Deficiencies (last 6 years)
Deficiencies (over 6 years)
13 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
136% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
28
21
14
7
0
Occupancy
Latest occupancy rate
83% occupied
Based on a August 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Routine
Census: 99
Deficiencies: 8
Date: 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.
Deficiencies (8)
Failure to complete Employee Disqualification List and Nurse Aide Registry checks timely for one employee.
Failure to provide timely assistance with eating to a resident at risk for malnutrition.
Hot water temperatures in multiple resident access areas exceeded 120 degrees Fahrenheit, increasing risk of burns.
Failure to provide physician ordered dietary supplements to residents at risk for weight loss.
Failure to maintain accurate reconciliation and accounting for controlled medications and failure to destroy expired or unused medications.
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.
Failure to implement effective infection prevention and control program including hand hygiene, PPE use, and glucometer disinfection.
Failure to maintain a sanitary environment in kitchens and food service areas including dirty ceiling vents, light covers, walls, and non-contact food surfaces.
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
Plan of Correction
Census: 99
Capacity: 120
Deficiencies: 9
Date: Aug 16, 2024
Visit Reason
The inspection was conducted to assess compliance with life safety and fire safety codes, including fire alarm system maintenance, sprinkler system testing, fire extinguisher inspections, fire drills, electrical system maintenance, and emergency preparedness.
Findings
The facility was found deficient in maintaining fire-rated building construction, fire alarm system testing and maintenance, sprinkler system maintenance, portable fire extinguisher inspections, fire drills, electrical system testing, and emergency generator maintenance. Deficiencies had the potential to affect all residents, staff, and visitors.
Deficiencies (9)
K161 Building Construction Type and Height: The facility failed to maintain the one-hour fire rating of ceilings due to unsealed penetrations around sprinkler escutcheon rings in multiple locations.
K345 Fire Alarm System - Testing and Maintenance: The facility failed to inspect and maintain the fire alarm system properly, including certification and cleaning of strobe lights.
K353 Sprinkler System - Maintenance and Testing: The facility failed to ensure sprinkler heads were free from debris and properly maintained, with no set procedure for checking sprinkler heads.
K355 Portable Fire Extinguishers: The facility failed to ensure fire extinguishers were inspected monthly and maintained with current tags.
K712 Fire Drills: The facility failed to conduct monthly fire drills once per shift and maintain documentation of fire drills.
K914 Electrical Systems - Maintenance and Testing: The facility failed to document required annual receptacle testing and maintain electrical systems properly.
K918 Electrical Systems - Essential Electric System: The facility failed to maintain and test emergency generator and transfer switches according to standards.
K920 Electrical Equipment - Power Cords and Extensions: The facility failed to maintain proper use and inspection of power strips and extension cords in patient care areas.
K923 Gas Equipment - Cylinder and Container Storage: The facility failed to ensure proper storage and separation of full and empty oxygen cylinders with appropriate signage.
Report Facts
Facility capacity: 120
Resident census: 99
Deficiencies cited: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Named as responsible for compliance and corrective actions related to fire safety and maintenance deficiencies | |
| Administrator | Named as responsible for compliance and oversight of corrective actions |
Inspection Report
Complaint Investigation
Census: 97
Deficiencies: 1
Date: 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.
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.
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.
Deficiencies (1)
Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
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: 97
Deficiencies: 1
Date: May 14, 2024
Visit Reason
The inspection was conducted in response to allegations of abuse, neglect, exploitation, or mistreatment at the facility.
Complaint Details
The complaint investigation was triggered by allegations of abuse involving one resident. The investigation found the resident's hallucinations were the root cause and no abuse was substantiated.
Findings
The facility failed to ensure all allegations of possible abuse were reported immediately to the State Survey Agency within the required timeframes. An investigation determined that the root cause of the incident was hallucinations and no abuse, neglect, or exploitation was substantiated.
Deficiencies (1)
F 609 Reporting of Alleged Violations: The facility failed to report all alleged violations involving abuse, neglect, exploitation, or mistreatment immediately, but not later than two hours after the allegation was made, to the State Survey Agency.
Report Facts
Facility census: 97
Number of sampled residents: 7
Inspection Report
Complaint Investigation
Census: 99
Deficiencies: 1
Date: 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.
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.
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.
Deficiencies (1)
Failed to protect each resident from the wrongful use of the resident's belongings or money.
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
Plan of Correction
Census: 99
Deficiencies: 1
Date: Apr 18, 2024
Visit Reason
The visit was conducted to investigate a past non-compliance related to misappropriation/exploitation involving a staff member taking money from a resident. The report serves as a statement of deficiencies and plan of correction.
Findings
The facility failed to keep all residents free from misappropriation when a Certified Nurse Aide (CNA) took money from a resident. The facility conducted an investigation, terminated the CNA, provided staff training, and implemented ongoing abuse and neglect training and monitoring.
Deficiencies (1)
F 602: The facility failed to keep residents free from misappropriation when a CNA took money from a resident. The CNA was terminated and staff were trained on abuse and neglect prevention.
Report Facts
Resident census: 99
Monetary amount: 2000
Monetary amount: 500
Monetary amount: 25
Inspection Report
Plan of Correction
Census: 77
Deficiencies: 1
Date: Nov 22, 2022
Visit Reason
The inspection was conducted to address a past non-compliance related to significant medication errors identified at the facility. The visit included review of medication administration practices and documentation following notification of the past non-compliance.
Findings
The facility failed to ensure residents were free of significant medication errors, specifically involving incorrect medication pulled from the stat safe for one resident over five days. Staff interviews and record reviews confirmed the medication error and subsequent corrective actions.
Deficiencies (1)
F 760: The facility failed to ensure residents were free of significant medication errors as staff pulled incorrect medication from the stat safe for one resident, resulting in incorrect medication administration for five days.
Report Facts
Facility census: 77
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse E | Registered Nurse | Involved in medication error and interviewed regarding medication administration procedures |
| Director of Nursing | Director of Nursing | Notified about medication error and resident's responsible party |
| Licensed Practical Nurse D | Licensed Practical Nurse | Interviewed about medication card checks and medication error procedures |
| Certified Medication Technician A | Certified Medication Technician | Involved in pulling medication from stat safe during error period |
| Certified Medication Technician B | Certified Medication Technician | Found incorrect medication in resident's cabinet |
| Certified Medication Technician C | Certified Medication Technician | Interviewed about medication checks and reporting errors |
| Certified Medication Technician F | Certified Medication Technician | Interviewed about medication order checks and stat safe procedures |
| Assistant Director of Nursing | Assistant Director of Nursing | Participated in interview regarding medication administration and error monitoring |
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 5
Date: 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.
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.
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.
Deficiencies (5)
Failure to protect residents from abuse and neglect, including verbal abuse and refusal to provide care.
Failure to timely report suspected abuse, neglect, or theft to proper authorities within two hours.
Failure to complete full and documented investigations of abuse allegations within five working days.
Failure to provide timely written notification to residents or their representatives of hospital transfers, including reason for transfer and appeal rights.
Failure to ensure proper supervision and daily functioning checks of a resident's wanderguard bracelet to prevent elopement.
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
Complaint Investigation
Census: 81
Deficiencies: 10
Date: Oct 3, 2022
Visit Reason
The inspection was conducted due to allegations of abuse and neglect involving several residents at the facility. The investigation focused on verifying these allegations and assessing the facility's compliance with abuse prevention and reporting regulations.
Complaint Details
The complaint investigation was substantiated. The facility was found to have failed in preventing abuse and neglect, timely reporting of alleged violations, and conducting thorough investigations. Multiple residents were involved in incidents of verbal abuse, neglect, and refusal of care by staff. The facility also failed to notify residents and representatives of transfers and failed to maintain adequate supervision and safety devices.
Findings
The facility failed to ensure residents were free from abuse and neglect, including verbal abuse and refusal of care by staff. The facility also failed to report alleged violations of abuse and neglect to the appropriate authorities within required timeframes. Multiple residents were involved in incidents of verbal abuse and neglect by staff members.
Deficiencies (10)
F600 Freedom from Abuse, Neglect, and Exploitation: The facility failed to ensure all residents were free from verbal abuse and neglect by staff, including refusal to assist with bowel programs and use of profane language toward residents.
F609 Reporting of Alleged Violations: The facility failed to report alleged violations involving abuse and neglect to management and the State Survey Agency within required timeframes.
F610 Investigate/Prevent/Correct Alleged Violation: The facility failed to complete full and timely investigations of alleged abuse and neglect involving multiple residents.
F623 Notice Requirements Before Transfer/Discharges: The facility failed to notify residents and their representatives in writing of transfers or discharges as required by regulation.
F689 Free of Accident Hazards/Suspension/Devices: The facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents, including failure to check wander guard functionality.
A4074 Protective Oversight, Voluntary Leave: The facility failed to provide required protective oversight and supervision for residents on voluntary leave.
A4075 Nursing Care per Resident Condition: The facility failed to provide personal attention and nursing care consistent with residents' conditions.
A8023 Develop/Implement ANE Policies: The facility failed to develop and implement policies to prohibit mistreatment, neglect, and abuse of residents.
A8025 Report ANE to DHSS/DMH When Needed: The facility failed to report suspected abuse or neglect to the Department of Mental Health as required.
A8030 Dignity/Privacy: The facility failed to treat residents with dignity and respect, including privacy in treatment and care.
Report Facts
Facility census: 81
Deficiencies cited: 10
Plan of correction completion dates: All corrective actions have a completion date of 2022-11-15
Inspection Report
Life Safety
Census: 81
Capacity: 120
Deficiencies: 9
Date: Oct 3, 2022
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 maintain the integrity of building construction fire ratings, fire alarm system functionality, fire extinguisher availability, corridor door maintenance, smoking area safety, fire door operation, electrical system safety, and gas equipment storage. Multiple deficiencies were identified that could affect residents, staff, and visitors in the event of a fire.
Deficiencies (9)
K161 Building Construction Type & Height: The facility failed to maintain the one-hour fire rating of ceilings due to unsealed penetrations between the attic and areas below, risking smoke passage affecting residents and staff.
K345 Fire Alarm System - Testing and Maintenance: The facility failed to maintain a fully functional fire alarm system, including non-sounding alarms and incomplete annual functional testing of smoke alarms.
K355 Portable Fire Extinguishers: The facility lacked K-extinguishers in cooking areas, and some extinguishers were not readily accessible, risking inadequate fire suppression capability.
K363 Corridor Doors: The facility failed to maintain smoke-resistant corridor doors by allowing unsealed gaps, risking smoke passage into exit corridors.
K741 Smoking Regulations: The facility failed to maintain smoking areas properly, allowing cigarette butts to accumulate and lacking self-closing containers for disposal.
K761 Maintenance, Inspection & Testing - Doors: Fire doors failed to release from magnetic holders during fire alarm activation, risking fire containment failure.
K912 Electrical Systems - Receptacles: Electrical outlets near water sources lacked ground fault circuit interrupters (GFI), risking electrical hazards.
K914 Electrical Systems - Maintenance and Testing: The facility failed to complete required electrical certification and maintenance documentation for 2022.
K923 Gas Equipment - Cylinder and Container Storage: The facility improperly stored combustible gas cylinders in attic spaces without adequate safety measures, risking fire hazards.
Report Facts
Facility Capacity: 120
Resident Census: 81
Inspection Report
Abbreviated Survey
Census: 29
Capacity: 72
Deficiencies: 2
Date: Apr 27, 2022
Visit Reason
The visit was an abbreviated survey conducted due to an immediate jeopardy situation related to failure to initiate timely CPR for a resident.
Complaint Details
The violation was determined to be at an imminent danger Class I level at the time of the complaint investigation. The facility implemented corrective actions during the onsite visit.
Findings
The facility failed to initiate timely cardio-pulmonary resuscitation (CPR) for a resident, delayed calling 911, and lacked a system to notify staff promptly. The facility implemented corrective actions and re-educated staff on CPR policies.
Deficiencies (2)
F678 Cardio-Pulmonary Resuscitation (CPR) was not initiated timely for a resident, staff failed to call 911 immediately, and the facility lacked a system to notify other staff for assistance during CPR.
A4075 Nursing care was not provided in accordance with the resident's condition and current nursing practice, linked to the CPR deficiency.
Report Facts
Facility census: 29
Total licensed capacity: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Named in CPR initiation and delay in calling 911 |
| LPN D | Licensed Practical Nurse | Assisted with CPR and involved in delay |
| CNA C | Certified Nursing Assistant | Found resident unresponsive and alerted RN |
| Administrator | Administrator | Notified of immediate jeopardy and responsible for corrective actions |
| Director of Nursing | Director of Nursing | Involved in notification and corrective action |
| Assistant Director of Nursing | Assistant Director of Nursing | Involved in notification and corrective action |
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 4
Date: Oct 13, 2021
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to notify a resident's family about an antibiotic treatment and concerns about accident hazards and supervision related to resident transfers and use of specialty cushions.
Complaint Details
The complaint investigation substantiated that the facility failed to notify the family of Resident #1 about antibiotic treatment initiation and failed to prevent accident hazards during resident transfers, resulting in a fall and fracture.
Findings
The facility failed to notify a resident's family about initiation of antibiotic treatment and did not ensure all residents were free from accident hazards during transfers, including improper use of a specialty wheelchair cushion and insufficient staff assistance during transfers.
Deficiencies (4)
F580 Notify of Changes: The facility failed to notify one resident's family after initiating antibiotic treatment for a possible foot infection, violating notification requirements.
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to ensure residents were free from accident hazards when staff did not assess the use of a cushion in a resident's wheelchair and did not have sufficient staff present during a resident transfer, resulting in a fall and fracture.
A4073 Protective Oversight, Voluntary Leave: The facility did not meet requirements for protective oversight for residents on voluntary leave, referencing F689 for details.
A4087 Notify Responsible Party-Change in Condition: The facility failed to immediately notify the responsible party of significant changes in a resident's condition, referencing F580 for details.
Report Facts
Facility census: 86
Date of survey: Oct 13, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | ADON | Interviewed regarding notification of family about antibiotic orders |
| Director of Nursing | DON | Interviewed regarding notification responsibilities and transfer policies |
| CNA A | Certified Nurse Aide | Interviewed about resident transfer and use of Hoyer sling |
| CNA B | Certified Nurse Aide | Interviewed about use of wheelchair cushions and mechanical lift transfers |
| LPN C | Licensed Practical Nurse | Interviewed about placement of gel-type cushion and consultation with therapy |
| LPN D | Licensed Practical Nurse | Performed resident assessment after fall |
| Area Therapy Manager | Interviewed about therapy involvement in pressure relief devices | |
| Facility Administrator | Administrator | Interviewed about resident use of Broda chair and transfer policies |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 9, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey and a COVID-19 Focused Emergency Preparedness survey were conducted on 02/09/2021 to assess compliance with CMS and CDC recommended practices and related regulations.
Complaint Details
No deficiencies were cited on this complaint investigation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control and emergency preparedness. No deficiencies were cited during this complaint investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 5, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Complaint Details
No deficiencies were cited on this complaint investigation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 (b)(6) and CDC recommended practices for COVID-19. No deficiencies were cited during this complaint investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 6, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Complaint Details
No deficiencies were cited on this complaint investigation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended infection control practices. No deficiencies were cited during this complaint investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 13, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices for COVID-19 preparedness.
Complaint Details
No deficiencies were cited on this complaint investigation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CMS/CDC recommended practices for COVID-19. No deficiencies were cited during this complaint investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 13, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Complaint Details
No deficiencies were cited on this complaint investigation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 (b)(6) and CDC recommended practices for COVID-19. No deficiencies were cited during this complaint investigation.
Inspection Report
Routine
Deficiencies: 0
Date: Sep 16, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 21, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Complaint Details
No deficiencies were cited on this complaint investigation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CDC recommended practices for COVID-19. No deficiencies were cited during this complaint investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 9, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Complaint Details
No deficiencies were cited on this complaint investigation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 (b)(6) and CDC recommended practices for COVID-19. No deficiencies were cited during this complaint investigation.
Inspection Report
Routine
Deficiencies: 0
Date: Jun 30, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Complaint Details
No deficiencies were cited on this complaint investigation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and infection control practices. No deficiencies were cited during this complaint investigation.
Inspection Report
Routine
Deficiencies: 0
Date: May 29, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with relevant CMS and CDC guidelines.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 2
Date: Jan 27, 2020
Visit Reason
The inspection was conducted in response to allegations of abuse involving one resident at the facility.
Complaint Details
The complaint investigation was substantiated as the facility failed to report an allegation of abuse involving one resident within the required timeframe to the Department of Health and Senior Services.
Findings
The facility failed to report an allegation of possible abuse involving a resident to the Department of Health and Senior Services within the required timeframe. Interviews and record reviews showed that staff did not report the abuse allegation as required by policy and regulation.
Deficiencies (2)
F609: The facility failed to report an allegation of possible abuse involving one resident to the Department of Health and Senior Services within the required timeframe following staff awareness of the allegation.
A8023: The facility did not develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and require timely reporting to the department for any resident or vulnerable person.
Report Facts
Facility census: 82
Inspection Report
Plan of Correction
Census: 84
Deficiencies: 1
Date: Oct 31, 2019
Visit Reason
The inspection was conducted in response to allegations of abuse, neglect, exploitation, or mistreatment at the facility.
Findings
The facility failed to report an allegation of abuse to the State Agency within the required two-hour timeframe after staff became aware of the incident involving one resident. Interviews and record reviews confirmed the delay in reporting and lack of immediate notification to appropriate authorities.
Deficiencies (1)
F 609: The facility failed to report an allegation of abuse to the State Agency within two hours of staff awareness, violating CFR 483.12(c)(1)(4). The delay involved one resident and was confirmed through interviews and record reviews.
Report Facts
Facility census: 84
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse A | Registered Nurse | Interviewed regarding the abuse incident and reporting procedures |
| CNA C | Certified Nurse Assistant | Interviewed regarding training and incident awareness |
| Licence Practical Nurse D | Licensed Practical Nurse | Interviewed regarding abuse reporting procedures |
| Administrator | Executive Director | Conducted investigation and contacted family and authorities |
Inspection Report
Routine
Census: 72
Deficiencies: 6
Date: 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.
Deficiencies (6)
Failed to document and track residents' grievances and failed to make prompt efforts to resolve grievances for four residents.
Failed to revise care plans for two residents to include exit seeking behaviors and use of a seatbelt.
Failed to obtain a physician order for oxygen for two residents.
Failed to provide ongoing communication with the dialysis center for one resident receiving dialysis.
Failed to ensure medication error rates were less than 5 percent; six medication errors observed including insulin pen priming and dosing errors.
Failed to use appropriate infection control procedures by not attaching a cap on the end of a PICC line for one resident.
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 |
Inspection Report
Plan of Correction
Census: 72
Deficiencies: 7
Date: Oct 15, 2019
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements and to address grievances and care plan deficiencies at Neighborhoods at Quail Creek.
Findings
The facility failed to document and track residents' grievances promptly and did not revise care plans to address exit-seeking behaviors and use of seatbelts for certain residents. The facility also failed to obtain physician orders for oxygen for two residents and did not ensure residents were free of significant medication errors.
Deficiencies (7)
F 585 Grievances: The facility failed to document and track grievances for four residents and did not make prompt efforts to resolve them.
F 657 Care Plan Timing and Revision: The facility failed to revise care plans for two residents to include exit-seeking behaviors and use of a seatbelt.
F 695 Respiratory/Tracheostomy Care and Suctioning: The facility failed to obtain physician orders for oxygen for two residents requiring respiratory care.
F 698 Dialysis: The facility failed to provide ongoing communication with the dialysis center for one resident receiving dialysis.
F 759 Free of Medication Error Rates 5 Percent or More: The facility failed to ensure medication error rates were less than 5 percent, affecting six residents.
F 760 Residents are Free of Significant Med Errors: The facility failed to ensure residents were free of significant medication errors related to insulin administration.
F 880 Infection Prevention & Control: The facility failed to use appropriate infection control procedures to prevent spread of infections and failed to monitor PICC line care for one resident.
Report Facts
Facility census: 72
Residents with grievances not documented: 4
Residents affected by medication errors: 6
Sample size for care plan review: 20
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Oct 15, 2019
Visit Reason
Annual recertification survey and licensure inspection of the facility.
Findings
No Emergency Preparedness deficiencies were cited as a result of the annual recertification survey. No state licensure deficiencies were cited as a result of the licensure inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 30, 2018
Visit Reason
The inspection was conducted as a licensure inspection and complaint investigation for the facility.
Complaint Details
No deficiencies were cited as a result of the complaint investigation.
Findings
No health facility survey deficiencies or state licensure deficiencies were cited as a result of this inspection and complaint investigation.
Inspection Report
Annual Inspection
Census: 63
Capacity: 120
Deficiencies: 8
Date: Nov 26, 2018
Visit Reason
The inspection was an annual recertification survey to assess compliance with the Life Safety Code and related regulations at The Neighborhoods at Quail Creek facility.
Findings
The facility failed to meet several Life Safety Code requirements including kitchen hood filter maintenance, prohibition of portable space heaters, emergency generator fuel testing, and electrical system safety. Deficiencies had the potential to affect all residents, staff, and visitors.
Deficiencies (8)
K324 Cooking Facilities: The facility failed to ensure kitchen hood filters remained intact to prevent grease laden vapors from passing through, risking a grease buildup in the exhaust vent.
K781 Portable Space Heaters: The facility failed to ensure no portable space heaters were in use, as a heater was found on the nurses' desk in a smoke compartment.
K918 Electrical Systems - Essential Electric System: The facility failed to conduct an annual fuel quality test for the emergency generator, risking generator failure during a power outage.
K919 Electrical Equipment - Other: The facility failed to maintain electrical system integrity by allowing furniture to press against electrical outlets in resident rooms, risking fire from electrical shorts.
A2017 Range Hood Certification: The facility failed to certify the cooking range hood and extinguishing system at least twice annually as required by NFPA 96.
A3001 Substantially Constructed/Maintained: The building must be maintained in good repair and comply with physical plant construction standards.
A3027 Heating System-No Portable: Portable heater use is prohibited; the heating system must be restricted to approved devices to safeguard against fire hazards.
A3030 Electrical Wiring & Equipment Maintained: Electrical wiring and equipment must be installed and maintained per NFPA 70 standards to prevent hazards.
Report Facts
Facility capacity: 120
Resident census: 63
Number of kitchen hood filters: 5
Date of inspection observations: Nov 26, 2018
Inspection Report
Re-Inspection
Census: 79
Deficiencies: 2
Date: Jun 26, 2018
Visit Reason
This inspection was a re-inspection to verify correction of previously cited deficiencies related to personal privacy/confidentiality of records and quality of care.
Findings
The facility failed to protect resident privacy during financial discussions and failed to ensure quality of care related to medication administration, including missed doses and failure to notify physicians of medication errors. The facility submitted a plan of correction addressing these issues.
Deficiencies (2)
F583 Personal Privacy/Confidentiality of Records: The facility failed to protect a resident's financial and billing information from being discussed in front of other residents.
F684 Quality of Care: The facility failed to administer ordered intravenous antibiotics, failed to notify physicians of medication errors, and failed to properly document medication administration for multiple residents.
Report Facts
Facility census: 79
Deficiencies cited: 2
Missed IV antibiotic doses: 5
Residents involved in medication errors: 6
Report
Aug 16, 2024
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