2046 Corridor Requirements - Corridors were not maintained free of obstruction as referenced in K222.
A2050 Emergency Lighting - Emergency lighting system testing and maintenance were deficient as referenced in K291.
A2054 Smoke Section Walls/Doors - Smoke section walls and doors were not properly maintained as referenced in K372.
A2056 Smoking-Designated Areas/Assess Supervision - Smoking areas and supervision were not properly managed as referenced in K741.
A2057 Ashtrays Noncombustibles/Safe/Disposal - Ashtrays were not safely maintained as referenced in K741.
A3001 Substantially Constructed/Maintained - The building was not properly maintained as referenced in K363.
A3030 Electrical Wiring & Equipment Maintained - Electrical wiring and equipment were not properly maintained as referenced in K920.
A3037 Extension Cords/Duplex Receptacles - Extension cords were improperly used as referenced in K920.
Report Facts
Facility capacity: 84
Resident census: 48
Delayed egress doors affected: 4
Sprinkler heads dusted: 7
Inspection Report
Annual Inspection
Census: 39
Deficiencies: 4
Date: Oct 18, 2021
Visit Reason
The inspection was conducted as an annual survey of Quail Run Health Care Center to assess compliance with federal and state regulations.
Findings
The facility was found deficient in providing adequate resident care, including failure to ensure residents received showers as scheduled and issues with staff smoking policies. Observations and interviews revealed noncompliance with smoking regulations and resident hygiene care.
Deficiencies (4)
F677: The facility failed to ensure residents received showers as scheduled, with multiple refusals documented and residents requiring assistance with bathing and care.
F926: The facility failed to enforce smoking policies, with a Licensed Practical Nurse consuming smokeless tobacco while providing resident care and not following hygiene protocols after spitting.
A4015: Personnel were not fully informed of facility policies and their duties, as evidenced by the smoking policy violations.
A4075: Residents were not kept clean, dry, and free from offensive body and mouth odors, indicating inadequate personal hygiene care.
Report Facts
Facility census: 39
Deficiencies cited: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Observed consuming smokeless tobacco and not following hygiene protocols | |
| Administrator (ADM) | Interviewed regarding facility staffing and smoking policy |
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 2
Date: Jun 22, 2021
Visit Reason
The inspection was conducted due to a complaint investigation regarding the employment of an individual listed on the Employee Disqualification List (EDL).
Complaint Details
The complaint was substantiated as the facility employed an individual listed on the Employee Disqualification List, violating regulatory requirements.
Findings
The facility failed to identify and prevent the employment of a Licensed Practical Nurse (LPN) who was listed on the Employee Disqualification List. The Business Office Manager did not perform or report EDL checks properly, and the Administrator and Director of Nursing were unaware of the issue.
Deficiencies (2)
F606: The facility employed an LPN listed on the Employee Disqualification List, which is prohibited. The Business Office Manager failed to perform or report EDL checks, and the Administrator and Director of Nursing were unaware of the LPN's status.
A4021: No person listed on the employee disqualification list shall work or volunteer in the facility. This regulation was not met as referenced by F606.
Report Facts
Facility census: 42
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Oct 21, 2020
Visit Reason
A COVID-19 focused infection control and emergency preparedness survey was conducted to assess compliance with CMS and CDC recommended practices and federal regulations.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control and with 42 CFR 483.73 related to emergency preparedness.
Inspection Report
Routine
Deficiencies: 0
Date: Sep 29, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and a COVID-19 Focused Emergency Preparedness survey were conducted from September 24 to September 29, 2020.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control and with 42 CFR 483.73 related to emergency preparedness.
Inspection Report
Routine
Deficiencies: 0
Date: May 27, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and a COVID-19 Focused Emergency Preparedness survey were conducted on May 26 and May 27, 2020 to assess compliance with CMS and CDC recommended practices and federal regulations.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control and with 42 CFR 483.73 related to emergency preparedness.
Inspection Report
Annual Inspection
Census: 38
Deficiencies: 10
Date: Apr 26, 2019
Visit Reason
Annual inspection survey conducted on 04/26/2019 to assess compliance with federal and state regulations for Quail Run Health Care Center.
Findings
The facility was found deficient in multiple areas including resident rights notification, comprehensive care planning, professional standards of care, pressure ulcer prevention, infection control, medication error rates, and safety measures related to smoking and accident hazards. Several residents' care plans and staff practices did not meet regulatory requirements.
Deficiencies (10)
F572 Resident rights were not properly informed or documented; nine of nine residents interviewed were unaware of their rights and no documentation was found in resident council meeting notes.
F656 The facility failed to develop and implement comprehensive, person-centered care plans with measurable objectives for residents, including safe smoking practices and wandering behavior interventions.
F658 The facility did not meet professional standards of care; staff failed to follow guidelines for treatments and maintain confidentiality, leaving ointment unattended on medication carts.
F686 The facility failed to prevent and treat pressure ulcers properly for one resident, lacking appropriate interventions and documentation.
F689 The facility did not ensure safety measures to prevent accidents related to smoking materials; two residents were assessed as unsafe to keep cigarette lighters.
F690 The facility failed to provide adequate care for bowel and bladder incontinence, including catheter care and infection prevention for one resident.
F732 The facility failed to post nurse staffing information daily in a prominent and accessible location for residents and visitors.
F759 The facility's medication error rate exceeded 5%, with two errors out of 26 opportunities, and failed to ensure safe insulin administration.
F812 The facility failed to ensure dietary staff washed hands between glove changes and tasks, risking food safety.
F880 The facility failed to establish and maintain an effective infection prevention and control program, including hand hygiene and cleaning of equipment.
Report Facts
Facility census: 38
Medication error rate: 7.68
Medication error opportunities: 26
Medication errors: 2
Residents sampled: 12
Inspection Report
Life Safety
Census: 38
Capacity: 84
Deficiencies: 9
Date: Apr 26, 2019
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code and related fire safety regulations at Quail Run Health Care Center.
Findings
The facility failed to meet several Life Safety Code requirements including illumination of means of egress, kitchen hood suppression system inspections, fire alarm system documentation and testing, smoke barrier integrity, door inspections and maintenance, and electrical equipment safety. The facility had multiple deficiencies with potential to affect all residents and staff.
Deficiencies (9)
K281 Illumination of Means of Egress: The facility failed to provide continuous illumination to means of egress at all times during an emergency, with emergency exit lights on timers and motion sensors not connected to the fire alarm system.
K324 Cooking Facilities: The kitchen hood suppression system was not inspected at least every six months, risking fire safety in five smoke compartments.
K343 Fire Alarm System - Notification: The facility failed to document monthly activation of the fire alarm, affecting staff readiness and emergency assurance.
K345 Fire Alarm System - Testing and Maintenance: The facility failed to conduct semi-annual fire alarm inspections as required, risking fire alarm functionality.
K372 Subdivision of Building Spaces - Smoke Barrier: The facility failed to maintain smoke barrier walls free of penetrations, affecting all five smoke compartments and all residents.
K374 Subdivision of Building Spaces - Smoke Barrier Doors: Two of four smoke barrier doors lacked legible fire resistance rating labels, affecting four smoke compartments and all residents.
K761 Maintenance, Inspection & Testing - Doors: The facility failed to complete an annual door inspection as required, affecting all residents.
K920 Electrical Equipment - Power Cords and Extension Cords: Unsafe use of power strips and daisy-chained adapters was observed, affecting two of six smoke compartments and residents.
K921 Electrical Equipment - Testing and Maintenance: The facility failed to perform and document required testing of resident room electrical receptacles, risking resident safety.
Report Facts
Facility Capacity: 84
Resident Census: 38
Inspection Report
Annual Inspection
Census: 35
Deficiencies: 11
Date: Jun 8, 2018
Visit Reason
Annual state survey inspection of Quail Run Health Care Center to assess compliance with federal and state regulations.
Findings
The facility was found to have multiple deficiencies including failure to respect residents' dignity and privacy, inadequate accommodations, lack of advance directives, unsafe environment conditions, improper medication storage and administration, and insufficient infection control practices. Plans of correction were submitted addressing these issues.
Deficiencies (11)
F557 Respect and Dignity: Facility staff failed to respect the privacy and dignity of residents by administering inhalers in the dining room and allowing a resident to wear soiled clothing in public areas.
F558 Reasonable Accommodations Needs/Preferences: Facility failed to provide a comfortable chair for a resident, resulting in discomfort and open wounds on the resident's legs.
F578 Request/Refuse/Discontinue Treatment/Advance Directive: Facility failed to maintain a current copy of a resident's advance directive and did not provide proper notification of transfers to the Ombudsman.
F584 Safe/Clean/Comfortable/Homelike Environment: Facility failed to maintain a clean, comfortable, and homelike environment, with issues including wax buildup, rust, missing trim, strong odors, and damaged flooring.
F623 Notice Requirements Before Transfer/Discharge: Facility failed to provide timely and proper notice of resident transfers and discharges to residents, representatives, and Ombudsman.
F656 Develop/Implement Comprehensive Care Plan: Facility failed to develop and implement comprehensive care plans consistent with residents' needs and conditions.
F658 Services Provided Meet Professional Standards: Facility failed to provide services meeting professional standards, including proper administration of eye drops and nasal sprays.
F689 Free of Accident Hazards/Supervision/Devices: Facility failed to ensure a safe environment free of accident hazards, including improper use of mechanical lifts and unsecured equipment.
F761 Label/Store Drugs and Biologicals: Facility failed to properly store and discard medications, including expired drugs and lack of proper labeling.
F812 Food Procurement, Store, Prepare, Serve-Sanitary: Facility failed to ensure proper handwashing and sanitary food service practices among dietary staff.
F880 Infection Prevention & Control: Facility failed to establish and maintain an effective infection prevention and control program, including improper handling of medications and linens.
Report Facts
Facility census: 35
Deficiency count: 11
Inspection Report
Life Safety
Census: 35
Capacity: 84
Deficiencies: 11
Date: Jun 8, 2018
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code and related emergency preparedness requirements for the facility.
Findings
The facility failed to meet several Life Safety Code requirements including emergency preparedness, building construction standards, exit discharge conditions, exit signage, sprinkler system maintenance, corridor door compliance, smoke barrier doors, fire drills, electrical systems, and safe use of power strips and oxygen storage. The facility census was 35 with a licensed capacity of 84 beds.
Deficiencies (11)
E001: The facility failed to comply with emergency preparedness requirements when staff did not have keys to unlock the Administrator's office and maintenance office. The facility census was 35.
K161: The facility failed to maintain the Type V protected wood-frame construction standard, with multiple gaps and holes in vents, ceilings, and attic access panels. The facility has a capacity of 84 and a census of 35.
K271: The facility failed to provide a level walking surface for exit discharges, with cracked, chipped, and rocky parking lot and sidewalk surfaces. The facility has a bed capacity of 84 and a census of 35.
K293: The facility failed to provide exit signage to mark means of egress, including a locked courtyard door without exit signage. The facility has a bed capacity of 84 and a census of 35.
K353: The facility failed to maintain its automatic sprinkler system, with sprinkler heads covered in dust and debris, no signage for fire department connection, and light fixtures too close to sprinkler heads. The facility has a bed capacity of 84 and a census of 35.
K363: The facility failed to assure resident room doors shut flush to the frame to resist smoke passage, with gaps observed in multiple resident rooms. The facility has a capacity of 84 and a census of 35.
K374: The facility failed to maintain smoke barrier doors, with gaps between doors and frames and doors with holes that would not resist smoke passage. The facility has a bed capacity of 84 and a census of 35.
K711: The facility failed to ensure staff knew what to do in case of a kitchen fire and did not provide training on the range hood suppression system. The facility census was 35.
K712: The facility failed to conduct fire drills at varied times within shifts as required, with drills conducted only at expected times. The facility has a capacity of 84 and a census of 35.
K918: The facility failed to ensure the emergency generator had an emergency shut off switch and failed to maintain electrical equipment and power cords safely, including unsecured power strips and unsafe use of power strips. The facility has a bed capacity of 84 and a census of 35.
K923: The facility failed to store oxygen cylinders safely, with unsecured cylinders and oxygen stored less than five feet from combustible items. The facility has a capacity of 84 and a census of 35.
Report Facts
Facility census: 35
Total licensed capacity: 84
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