Deficiencies (last 3 years)
Deficiencies (over 3 years)
7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
27% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
99 residents
Based on a August 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Routine
Census: 99
Deficiencies: 8
Aug 16, 2024
Visit Reason
Routine inspection of Neighborhoods at Quail Creek nursing home to assess compliance with regulatory standards including staff screening, resident care, safety, medication management, infection control, and facility cleanliness.
Findings
The facility was found deficient in multiple areas including failure to timely complete Employee Disqualification List and Nurse Aide Registry checks for staff, inadequate assistance with resident meals, unsafe hot water temperatures, failure to provide ordered dietary supplements, medication administration and storage issues, infection control lapses including hand hygiene and PPE use, and poor sanitation in kitchen and food service areas.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 8
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to complete Employee Disqualification List and Nurse Aide Registry checks timely for one employee. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide timely assistance with eating to a resident at risk for malnutrition. | Level of Harm - Minimal harm or potential for actual harm |
| Hot water temperatures in multiple resident access areas exceeded 120 degrees Fahrenheit, increasing risk of burns. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide physician ordered dietary supplements to residents at risk for weight loss. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain accurate reconciliation and accounting for controlled medications and failure to destroy expired or unused medications. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to store controlled substances under two locks, medication carts left unlocked when unattended, medications left on resident bedside without order, and removal of prescription labels from medications. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to implement effective infection prevention and control program including hand hygiene, PPE use, and glucometer disinfection. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain a sanitary environment in kitchens and food service areas including dirty ceiling vents, light covers, walls, and non-contact food surfaces. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Census: 99
Weight loss: 9.8
Weight loss: 5
Hot water temperature: 134.6
Hot water temperature: 132.8
Hot water temperature: 130.2
Hot water temperature: 130.1
Hot water temperature: 122
Medication count discrepancy: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Named in failure to complete timely Employee Disqualification List and Nurse Aide Registry checks |
| LPN B | Licensed Practical Nurse | Responsible for background checks and EDL/NA registry checks |
| Director of Nursing | DON | Interviewed regarding oversight of background checks and resident care |
| Administrator | Interviewed regarding staff screening and facility policies | |
| CNA T | Certified Nursing Assistant | Interviewed regarding resident feeding assistance and infection control |
| CNA U | Certified Nursing Assistant | Interviewed regarding resident feeding assistance and infection control |
| MDS Coordinator X | Interviewed regarding resident care plans and isolation precautions | |
| Clinical Dietary Nurse | Interviewed regarding resident nutrition and dietary supplements | |
| Dietary Consultant Nurse | Interviewed regarding resident weights and dietary orders | |
| Dietary Manager | Interviewed regarding dietary services and supplement administration | |
| RN M | Registered Nurse | Interviewed regarding medication administration and infection control |
| CMT L | Certified Medication Technician | Interviewed regarding medication administration and controlled substance count |
| LPN J | Licensed Practical Nurse | Interviewed regarding medication storage and infection control |
| CMT O | Certified Medication Technician | Interviewed regarding medication storage and controlled substance count |
| CMT N | Certified Medication Technician | Interviewed regarding medication storage and controlled substance count |
| Homemaker D | Interviewed regarding kitchen hygiene and hairnet use | |
| Homemaker F | Interviewed regarding kitchen hygiene and hairnet use | |
| Homemaker G | Interviewed regarding kitchen hygiene and hairnet use | |
| Chef C | Interviewed regarding kitchen hygiene and hairnet use | |
| CNA R | Certified Nursing Assistant | Observed and interviewed regarding infection control during resident care |
| CNA S | Certified Nursing Assistant | Observed and interviewed regarding infection control during resident care |
| LPN K | Licensed Practical Nurse | Observed and interviewed regarding glucometer use and infection control |
| LPN W | Licensed Practical Nurse | Observed and interviewed regarding feeding tube medication administration and infection control |
Inspection Report
Complaint Investigation
Census: 97
Deficiencies: 1
May 14, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to report an allegation of possible physical abuse made by one resident in a timely manner to the State Survey Agency.
Findings
The facility failed to report allegations of possible abuse within the required two-hour timeframe. An investigation concluded that the resident's allegations were unsubstantiated and related to hallucinations. Staff interviews confirmed reporting procedures, but the Administrator did not report the allegation to the state agency because the investigation found no suspected abuse.
Complaint Details
The complaint involved an allegation by Resident #1 of physical abuse, including staff pinching and stealing personal items. The resident had severe cognitive impairment and hallucinations. The facility's investigation found no evidence of abuse, and the allegation was deemed unsubstantiated. The Administrator did not report to the State Survey Agency within two hours because the allegation was disproved within that timeframe.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Facility census: 97
Residents sampled: 7
Resident admission date: Jun 2, 2023
MDS assessment date: Dec 23, 2023
Nurse's progress note date: Mar 7, 2024
Investigation date: Mar 7, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Reported resident's allegations to Administrator and conducted investigation |
| LPN C | Licensed Practical Nurse | Described reporting procedures for abuse allegations |
| CNA E | Certified Nursing Assistant | Described reporting procedures for abuse allegations |
| RN B | Registered Nurse | Described reporting procedures for abuse allegations |
| CMT D | Certified Medication Technician | Described reporting procedures for abuse allegations |
| CNA F | Certified Nursing Assistant | Described reporting procedures for abuse allegations |
| DON | Director of Nursing | Explained investigation and reporting decisions regarding the abuse allegation |
| Administrator | Received report from RN A, conducted investigation, and decided not to report to DHSS due to unsubstantiated allegation |
Inspection Report
Complaint Investigation
Census: 99
Deficiencies: 1
Apr 18, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding a staff member (CNA A) who asked for and took money from a resident (Resident #1), which is alleged misappropriation.
Findings
The facility failed to protect residents from misappropriation when CNA A accepted a $2,000 check from Resident #1 under questionable circumstances. The facility investigated, suspended, and terminated CNA A, provided staff training on abuse and neglect, and implemented ongoing monitoring and corrective actions.
Complaint Details
The complaint involved CNA A asking for and accepting $2,000 from Resident #1 purportedly to help pay for the CNA's child's surgery. The resident reported the incident after CNA A became defensive and tried to manipulate the situation. The facility self-reported to DHSS and notified police. CNA A was terminated. Multiple staff interviews confirmed the inappropriateness of the conduct and the violation of facility policy.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to protect each resident from the wrongful use of the resident's belongings or money. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Amount of money involved: 2000
Facility census: 99
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nurse Aide | Staff member who asked for and took money from Resident #1, terminated for policy violation |
| RN C | Registered Nurse | Reported the incident to Director of Nursing and Administrator |
| CNA E | Certified Nurse Aide | Interviewed and stated it is inappropriate to ask residents for money |
| LPN D | Licensed Practical Nurse | Interviewed and stated misappropriation training was provided and taking money from residents is inappropriate |
| Social Services Director | Social Services Director | Interviewed and stated it is not appropriate to take money from residents |
| DON | Director of Nursing | Interviewed and stated staff should be professional and was not aware of CNA A's actions until reported |
| Administrator | Administrator | Notified of incident, initiated investigation, and confirmed policy violations |
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 5
Oct 3, 2022
Visit Reason
The inspection was conducted due to complaints involving allegations of abuse, neglect, and failure to report and investigate these allegations properly in a nursing home facility.
Findings
The facility failed to ensure residents were free from abuse and neglect, failed to timely report suspected abuse to authorities, failed to complete full investigations of abuse allegations within required timeframes, failed to notify residents or their representatives in writing of hospital transfers, and failed to ensure proper supervision and functioning of a wanderguard bracelet for a resident at risk of elopement.
Complaint Details
The complaint investigation involved allegations of abuse and neglect concerning four residents (Residents #1, #32, #55, and #71), including verbal abuse by staff, refusal to provide care, failure to report allegations to the State Survey Agency within two hours, and failure to conduct timely investigations.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to protect residents from abuse and neglect, including verbal abuse and refusal to provide care. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to timely report suspected abuse, neglect, or theft to proper authorities within two hours. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to complete full and documented investigations of abuse allegations within five working days. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide timely written notification to residents or their representatives of hospital transfers, including reason for transfer and appeal rights. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure proper supervision and daily functioning checks of a resident's wanderguard bracelet to prevent elopement. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Facility census: 81
Residents affected: 4
Residents affected: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN K | Licensed Practical Nurse | Named in findings related to refusal to provide care and verbal abuse of residents. |
| LPN L | Licensed Practical Nurse | Reported incidents of abuse and refusal to provide care by LPN K. |
| CNA I | Certified Nurse Aide | Reported refusal of LPN K to assist resident and verbal abuse incidents. |
| ADON | Assistant Director of Nursing | Provided statements on abuse definitions and facility policies. |
| Administrator | Provided statements on abuse reporting and investigation policies. | |
| DON | Director of Nursing | Provided statements on abuse reporting and investigation policies. |
| RN M | Registered Nurse | Involved in reporting and investigation of abuse allegations. |
| LPN H | Licensed Practical Nurse | Received reports of abuse allegations and involved in reporting process. |
| CNA C | Certified Nurse Aide | Provided information on wanderguard monitoring practices. |
| LPN D | Licensed Practical Nurse | Provided information on wanderguard monitoring and resident checks. |
| Concierge Supervisor | Provided information on wanderguard system monitoring. | |
| Concierge Staff F | Performed wanderguard functioning checks and provided information on resident monitoring. | |
| Social Services A | Provided information on family notification regarding bed hold policy. | |
| Social Services B | Provided information on family notification regarding bed hold policy. |
Inspection Report
Routine
Census: 72
Deficiencies: 6
Oct 15, 2019
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements including grievance handling, care planning, respiratory care, dialysis communication, medication administration, and infection control.
Findings
The facility was found deficient in multiple areas including failure to document and resolve resident grievances, incomplete care plans for residents with exit-seeking behavior and seatbelt use, lack of physician orders for oxygen therapy, inadequate communication with dialysis center, medication administration errors including insulin pen priming and dosing errors, and failure to maintain infection control by not capping a PICC line.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to document and track residents' grievances and failed to make prompt efforts to resolve grievances for four residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to revise care plans for two residents to include exit seeking behaviors and use of a seatbelt. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to obtain a physician order for oxygen for two residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide ongoing communication with the dialysis center for one resident receiving dialysis. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure medication error rates were less than 5 percent; six medication errors observed including insulin pen priming and dosing errors. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to use appropriate infection control procedures by not attaching a cap on the end of a PICC line for one resident. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected by grievance deficiency: 4
Facility census: 72
Medication errors: 6
Medication error rate: 17.6
Dialysis frequency: 3
Insulin doses: 2
Insulin doses: 15
Insulin doses: 22
PICC flush volume: 10
PICC flush volume: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN F | Licensed Practical Nurse | Named in insulin administration errors and PICC line flushing |
| LPN M | Licensed Practical Nurse | Named in PICC line flushing and antibiotic administration |
| RN N | Registered Nurse | Named in PICC line infection control deficiency |
| Director of Nursing | DON | Provided statements on care plan requirements, medication administration, and infection control |
| Administrator | Provided statements on grievance follow-up, care plan content, and dialysis communication | |
| Assistant Director of Nursing | ADON | Provided statements on dialysis communication and care plan issues |
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